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Cano J, Zorio E, Mazzanti A, Arnau MÁ, Trenor B, Priori SG, Saiz J, Romero L. Ranolazine as an Alternative Therapy to Flecainide for SCN5A V411M Long QT Syndrome Type 3 Patients. Front Pharmacol 2020; 11:580481. [PMID: 33519442 PMCID: PMC7845660 DOI: 10.3389/fphar.2020.580481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/16/2020] [Indexed: 12/14/2022] Open
Abstract
The prolongation of the QT interval represents the main feature of the long QT syndrome (LQTS), a life-threatening genetic disease. The heterozygous SCN5A V411M mutation of the human sodium channel leads to a LQTS type 3 with severe proarrhythmic effects due to an increase in the late component of the sodium current (INaL). The two sodium blockers flecainide and ranolazine are equally recommended by the current 2015 ESC guidelines to treat patients with LQTS type 3 and persistently prolonged QT intervals. However, awareness of pro-arrhythmic effects of flecainide in LQTS type 3 patients arose upon the study of the SCN5A E1784K mutation. Regarding SCN5A V411M individuals, flecainide showed good results albeit in a reduced number of patients and no evidence supporting the use of ranolazine has ever been released. Therefore, we ought to compare the effect of ranolazine and flecainide in a SCN5A V411M model using an in-silico modeling and simulation approach. We collected clinical data of four patients. Then, we fitted four Markovian models of the human sodium current (INa) to experimental and clinical data. Two of them correspond to the wild type and the heterozygous SCN5A V411M scenarios, and the other two mimic the effects of flecainide and ranolazine on INa. Next, we inserted them into three isolated cell action potential (AP) models for endocardial, midmyocardial and epicardial cells and in a one-dimensional tissue model. The SCN5A V411M mutation produced a 15.9% APD90 prolongation in the isolated endocardial cell model, which corresponded to a 14.3% of the QT interval prolongation in a one-dimensional strand model, in keeping with clinical observations. Although with different underlying mechanisms, flecainide and ranolazine partially countered this prolongation at the isolated endocardial model by reducing the APD90 by 8.7 and 4.3%, and the QT interval by 7.2 and 3.2%, respectively. While flecainide specifically targeted the mutation-induced increase in peak INaL, ranolazine reduced it during the entire AP. Our simulations also suggest that ranolazine could prevent early afterdepolarizations triggered by the SCN5A V411M mutation during bradycardia, as flecainide. We conclude that ranolazine could be used to treat SCN5A V411M patients, specifically when flecainide is contraindicated.
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Affiliation(s)
- Jordi Cano
- Centro de Investigación e Innovación en Bioingeniería (CI2B), Universitat Politècnica de València, Valencia, España
| | - Esther Zorio
- Unidad de Cardiopatías Familiares y Muerte Súbita, Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, España.,Center for Biomedical Network Research on Cardiovascular Diseases (CIBERCV), Madrid, Spain
| | - Andrea Mazzanti
- Molecular Cardiology, IRCCS, Istituti Clinici Scientifici Maugeri, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Miguel Ángel Arnau
- Unidad de Cardiopatías Familiares y Muerte Súbita, Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Beatriz Trenor
- Centro de Investigación e Innovación en Bioingeniería (CI2B), Universitat Politècnica de València, Valencia, España
| | - Silvia G Priori
- Molecular Cardiology, IRCCS, Istituti Clinici Scientifici Maugeri, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Javier Saiz
- Centro de Investigación e Innovación en Bioingeniería (CI2B), Universitat Politècnica de València, Valencia, España
| | - Lucia Romero
- Centro de Investigación e Innovación en Bioingeniería (CI2B), Universitat Politècnica de València, Valencia, España
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Hwang J, Kim TY, Terentyev D, Zhong M, Kabakov AY, Bronk P, Arunachalam K, Belardinelli L, Rajamani S, Kunitomo Y, Pfeiffer Z, Lu Y, Peng X, Odening KE, Qu Z, Karma A, Koren G, Choi BR. Late I Na Blocker GS967 Supresses Polymorphic Ventricular Tachycardia in a Transgenic Rabbit Model of Long QT Type 2. Circ Arrhythm Electrophysiol 2020; 13:e006875. [PMID: 32628505 PMCID: PMC10626560 DOI: 10.1161/circep.118.006875] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Long QT syndrome has been associated with sudden cardiac death likely caused by early afterdepolarizations (EADs) and polymorphic ventricular tachycardias (PVTs). Suppressing the late sodium current (INaL) may counterbalance the reduced repolarization reserve in long QT syndrome and