Shortening of the action potential and reduction of pacemaker activity by lidocaine, quinidine, and procainamide in sheep cardiac purkinje fibers. An effect on Na or K currents?

Persistent sodium currents in neurons: potential mechanisms and pharmacological blockers

Persistent sodium current (INaP) is an important activity-dependent regulator of neuronal excitability. It is involved in a variety of physiological and pathological processes, including pacemaking, prolongation of sensory potentials, neuronal injury, chronic pain and diseases such as epilepsy and amyotrophic lateral sclerosis. Despite its importance, neither the molecular basis nor the regulation of INaP are sufficiently understood. Of particular significance is a solid knowledge and widely accepted consensus about pharmacological tools for analysing the function of INaP and for developing new therapeutic strategies. However, the literature on INaP is heterogeneous, with varying definitions and methodologies used across studies. To address these issues, we provide a systematic review of the current state of knowledge on INaP, with focus on mechanisms and effects of this current in the central nervous system. We provide an overview of the specificity and efficacy of the most widely used INaP blockers: amiodarone, cannabidiol, carbamazepine, cenobamate, eslicarbazepine, ethosuximide, gabapentin, GS967, lacosamide, lamotrigine, lidocaine, NBI-921352, oxcarbazepine, phenytoine, PRAX-562, propofol, ranolazine, riluzole, rufinamide, topiramate, valproaic acid and zonisamide. We conclude that there is strong variance in the pharmacological effects of these drugs, and in the available information. At present, GS967 and riluzole can be regarded bona fide INaP blockers, while phenytoin and lacosamide are blockers that only act on the slowly inactivating component of sodium currents.

Anti-malarial drugs: Mechanisms underlying their proarrhythmic effects

Malaria remains the leading cause of parasitic death in the world. Artemisinin resistance is an emerging threat indicating an imminent need for novel combination therapy. Given the key role of mass drug administration, it is pivotal that the safety of anti-malarial drugs is investigated thoroughly prior to widespread use. Cardiotoxicity, most prominently arrhythmic risk, has been a concern for anti-malarial drugs. We clarify the likely underlying mechanisms by which anti-malarial drugs predispose to arrhythmias. These relate to disruption of (1) action potential upstroke due to effects on the sodium currents, (2) action potential repolarisation due to effects on the potassium currents, (3) cellular calcium homeostasis, (4) mitochondrial function and reactive oxygen species production and (5) cardiac fibrosis. Together, these alterations promote arrhythmic triggers and substrates. Understanding these mechanisms is essential to assess the safety of these drugs, stratify patients based on arrhythmic risk and guide future anti-malarial drug development.

From Bernstein's rheotome to Neher-Sakmann's patch electrode. The action potential

The aim of this review was to provide an overview of the most important stages in the development of cellular electrophysiology. The period covered starts with Bernstein's formulation of the membrane hypothesis and the measurement of the nerve and muscle action potential. Technical innovations make discoveries possible. This was the case with the use of the squid giant axon, allowing the insertion of "large" intracellular electrodes and derivation of transmembrane potentials. Application of the newly developed voltage clamp method for measuring ionic currents, resulted in the formulation of the ionic theory. At the same time transmembrane measurements were made possible in smaller cells by the introduction of the microelectrode. An improvement of this electrode was the next major (r)evolution. The patch electrode made it possible to descend to the molecular level and record single ionic channel activity. The patch technique has been proven to be exceptionally versatile. In its whole-cell configuration it was the solution to measure voltage clamp currents in small cells. See also: https://doi.org/10.14814/phy2.13860 & https://doi.org/10.14814/phy2.13862.

Isolating the direct effects of adverse developmental conditions on in vivo cardiovascular function at adulthood: the avian model

It is now well accepted that exposure to adverse environmental conditions in utero can predispose a fetus to disease later in life. Using an avian model to study the programming of disease has a unique advantage as it allows isolation of the direct effects of adverse conditions on fetal physiology, without any confounding effects via the mother or placenta. However, experiments in avian models are limited by the lack of well-established surgical protocols for the adult bird, which we have established in this study. Surgery was performed on seven young adult Bovan Brown chickens (body weight 1617±214 g, mean±s.d.) in order to instrument them with femoral arterial and venous catheters and a femoral arterial flow probe. Isoflurane and lidocaine were both found to have depressive effects on chicken cardiovascular function. Optimised methods of anaesthesia, intraoperative monitoring, surgical approach, postoperative care, and experimentation are described. Chickens recovered rapidly from surgery without significant blood gas perturbation, and basal in vivo cardiovascular studies were performed following 5 days of recovery. These techniques allow detailed investigation of avian cardiometabolic function, permitting determination of the consequences in later life of direct environmental insults to fetal physiology, isolated from additional effects on maternal physiology and/or placental endocrinology.

The Hyperpolarization-Activated Cyclic Nucleotide-Gated Channels: from Biophysics to Pharmacology of a Unique Family of Ion Channels

Hyperpolarization-activated, cyclic nucleotide-gated (HCN) channels are important members of the voltage-gated pore loop channels family. They show unique features: they open at hyperpolarizing potential, carry a mixed Na/K current, and are regulated by cyclic nucleotides. Four different isoforms have been cloned (HCN1-4) that can assemble to form homo- or heterotetramers, characterized by different biophysical properties. These proteins are widely distributed throughout the body and involved in different physiologic processes, the most important being the generation of spontaneous electrical activity in the heart and the regulation of synaptic transmission in the brain. Their role in heart rate, neuronal pacemaking, dendritic integration, learning and memory, and visual and pain perceptions has been extensively studied; these channels have been found also in some peripheral tissues, where their functions still need to be fully elucidated. Genetic defects and altered expression of HCN channels are linked to several pathologies, which makes these proteins attractive targets for translational research; at the moment only one drug (ivabradine), which specifically blocks the hyperpolarization-activated current, is clinically available. This review discusses current knowledge about HCN channels, starting from their biophysical properties, origin, and developmental features, to (patho)physiologic role in different tissues and pharmacological modulation, ending with their present and future relevance as drug targets.

Cation and voltage dependence of lidocaine inhibition of the hyperpolarization-activated cyclic nucleotide-gated HCN1 channel

Lidocaine is known to inhibit the hyperpolarization-activated mixed cation current (I_h) in cardiac myocytes and neurons, as well in cells transfected with cloned Hyperpolarization-activated Cyclic Nucleotide-gated (HCN) channels. However, the molecular mechanism of I_h inhibition by this drug has been limitedly explored. Here, we show that inhibition of I_h by lidocaine, recorded from Chinese hamster ovary (CHO) cells expressing the HCN1 channel, reached a steady state within one minute and was reversible. Lidocaine inhibition of I_h was greater at less negative voltages and smaller current amplitudes whereas the voltage-dependence of I_h activation was unchanged. Lidocaine inhibition of I_h measured at −130 mV (a voltage at which I_h is fully activated) was reduced, and I_h amplitude was increased, when the concentration of extracellular potassium was raised to 60 mM from 5.4 mM. By contrast, neither I_h inhibition by the drug nor I_h amplitude at +30 mV (following a test voltage-pulse to −130 mV) were affected by this rise in extracellular potassium. Together, these data indicate that lidocaine inhibition of I_h involves a mechanism which is antagonized by hyperpolarizing voltages and current flow.

The arrhythmogenic consequences of increasing late INa in the cardiomyocyte

This review presents the roles of cardiac sodium channel NaV1.5 late current (late INa) in generation of arrhythmic activity. The assumption of the authors is that proper Na(+) channel function is necessary to the maintenance of the transmembrane electrochemical gradient of Na(+) and regulation of cardiac electrical activity. Myocyte Na(+) channels' openings during the brief action potential upstroke contribute to peak INa and initiate excitation-contraction coupling. Openings of Na(+) channels outside the upstroke contribute to late INa, a depolarizing current that persists throughout the action potential plateau. The small, physiological late INa does not appear to be critical for normal electrical or contractile function in the heart. Late INa does, however, reduce the net repolarizing current, prolongs action potential duration, and increases cellular Na(+) loading. An increase of late INa, due to acquired conditions (e.g. heart failure) or inherited Na(+) channelopathies, facilitates the formation of early and delayed afterpolarizations and triggered arrhythmias, spontaneous diastolic depolarization, and cellular Ca(2+) loading. These in turn increase the spatial and temporal dispersion of repolarization time and may lead to reentrant arrhythmias.

[Class I antiarrhythmic drugs: mechanisms, contraindications, and current indications]

Class I antiarrhythmic drugs are sodium channel inhibitors that act by slowing myocardial conduction and, thus, interrupting or preventing reentrant arrhythmia. Due to proarrhythmic effects and the risk of ventricular tachyarrhythmia, class I antiarrhythmics should not be administered in patients with structural heart disease. Nevertheless, there remains a broad spectrum of arrhythmias--among the most common being atrial fibrillation--that can successfully be treated with class I antiarrhythmic drugs. This review gives an overview on the classification, antiarrhythmic mechanisms, indications, side effects, and application modes of class I antiarrhythmic drugs.

Late sodium current in failing heart: friend or foe?

Most cardiac Na+ channels open transiently upon membrane depolarization and then are quickly inactivated. However, some channels remain active, carrying the so-called persistent or late Na+ current (INaL) throughout the action potential (AP) plateau. Experimental data and the results of numerical modeling accumulated over the past decade show the emerging importance of this late current component for the function of both normal and failing myocardium. INaL is produced by special gating modes of the cardiac-specific Na+ channel isoform. Heart failure (HF) slows channel gating and increases INaL, but HF-specific Na+ channel isoform underlying these changes has not been found. Na+ channels represent a multi-protein complex and its activity is determined not only by the pore-forming alpha subunit but also by its auxiliary beta subunits, cytoskeleton, calmodulin, regulatory kinases and phosphatases, and trafficking proteins. Disruption of the integrity of this protein complex may lead to alterations of INaL in pathological conditions. Increased INaL and the corresponding Na+ flux in failing myocardium contribute to abnormal repolarization and an increased cell Ca2+ load. Interventions designed to correct INaL rescue normal repolarization and improve Ca2+ handling and contractility of the failing cardiomyocytes. This review considers (1) quantitative integration of INaL into the established electrophysiological and Ca2+ regulatory mechanisms in normal and failing cardiomyocytes and (2) a new therapeutic strategy utilizing a selective inhibition of INaL to target both arrhythmias and impaired contractility in HF.