prevent EADs and PVTs. METHODS We tested the effects of the selective INaL blocker GS967 on PVT induction in a transgenic rabbit model of long QT syndrome type 2 using intact heart optical mapping, cellular electrophysiology and confocal Ca2+ imaging, and computer modeling. RESULTS GS967 reduced ventricular fibrillation induction under a rapid pacing protocol (n=7/14 hearts in control versus 1/14 hearts at 100 nmol/L) without altering action potential duration or restitution and dispersion. GS967 suppressed PVT incidences by reducing Ca2+-mediated EADs and focal activity during isoproterenol perfusion (at 30 nmol/L, n=7/12 and 100 nmol/L n=8/12 hearts without EADs and PVTs). Confocal Ca2+ imaging of long QT syndrome type 2 myocytes revealed that GS967 shortened Ca2+ transient duration via accelerating Na+/Ca2+ exchanger (INCX)-mediated Ca2+ efflux from cytosol, thereby reducing EADs. Computer modeling revealed that INaL potentiates EADs in the long QT syndrome type 2 setting through (1) providing additional depolarizing currents during action potential plateau phase, (2) increasing intracellular Na+ (Nai) that decreases the depolarizing INCX thereby suppressing the action potential plateau and delaying the activation of slowly activating delayed rectifier K+ channels (IKs), suggesting important roles of INaL in regulating Nai. CONCLUSIONS Selective INaL blockade by GS967 prevents EADs and abolishes PVT in long QT syndrome type 2 rabbits by counterbalancing the reduced repolarization reserve and normalizing Nai. Graphic Abstract: A graphic abstract is available for this article.
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Affiliation(s)
- Jungmin Hwang
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
- College of Pharmacy, Univ of Rhode Island, Kingstown, RI
| | - Tae Yun Kim
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
| | - Dmitry Terentyev
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
| | | | - Anatoli Y. Kabakov
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
| | - Peter Bronk
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
| | - Karuppiah Arunachalam
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
| | | | - Sridharan Rajamani
- Former employee: Dept of Biology, Gilead Science, Foster City, CA
- Amgen Inc, South San Francisco, CA
| | - Yukiko Kunitomo
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
| | - Zachary Pfeiffer
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
| | - Yichun Lu
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
| | - Xuwen Peng
- Dept of Comparative Medicine, Pennsylvania State Univ College of Medicine, Hershey, PA
| | - Katja E. Odening
- Dept of Cardiology & Angiology I, Heart Ctr, Univ of Freiburg, Germany
| | - Zhilin Qu
- Dept of Medicine, Univ of California, Los Angeles
| | - Alain Karma
- Dept of Physics, Northeastern Univ, Boston, MA
| | - Gideon Koren
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
| | - Bum-Rak Choi
- Cardiovascular Rsrch Ctr, Division of Cardiology, Rhode Island Hospital, Alpert Medical School of Brown Univ, Providence
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Guarini G, Huqi A, Morrone D, Capozza PFG, Marzilli M. Trimetazidine and Other Metabolic Modifiers. Eur Cardiol 2018; 13:104-111. [PMID: 30697354 DOI: 10.15420/ecr.2018.15.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Treatment goals for people with chronic angina should focus on the relief of symptoms and improving mortality rates so the patient can feel better and live longer. The traditional haemodynamic approach to ischaemic heart disease was based on the assumption that increasing oxygen supply and decreasing oxygen demand would improve symptoms. However, data from clinical trials, show that about one third of people continue to have angina despite a successful percutaneous coronary intervention and medical therapy. Moreover, several trials on chronic stable angina therapy and revascularisation have failed to show benefits in terms of primary outcome (survival, cardiovascular death, all-cause mortality), symptom relief or echocardiographic parameters. Failure to significantly improve quality of life and prognosis may be attributed in part to a limited understanding of ischaemic heart disease, by neglecting the fact that ischaemia is a metabolic disorder. Shifting cardiac metabolism from free fatty acids towards glucose is a promising approach for the treatment of patients with stable angina, independent of the underlying disease (macrovascular and/or microvascular disease). Cardiac metabolic modulators open the way to a greater understanding of ischaemic heart disease and its common clinical manifestations as an energetic disorder rather than an imbalance between the demand and supply of oxygen and metabolites.