Characterization of the slowly inactivating sodium current INa2 in canine cardiac single Purkinje cells

The aim of our experiments was to investigate by means of a whole cell patch-clamp technique the characteristics of the slowly inactivating sodium current (I(Na2)) found in the plateau range in canine cardiac Purkinje single cells. The I(Na2) was separated from the fast-activating and -inactivating I(Na) (labelled here I(Na1)) by applying a two-step protocol. The first step, from a holding potential (V(h)) of -90 or -80 mV to -50 mV, led to the quick activation and inactivation of I(Na1). The second step consisted of depolarizations of increasing amplitude from -50 mV to less negative values, which led to the quick activation and slow inactivation of I(Na2). The I(Na2) was fitted with a double exponential function with time constants of tens and hundreds milliseconds, respectively. After the activation and inactivation of I(Na1) at -50 mV, the slope conductance was very small and did not change with time. Instead, during I(Na2), the slope conductance was larger and decreased as a function of time. Progressively longer conditioning steps at -50 mV resulted in a progressive decrease in amplitude of I(Na2) during the subsequent test steps. Gradually longer hyperpolarizing steps (increments of 100 ms up to 600 ms) from V(h) -30 mV to -100 mV were followed on return to -30 mV by a progressively larger I(Na2), as were gradually more negative 500 ms steps from V(h) -30 mV to -90 mV. At the end of a ramp to -20 mV, a sudden repolarization to approximately -35 mV fully deactivated I(Na2). The I(Na2) was markedly reduced by lignocaine (lidocaine) and by low extracellular [Na(+)], but it was little affected by low and high extracellular [Ca(2+)]. At negative potentials, the results indicate that there was little overlap between I(Na2) and the transient outward current, I(to), as well as the calcium current, I(Ca). In the absence of I(to) and I(Ca) (blocked by means of 4-aminopyridine and nickel, respectively), I(Na2) reversed at 60 mV. In conclusion, I(Na2) is a sodium current that can be initiated after the inactivation of I(Na1) and has characteristics that are quite distinct from those of I(Na1). The results have a bearing on the mechanisms underlying the long plateau of Purkinje cell action potential and its modifications in different physiological and pathological conditions.

A slowly inactivating sodium current (INa2) in the plateau range in canine cardiac Purkinje single cells

The action potential of Purkinje fibres is markedly shortened by tetrodotoxin, suggesting the possibility that a slowly inactivating sodium current might flow during the plateau. The aim of the present experiments was to investigate, in canine cardiac Purkinje single cells by means of a whole cell patch clamp technique, whether a sodium current slowly inactivates at less negative potentials and (if so) some of its distinctive characteristics. The results showed that a 500 ms depolarizing step from a holding potential of -90 mV to -50 mV induced the fast inward current I(Na) (labelled here I(Na1)). With steps to -40 mV or less negative values, a slowly decaying component (tentatively labelled here I(Na2)) appeared, which peaked at -30 to -20 mV and decayed slowly and incompletely during the 500 ms steps. The I(Na2) was present also during steps to -10 mV, but then the transient outward current (I(to)) appeared. When the holding potential (V(h)) was decreased to -60 to -50 mV, I(Na2) disappeared even if a small I(Na1) might still be present. Tetrodotoxin (30 mum), lignocaine (100 mum) and cadmium (0.2 mm; but not manganese, 1 mm) blocked I(Na2). During fast depolarizing ramps, the rapid inactivation of I(Na1) was followed by a negative slope region. During repolarizing ramps, a region of positive slope was present, whereas I(Na1) was absent. At less negative values of V(h), the amplitude of the negative and positive slopes became gradually smaller. Gradually faster ramps increased the magnitude of the negative slope, and tetrodotoxin (30 mum) reduced or abolished it. Thus, Purkinje cells have a slowly decaying inward current owing to Na(+) entry (I(Na2)) that is different in several ways from the fast I(Na1) and that appears important for the duration of the plateau.

Calcium overload and cardiac function

The changes in cardiac function caused by calcium overload are reviewed. Intracellular Ca(2+) may increase in different structures [e.g. sarcoplasmic reticulum (SR), cytoplasm and mitochondria] to an excessive level which induces electrical and mechanical abnormalities in cardiac tissues. The electrical manifestations of Ca(2+) overload include arrhythmias caused by oscillatory (V(os)) and non-oscillatory (V(ex)) potentials. The mechanical manifestations include a decrease in force of contraction, contracture and aftercontractions. The underlying mechanisms involve a role of Na(+) in electrical abnormalities as a charge carrier in the Na(+)-Ca(2+) exchange and a role of Ca(2+) in mechanical toxicity. Ca(2+) overload may be induced by an increase in [Na(+)](i) through the inhibition of the Na(+)-K(+) pump (e.g. toxic concentrations of digitalis) or by an increase in Ca(2+) load (e.g. catecholamines). The Ca(2+) overload is enhanced by fast rates. Purkinje fibers are more susceptible to Ca(2+) overload than myocardial fibers, possibly because of their greater Na(+) load. If the SR is predominantly Ca(2+) overloaded, V(os) and fast discharge are induced through an oscillatory release of Ca(2+) in diastole from the SR; if the cytoplasm is Ca(2+) overloaded, the non-oscillatory V(ex) tail is induced at negative potentials. The decrease in contractile force by Ca(2+) overload appears to be associated with a decrease in high energy phosphates, since it is enhanced by metabolic inhibitors and reduced by metabolic substrates. The ionic currents I(os) and I(ex) underlie V(os) and V(ex), respectively, both being due to an electrogenic extrusion of Ca(2+) through the Na(+)-Ca(2+) exchange. I(os) is an oscillatory current due to an oscillatory release of Ca(2+) in early diastole from the Ca(2+)-overloaded SR, and I(ex) is a non-oscillatory current due to the extrusion of Ca(2+) from the Ca(2+)-overloaded cytoplasm. I(os) and I(ex) can be present singly or simultaneously. An increase in [Ca(2+)](i) appears to be involved in the short- and long-term compensatory mechanisms that tend to maintain cardiac output in physiological and pathological conditions. Eventually, [Ca(2+)](i) may increase to overload levels and contribute to cardiac failure. Experimental evidence suggests that clinical concentrations of digitalis increase force in Ca(2+)-overloaded cardiac cells by decreasing the inhibition of the Na(+)-K(+) pump by Ca(2+), thereby leading to a reduction in Ca(2+) overload and to an increase in force of contraction.

Patch-clamp analysis in canine cardiac Purkinje cells of a novel sodium component in the pacemaker range

A putative Na+ component playing a role in the initiation and maintenance of spontaneous discharge in Purkinje fibres was studied by means of the whole-cell patch-clamp technique in canine cardiac single Purkinje cells. In 4 mM [K+]o, during depolarising clamp steps, a slowly inactivating current appeared at approximately -58 mV, negative to the threshold for the fast Na+ current (INa; approximately -50 mV). During depolarising ramps, the current underwent inward rectification with a negative slope region that began at approximately -60 mV. The current underlying the negative slope increased during faster ramps, decreased as a function of time when the initial depolarising ramp was over, decreased during depolarisations positive to approximately -35 mV and was much larger than the current during the symmetrical repolarising ramp. Increasing biphasic ('oscillatory') voltage ramps required much smaller currents at a holding potential (Vh) of -60 mV than at -80 mV and were associated with a marked decrease in slope conductance. At Vh -50/-40 mV, the oscillatory ramp currents and superimposed pulse currents reversed direction. The negative slope in the I-V relation as well as the change in current direction at -50/-40 mV were markedly reduced by tetrodotoxin (15 microM) and lidocaine (lignocaine, 100 microM) and therefore are due to a slowly inactivating Na+ current, labelled here INa3. Lower [K+]o (2.7 mM) reduced the steady state slope conductance as well as the current in the diastolic range, and increased as well as shifted INa3 in a negative direction. High [K+]o had the opposite effects. Cs+ (2 mM) and Ba2+ (2 mM) reduced the initial current during depolarising ramps but not INa3. In current-clamp mode, current-induced voltage oscillations elicited action potentials through a gradual transition between diastolic depolarisation and upstroke, consistent with the activation of INa3. Thus, the initiation and maintenance of spontaneous discharge in Purkinje strands appear to involve a voltage- and K+-dependent decrease in K+ conductance as well as the activation of a voltage- and time-dependent inward Na+ current (INa3) with slow inactivation kinetics.

Lidocaine for prevention of reperfusion ventricular fibrillation after release of aortic cross-clamping

OBJECTIVE

To determine the efficacy of a bolus of lidocaine administered by way of the pump before releasing the aortic cross-clamp (ACC) in preventing the occurrence of reperfusion ventricular fibrillation.

DESIGN

Prospective, randomized study.

SETTING

University hospital.

PARTICIPANTS

Patients undergoing coronary artery bypass graft surgery (n = 34).

INTERVENTIONS

Seventeen patients received 100 mg of lidocaine by way of the pump 2 minutes before releasing the ACC, and a control group of 17 patients received 5 mL of normal saline.

MEASUREMENTS AND MAIN RESULTS

In the control group, the incidence of reperfusion ventricular fibrillation was 70%, which was significantly decreased to 11% in the lidocaine group. A higher cardiac output after weaning from cardiopulmonary bypass was observed in the lidocaine group; this may be attributed to the lower incidence of reperfusion ventricular fibrillation and consequently the lower need for defibrillation by electric countershocks.

CONCLUSIONS

The results suggest that a bolus of 100 mg of lidocaine administered 2 minutes before release of the ACC can safely decrease the incidence of reperfusion ventricular fibrillation and is associated with better hemodynamics after weaning from cardiopulmonary bypass.

Positive inotropic action of NMDA receptor antagonist (+)-MK801 in rat heart

(+)-MK801, a noncompetitive NMDA receptor antagonist, was reported to exhibit anticonvulsive and neuroprotective activities during the postischemic period. Intravenous administration of (+)-MK801 produced tachycardia in rats, but bradycardia in pigs. We examined the mechanical and electrophysiological effects of (+)-MK801 on rat cardiac tissues. (+)-MK801 dose-dependently increased (3-100 microM) twitch tension in rat atria and ventricular strips. The spontaneous beating rate in rat right atria, however, was dose-dependently decreased by (+)-MK801. The inotropic effect of (+)-MK801 was affected neither by alpha(1)-antagonist (1 microM prazosin) nor by beta(1)-adrenoceptor antagonist (3 microM atenolol), but significantly by a transient outward K(+) channel blocker (3 mM 4-aminopyridine). (+)-MK801 did not cause any significant change of intracellular cAMP content. Electrophysiological study in rat ventricular cells revealed that (+)-MK801 concentration-dependently prolonged the action potential duration with a concomitant decrease in the maximum rate of the action potential upstroke (V(max)) and an increase in the recovery time constant of V(max). Voltage clamp study showed that (+)-MK801 (3 microM) reduced inward Na(+) current (I(Na)), along with a slowing of its recovery from inactivation and a slight negative shift of its voltage-dependent steady-state inactivation curves. At a much higher concentration (30 microM), (+)-MK801 slightly reduced the amplitude of L-type calcium inward current (I(Ca)), although the voltage dependence of its steady-state inactivation was unaffected. For the potassium currents in rat ventricular cells, 3 microM of (+)-MK801 reduced the peak transient outward current (I(to)), steady-state outward current (I(ss)) and inward current through K(1) channels. The inhibition of I(to) was associated with a prominent negative shift in the voltage dependence of its steady-state inactivation curve. The outward current through K(1) channels was unaffected. These results indicate that (+)-MK801 may be a strong I(Na) and I(to) blocker with some I(Ca) blocking activity. The inhibition of I(to) and other K(+) efflux would prolong action potential duration, produce positive inotropic action and contribute to the negative chronotropic effect of (+)-MK801.