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Affiliation(s)
- Giacinta Guarini
- Cardiovascular Medicine Division, Cardiothoracic and Vascular Department, University of Pisa Italy
| | - Alda Huqi
- Cardiovascular Medicine Division, Ospedale della Versilia, Lido di Camaiore Italy
| | - Doralisa Morrone
- Cardiovascular Medicine Division, Cardiothoracic and Vascular Department, University of Pisa Italy
| | | | - Mario Marzilli
- Cardiovascular Medicine Division, Cardiothoracic and Vascular Department, University of Pisa Italy
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Moreno JD, Yang PC, Bankston JR, Grandi E, Bers DM, Kass RS, Clancy CE. Ranolazine for congenital and acquired late INa-linked arrhythmias: in silico pharmacological screening. Circ Res 2013; 113:e50-e61. [PMID: 23897695 DOI: 10.1161/circresaha.113.301971] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
RATIONALE The antianginal ranolazine blocks the human ether-a-go-go-related gene-based current IKr at therapeutic concentrations and causes QT interval prolongation. Thus, ranolazine is contraindicated for patients with preexisting long-QT and those with repolarization abnormalities. However, with its preferential targeting of late INa (INaL), patients with disease resulting from increased INaL from inherited defects (eg, long-QT syndrome type 3 or disease-induced electric remodeling (eg, ischemic heart failure) might be exactly the ones to benefit most from the presumed antiarrhythmic properties of ranolazine. OBJECTIVE We developed a computational model to predict if therapeutic effects of pharmacological targeting of INaL by ranolazine prevailed over the off-target block of IKr in the setting of inherited long-QT syndrome type 3 and heart failure. METHODS AND RESULTS We developed computational models describing the kinetics and the interaction of ranolazine with cardiac Na(+) channels in the setting of normal physiology, long-QT syndrome type 3-linked ΔKPQ mutation, and heart failure. We then simulated clinically relevant concentrations of ranolazine and predicted the combined effects of Na(+) channel and IKr blockade by both the parent compound ranolazine and its active metabolites, which have shown potent blocking effects in the therapeutically relevant range. Our simulations suggest that ranolazine is effective at normalizing arrhythmia triggers in bradycardia-dependent arrhythmias in long-QT syndrome type 3 as well tachyarrhythmogenic triggers arising from heart failure-induced remodeling. CONCLUSIONS Our model predictions suggest that acute targeting of INaL with ranolazine may be an effective therapeutic strategy in diverse arrhythmia-provoking situations that arise from a common pathway of increased pathological INaL.
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Affiliation(s)
- Jonathan D Moreno
- Tri-Institutional MD-PhD Program, Weill Cornell Medical College/The Rockefeller University/Sloan-Kettering Cancer Institute, New York, New York, USA, 10021
| | - Pei-Chi Yang
- Department of Pharmacology, University of California, Davis, Genome Building Rm 3503, Davis, CA 95616-8636
| | - John R Bankston
- Department of Pharmacology Columbia University College of Physicians and Surgeons 630 W. 168th St. New York, NY 10032, USA
| | - Eleonora Grandi
- Department of Pharmacology, University of California, Davis, Genome Building Rm 3503, Davis, CA 95616-8636
| | - Donald M Bers
- Department of Pharmacology, University of California, Davis, Genome Building Rm 3503, Davis, CA 95616-8636
| | - Robert S Kass
- Department of Pharmacology Columbia University College of Physicians and Surgeons 630 W. 168th St. New York, NY 10032, USA
| | - Colleen E Clancy
- Department of Pharmacology, University of California, Davis, Genome Building Rm 3503, Davis, CA 95616-8636
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Moreno JD, Clancy CE. Pathophysiology of the cardiac late Na current and its potential as a drug target. J Mol Cell Cardiol 2011; 52:608-19. [PMID: 22198344 DOI: 10.1016/j.yjmcc.2011.12.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 11/30/2011] [Accepted: 12/07/2011] [Indexed: 12/19/2022]
Abstract