Lidocaine inhibition of the hyperpolarization-activated current (I(f)) in sinoatrial myocytes

The aim of this study was to provide information on the dose dependence and biophysical details of lidocaine blockade of the hyperpolarization-activated current (I(f)) in the sinoatrial node. Isolated rabbit sinoatrial myocytes were patch-clamped in the whole-cell configuration at 36+/-0.5 degrees C, in the presence of 1 mM Ba2+ and 2 mM Mn2+ to minimize contamination by K+ and Ca2+ currents, respectively. Lidocaine inhibited I(f) dose-dependently with a maximal inhibition of 69.5% at 75 microM and a half-maximal effect at 38.2 microM. Lidocaine reduced the conductance of fully activated I(f), without affecting the current reversal potential; the blocking effect was independent of membrane potential. Voltage dependence of I(f) activation gating was not affected by lidocaine, whose effect was independent of use and rate. Lidocaine did not modify the time course of I(f) activation. At therapeutic concentrations, lidocaine significantly inhibited I(f) by reducing fully activated channel conductance. Lack of voltage and rate dependence of effect differentiates lidocaine from most of other blockers of this current.

Taurine modulates I(Kr) but I(Ks) in guinea-pig ventricular cardiomyocytes

1. Effects of taurine on the delayed rectifier K+ current (I(K)) in isolated guinea-pig ventricular cardiomyocytes were examined at different intracellular Ca2+ concentration ([Ca2+]i), using whole-cell voltage and current clamp techniques. Experiments were performed at 36 degrees C. 2. Addition of taurine (10-20 mM) decreased the action potential duration (APD) at pCa 8, but increased the APD at pCa 6. Taurine (20 mM) enhanced I(K) at 70 mV by 22.4 +/- 3.1% (n = 6, P < 0.01) at pCa 8, whereas taurine inhibited the I(K) by 27.1 +/- 2.7% (n = 6, P < 0.01) at pCa 6. These responses behaved in a concentration-dependent manner. 3. The I(K) is composed of the rapid and slow components (I(Kr) and I(Ks)). When [Ca2+]i was pCa 6, taurine at 20 mM reduced the tail current of I(Kr) at 70 mV by 16.5 +/- 2.7% (n = 5, P < 0.05) and that of I(Ks) at 70 mV by 27.1 +/- 2.8% (n = 6, P < 0.01). In contrast, at pCa 8, the tail currents of I(Kr) and I(Ks) at 70 mV were enhanced by 13.4 +/- 3.2% (n = 7, P < 0.05) and by 22.4 +/- 3.1% (n = 7, P < 0.01), respectively. The voltages of half-maximum activation (V1/2) for I(Kr) and I(Ks) were not modified by taurine. 4. Addition of E-4031 (5 microM) to taurine had a complete blockade of the tail current of I(Kr), but not I(Ks). The remained tail current (I(Ks)) in the presence of E-4031 (5 microM) was not affected by taurine (20 mM), but was blocked by 293B (30 microM). 5. These results indicate that taurine modulates I(Kr) but not I(Ks), depending on [Ca2+]i, resulting in regulation of the APD.

Antiarrhythmic drugs and cardiac ion channels: mechanisms of action

In this review a description and an analysis are given of the interaction of antiarrhythmic drugs with their molecular target, i.e. ion channels and receptors. Our approach is based on the concept of vulnerable parameter, i.e. the electrophysiological property which plays a crucial role in the genesis of arrhythmias. To prevent or stop the arrhythmia a drug should modify the vulnerable parameter by its action on channel or receptor targets. In the first part, general aspects of the interaction between drugs channel molecules are considered. Drug binding depends on the state of the channel: rested, activated pre-open, activated open, or inactivated state. The change in channel behaviour with state is presented in the framework of the modulated-receptor hypothesis. Not only inhibition but also stimulation can be the result of drug binding. In the second part a detailed and systematic description and an analysis are given of the interaction of drugs with specific channels (Na+, Ca2+, K+, "pacemaker") and non-channel receptors. Emphasis is given to the type of state-dependent block involved (rested, activated and inactivated state block) and the change in channel kinetics. These properties vary and determine the voltage- and frequency-dependence of the change in ionic current. Finally, the question is asked as to whether the available drugs by their action on channels and receptors modify the vulnerable parameter in the desired way to stop or prevent arrhythmias.

Electrophysiological mechanisms for the antiarrhythmic activities of naloxone on cardiac tissues

It has been reported that naloxone, an opioid antagonist, has antiarrhythmic activity in vivo. In Langendorff perfused rat hearts, we found that ischemia-reperfusion-induced ventricular tachyarrhythmia reverted to normal sinus rhythm after the treatment with naloxone (3 approximately 10 microM). The method of voltage and current clamp were used to study the underlying mechanism of its antiarrhythmic activity on isolated cardiac myocytes. In isolated rat ventricular and in guinea-pig and human atrial myocytes, naloxone prolonged the action potential duration reversibly. In rat ventricular myocytes, naloxone (1 approximately 30 microM) inhibited sodium current (I(Na)), transient outward potassium current (I(to)), and calcium current (I(Ca)). On the contrary, the addition of naloxone significantly increased inward rectifier potassium current (I(K1)). For the effect on I(Na), naloxone did not shift the inactivation curve of I(Na) but retarded the I(Na) recovery rate from inactivation state. Naloxone suppressed I(to) with a significant left-shift of the inactivation curve, however, the time course of I(to) recovery from inactivation was not affected. In guinea pig atrial myocytes, naloxone (10 microM) decreased the delayed rectifier K+ current (IK). These results show that naloxone exert various extent of inhibition on I(Na), I(to), IK and I(Ca). The prolongation of cardiac action potential is related to the inhibition of I(to) and IK. The antiarrhythmic activity of naloxone is more closely related to the inhibition of Na+ and K+ currents rather than the blockade of myocardial opioid receptors.

Relation between bradycardia dependent long QT syndrome and QT prolongation by disopyramide in humans

BACKGROUND

Recent molecular biological investigations have identified abnormal genes in familial forms of long QT syndrome, but in bradycardia dependent acquired long QT syndrome, no such genetic abnormality has yet been identified.

OBJECTIVE

To investigate the relation between the responses of QT interval to pacing change and to disopyramide.

METHODS

This study included 13 patients with bradyarrhythmia who had undergone pacemaker implantation. The patients were divided into two groups: group I (n = 8), patients with QT prolongation (QT interval > or = 500 ms) during bradycardia; group II (n = 5), patients without QT prolongation (QT interval < 500 ms) during bradycardia. The responses of QT interval caused by the change of pacing rate were determined and compared with the changes of the QT interval after disopyramide administration.

RESULTS

The QT interval in group I was significantly longer than that in group II when the pacing rate was decreased from 110 to 50 beats/min: mean (SD) 451 (16) v 416 (17) ms at 90 beats/min (p = 0.0033), and 490 (19) v 432 (18) ms at 70 beats/min (p = 0.0002), respectively. The QT interval was prolonged significantly by disopyramide in both groups, but the change was more pronounced in group I than in group II: 78 (33) v 35 (10) ms (p < 0.05).

CONCLUSIONS

This study suggests that the patients showing bradycardia dependent QT prolongation are also more markedly affected by disopyramide and that abnormal potassium channel may be the underlying mechanism.

Electrophysiological basis for the antiarrhythmic action and positive inotropy of HA-7, a furoquinoline alkaloid derivative, in rat heart

1. HA-7, a new synthetic derivative of furoquinoline alkaloid, increased the contractile force of right ventricular strips and effectively suppressed the ischaemia-reperfusion induced polymorphic ventricular tachyrhythmias in adult rat heart (EC50 = 2.8 microM). 2. In rat ventricular myocytes, HA-7 concentration-dependently prolonged the action potential duration (APD) and decreased the maximal rate of rise of the action potential upstroke (Vmax). The action potential amplitude and resting membrane potential were also reduced, but to a smaller extent. The prolongation of APD by HA-7 was prevented by pretreating the cells with 1 mM 4-AP. 3. Voltage clamp experiments revealed that HA-7 decreased the maximal current amplitude of I(Na) (IC50 = 4.1 microM) and caused a negative shift of its steady-state inactivation curve and slowed its rate of recovery from inactivation. The use-dependent inhibition of I(Na) by HA-7 was enhanced at a higher stimulation rate. The L-type Ca2+ current (I(Ca)) was also reduced, but to a lesser degree (IC50 = 5.3 microM, maximal inhibition = 31.8%). 4. This agent also influenced the time- and voltage-dependent K currents. The prolongation of APD was associated with an inhibition of a 4-AP sensitive transient outward K current (I(to)) (IC50 = 2.9 microM) and a slowly inactivating, steady-state outward current (I(SS)) (IC50 = 2.5 microM). The inhibition of I(to) by HA-7 was associated with an acceleration of its time constant of inactivation. HA-7 suppressed I(to) in a time-dependent manner and caused a significant negative shift of the voltage-dependent steady-state inactivation curve but did not affect its rate of recovery from inactivation. 5. At higher concentrations, the inward rectifier K+ current (I(KI)) was also inhibited but to a less extent. Its slope conductance after 3, 10 and 30 microM HA-7 was decreased by 24+/-4%, 41+/-5% and 54+/-8%. respectively. 6. We conclude that HA-7 predominantly blocks I(to) and Na+ channels and that it also weakly blocks Ca2+ and I(KI) channels. These changes alter the electrophysiological properties of the heart and terminate the ischaemia reperfusion induced ventricular arrhythmia. The significant I(to) inhibition and minimal I(Ca) suppression may afford an opportunity to develop an effective antiarrhythmic agent linked with positive inotropy.

Ionic mechanism responsible for prolongation of cardiac action-potential duration by berberine

This study was designed to investigate the effects of berberine on membrane currents forming the repolarization phase of action potentials in isolated guinea pig ventricular myocytes by using the patch-clamp technique. Application of berberine (3-30 microM) to the current-clamped myocytes produced a significant prolongation of action-potential duration (APD), which was concentration dependent. However, this agent (3-30 microM) did not affect the resting potential and action-potential amplitude. The prolongation of APD caused by berberine was not attenuated by tetrodotoxin (TTX, 10 microM), and TTX (10 microM) failed to shorten APD in cells pretreated with 30 microM berberine. Under the voltage-clamp conditions, berberine (3-30 microM) inhibited the delayed rectifier K+ currents (I(K)). Under conditions in which the rapidly activating components (I(Kr)) and slowly activating component (I(Ks)) were dissected out, berberine was shown to block I(Ks) without affecting I(Kr). Application of berberine (3-30 microM) increased the Na+-Ca2+ exchange currents, which were completely abolished by 5 mM NiCl. The L-type Ca2+ currents (I(Ca)) also were increased by 3-30 microM berberine, but the threshold potential, the potential at which I(Ca) was maximal, and the apparent reversal potential remained unchanged. Berberine at either 3 or 30 microM did not affect the inward rectifier K+ currents. This study suggests that the prolongation of cardiac repolarization by berberine is mainly caused by the inhibition of I(Ks) and increase of I(Ca).