A pathological increase in the late component of the cardiac Na(+) current, I(NaL), has been linked to disease manifestation in inherited and acquired cardiac diseases including the long QT variant 3 (LQT3) syndrome and heart failure. Disruption in I(NaL) leads to action potential prolongation, disruption of normal cellular repolarization, development of arrhythmia triggers, and propensity to ventricular arrhythmia. Attempts to treat arrhythmogenic sequelae from inherited and acquired syndromes pharmacologically with common Na(+) channel blockers (e.g. flecainide, lidocaine, and amiodarone) have been largely unsuccessful. This is due to drug toxicity and the failure of most current drugs to discriminate between the peak current component, chiefly responsible for single cell excitability and propagation in coupled tissue, and the late component (I(NaL)) of the Na(+) current. Although small in magnitude as compared to the peak Na(+) current (~1-3%), I(NaL) alters action potential properties and increases Na(+) loading in cardiac cells. With the increasing recognition that multiple cardiac pathological conditions share phenotypic manifestations of I(NaL) upregulation, there has been renewed interest in specific pharmacological inhibition of I(Na). The novel antianginal agent ranolazine, which shows a marked selectivity for late versus peak Na(+) current, may represent a novel drug archetype for targeted reduction of I(NaL). This article aims to review common pathophysiological mechanisms leading to enhanced I(NaL) in LQT3 and heart failure as prototypical disease conditions. Also reviewed are promising therapeutic strategies tailored to alter the molecular mechanisms underlying I(Na) mediated arrhythmia triggers.
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Affiliation(s)
- Jonathan D Moreno
- Tri-Institutional MD-PhD Program, Weill Cornell Medical College/The Rockefeller University/Sloan-Kettering Cancer Institute, New York, NY 10021, USA
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Thireau J, Pasquié JL, Martel E, Le Guennec JY, Richard S. New drugs vs. old concepts: a fresh look at antiarrhythmics. Pharmacol Ther 2011; 132:125-45. [PMID: 21420430 DOI: 10.1016/j.pharmthera.2011.03.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 03/01/2011] [Indexed: 01/10/2023]
Abstract
Common arrhythmias, particularly atrial fibrillation (AF) and ventricular tachycardia/fibrillation (VT/VF) are a major public health concern. Classic antiarrhythmic (AA) drugs for AF are of limited effectiveness, and pose the risk of life-threatening VT/VF. For VT/VF, implantable cardiac defibrillators appear to be the unique, yet unsatisfactory, solution. Very few AA drugs have been successful in the last few decades, due to safety concerns or limited benefits in comparison to existing therapy. The Vaughan-Williams classification (one drug for one molecular target) appears too restrictive in light of current knowledge of molecular and cellular mechanisms. New AA drugs such as atrial-specific and/or multichannel blockers, upstream therapy and anti-remodeling drugs, are emerging. We focus on the cellular mechanisms related to abnormal Na⁺ and Ca²⁺ handling in AF, heart failure, and inherited arrhythmias, and on novel strategies aimed at normalizing ionic homeostasis. Drugs that prevent excessive Na⁺ entry (ranolazine) and aberrant diastolic Ca²⁺ release via the ryanodine receptor RyR2 (rycals, dantrolene, and flecainide) exhibit very interesting antiarrhythmic properties. These drugs act by normalizing, rather than blocking, channel activity. Ranolazine preferentially blocks abnormal persistent (vs. normal peak) Na⁺ currents, with minimal effects on normal channel function (cell excitability, and conduction). A similar "normalization" concept also applies to RyR2 stabilizers, which only prevent aberrant opening and diastolic Ca²⁺ leakage in diseased tissues, with no effect on normal function during systole. The different mechanisms of action of AA drugs may increase the therapeutic options available for the safe treatment of arrhythmias in a wide variety of pathophysiological situations.
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Affiliation(s)
- Jérôme Thireau
- Inserm U1046 Physiologie & Médecine Expérimentale du Cœur et des Muscles, Université Montpellier-1, Université Montpellier-2, 34295 Montpellier Cedex 5, France
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