Antiarrhythmic and Arrhythmogenic Actions of Varying Levels of Extracellular Magnesium: Possible Cellular Basis for the Differences in the Efficacy of magnesium and Lidocaine in Torsade de Pointes

BACKGROUND: In recent years, there has been an increasing use of antiarrhythmic drugs that act predominantly by prolonging myocardial repolarization. An inevitable electrophysiologic consequence of these drugs is the development of torsade de pointes as a proarrhythmic reaction. Both intravenous lidocaine and magnesium sulphate have been used in the acute control of such a proarrhythmia. Their electrophysiologic mechanisms in this setting are not well defined. METHODS AND RESULTS: Using the standard microelectrode techniques, the effects of magnesium (Mg) and lidocaine on action potential duration (APD), and on barium-induced spontaneous action potentials, were studied in canine Purkinje fiber preparations. The objective was to clarify the direct and indirect effects of magnesium on triggered activities due to early afterdepolarizations. Superfusion in media with 0.1 mM Mg and 2.5 mM K produced more pronounced increases in APD measured at -20mV repolarization time [APD(20)] than those in a solution with 5 mM K. This effect was further enhanced at lower stimulation frequencies. The striking prolongation of APD(20) by solutions with low potassium concentrations diminished as the Mg concentration was increased. In solutions with 2.5 mM K, Mg produced concentration-dependent decreases in APD(20). This effect was greater at lower stimulation frequencies. Lidocaine at 4.0 x 10(_5) M produced a marked shortening of the APD in the entire firing frequency of the abnormal automaticity in a concentration-dependent manner. With 10 mM Mg, such action potentials appeared only sporadically. Magnesium also decreased the amplitude and the maximum upstroke velocity of these action potentials. In contrast, lidocaine at 4.0 x 10(-5) M exhibited no significant effects on action potentials due to barium-induced abnormal automaticity, or on additional depolarizations developing from the repolarization phase of these action potentials. CONCLUSIONS: The data indicate that (i) hypomagnesemia may be arrhythmogenic when combined with hypokalemia and bradycardia leading to a prolongation of the plateau phase of the action potential, (ii) magnesium administration may suppress triggered activities mainly by a direct inhibition of the development of triggered potentials, and (iii) lidocaine may suppress triggered potentials only indirectly by preventing the development of early afterdepolarizations due to the shortening effect on the APD. These findings are consistent with the clinical observation of a high incidence of torsade de pointes in the setting of hypokalemia and hypomagnesemia introduced by a chronic diuretic therapy. They are also consistent with the marked effectiveness of intravenous Mg relative to the inconsistent clinical effects of lidocaine in controlling torsade de pointes.

Effects of lidocaine, ajmaline, and diltiazem on ventricular defibrillation energy requirements in isolated rabbit heart

The majority of patients with implanted cardioverter defibrillators (ICD) require antiarrhythmic (AR) drugs. ARs may increase defibrillation energy requirements. This study investigated the effects of lidocaine, ajmaline, and diltiazem on ventricular defibrillation energy needs. In 24 isolated rabbit hearts, the 50 and 80% successful defibrillation energy (ED50, ED80) was calculated in four phases: predrug baseline condition (phase 1), and phases 2, 3, and 4 with increasing concentrations of lidocaine, ajmaline, diltiazem (n = 18). Control experiments (n = 6) with only Tyrode's solution infusion indicated that the preparation was stable over time. Defibrillation energy requirements significantly (p < 0.05) increased with all ARs. Low, medium, and high lidocaine concentrations increased ED50 and ED80 to 146, 223, and 312% and 139, 207, and 285%, respectively. Ajmaline increased ED50 and ED80 to 133, 175, and 251% and 135, 208, and 285%, respectively. Diltiazem increased ED50 and ED80 by 175, 236, and 334% and 158, 212, and 286%, respectively. The results of this study demonstrate a dose-dependent increase in defibrillation energy requirements by using lidocaine, diltiazem, and ajmaline. In patients with ICDs, administration of these drugs might cause a critical increase in defibrillation energy requirements, resulting in device failure.

The effects of lidocaine on cardiac parasympathetic control in normal subjects and in subjects after myocardial infarction

It has been widely accepted that lidocaine has little or no effect on the autonomic nervous system. However, we have previously shown that in dogs with vagally induced atrial fibrillation, lidocaine has a pronounced parasympatholytic effect. To study the possible effect of lidocaine on autonomic cardiac control in humans, we performed spectral analysis of heart rate fluctuations in 19 healthy volunteers, who received an i.v. bolus of lidocaine (1.4 mg/kg), as well as in 13 patients suffering from acute inferior myocardial infarction (IMI) and 13 patients suffering from acute anterior myocardial infarction (AMI), who received therapeutic doses of i.v. lidocaine infusion (4 mg/min). Heart rate variability and respiratory pattern were monitored according to a predetermined protocol, with and without lidocaine. Computing the heart rate power spectrum and integrating over predetermined frequency bands, we focused mainly on the respiratory frequency band, known to predominantly reflect parasympathetic control. The administration of lidocaine resulted in a significant overall increase in mean heart rate: for the healthy control group an increase of 5.5 +/- 2.2% (mean +/- SE), for the IMI group an increase of 9.4 +/- 3.5%, and for the AMI group an increase of 8.1 +/- 2.9% (p < 0.01 for all). Simultaneously, following the administration of lidocaine, there was a decrease in the power of respiratory fluctuations: for the healthy control group a decrease of 38.4 +/- 12.5%, for the IMI group a decrease of 46.3 +/- 32.9%, and for the AMI group a decrease of 33.9 +/- 16.2% (p < 0.01 for all). These findings indicate that lidocaine has a consistent and significant parasympatholytic effect on the human heart, in healthy volunteers as well as in patients in the acute phase of myocardial infarction.

Electrophysiological mechanisms for antiarrhythmic efficacy and positive inotropy of liriodenine, a natural aporphine alkaloid from Fissistigma glaucescens

1. The antiarrhythmic potential and electromechanical effects of liriodenine, an aporphine alkaloid isolated from the plant, Fissistigma glaucescens, were examined. 2. In the Langendorff perfused (with constant pressure) rat heart, at a concentration of 0.3 to 3 microM, liriodenine was able to convert a polymorphic ventricular tachyrhythmia induced by the ischaemia-reperfusion (EC50 = 0.3 microM). 3. In isolated atrial and ventricular muscle, liriodenine increased the contractile force and slowed the spontaneous beating of the right atrium. 4. The liriodenine-induced positive inotropy was markedly attenuated by a transient outward K+ channel blocker, 4-aminopyridine (4-AP) but was not significantly affected by prazosin, propranolol, verapamil or carbachol. 5. In rat isolated ventricular myocytes, liriodenine prolonged action potential duration and decreased the maximal upstroke velocity of phase 0 depolarization (Vmax) and resting membrane potential in a concentration-dependent manner. The action potential amplitude was not significantly changed. 6. Whole-cell voltage clamp study revealed that liriodenine blocked the Na+ channel (INa) concentration-dependently (IC50 = 0.7 microM) and caused a leftward shift of its steady-state inactivation curve. However, its recovery rate from the inactivated state was not affected. The L-type Ca2+ currents (Ica) were also decreased, but to a lesser degree (IC50 = 2.5 microM, maximal inhibition = 35%). 7. Liriodenine inhibited the 4-AP-sensitive transient outward current (Ito) (IC50 = 2.8 microM) and moderately accelerated its rate of decay. The block of Ito was not associated with changes in the voltage-dependence of the steady-state inactivation curve or in the process of recovery from inactivation of the current. Liriodenine also reduced the amplitude of a slowly inactivating, steady-state outward current (Iss) (IC50 = 1.9 microM). These effects were consistent with its prolonging effect on action potential duration. The inwardly rectifying background K+ current (IK1), was also decreased but to a less degree. 8. Compared to quinidine, liriodenine exerted a stronger degree of block on INa, comparable degree of block on IK1, and lesser extent of block on ICa and Ito. 9. It is concluded that, through inhibition of Na+ and the Ito channel, liriodenine can suppress ventricular arrhythmias induced by myocardial ischaemia reperfusion. The positive inotropic effect can be explained by inhibition of the Ito channel and the subsequent prolongation of action potential duration. These results provide a satisfactory therapeutic potential for the treatment of cardiac arrhythmias.

Electrophysiological mechanisms for the antiarrhythmic action of (-)-caryachine in rat heart

(-)-Caryachine (CNMe) is a pavine derivative, isolated from Cryptocarya chinensis Hemsl. We wished to illustrate the electrophysiological effect and antiarrhythmic potential of this compound on rat cardiac tissues. Action potential and ionic currents in single ventricular cells were examined by current clamp or voltage clamp in a whole-cell configuration. CNMe concentration-dependently suppressed the maximum rate of rise of the action potential upstroke (V(max)) and prolonged the action potential duration at 50% of repolarization (APD(50)). A voltage-clamp study showed that the suppression of V(max) by CNMe was associated with an inhibition of sodium inward current (I(Na), IC(50), O = 4.1 microM). The prolongation of APD(50) was associated with an inhibition of transient outward current (I(to), IC(50) = 16.1 microM). CNMe reduced the I(Na) with a negative shift of its voltage-dependent steady-state inactivation curves and slowing of its recovery from inactivation. The use-dependent inhibition of I(Na) by CNMe was enhanced at a higher stimulation rate or at a longer prepulse duration. The fraction of fast recovery of I(Na) was reduced, but the recovery time constant of fast recovery component remained unaffected. The inhibition of I(to) by CNMe (10-30 microM) was associated with an acceleration of its time constant of inactivation. According to the analysis of the time course of inhibition of I(to), CNMe inhibited I(to) in a time-dependent manner. In isolated heart, CNMe could effectively inhibit ischemia/reperfusion-induced ventricular tachycardia with an EC(50) of 3.9 microM. The results indicate that CNMe is a strong I(Na) blocker with some I(to) blocking activity. The inhibition of I(Na), and I(to) may contribute to its antiarrhythmic activity against ischemia/reperfusion arrhythmia.

Antiarrhythmic effects of optical isomers of disopyramide on canine ventricular arrhythmias

Disopyramide is an effective class I antiarrhythmic drug and widely used for the treatment of arrhythmias, but it has anticholinergic side effects. In vitro studies demonstrated that dextrorotatory (D-) disopyramide has a stronger anticholinergic action, whereas the levorotatory (L-) isomer has a stronger Na channel blocking action. Because the antiarrhythmic mechanism of disopyramide suppressing digitalis- and two-stage coronary ligation-induced canine ventricular arrhythmias is the drug-induced Na channel block, we examined the antiarrhythmic efficacy of D- and L-disopyramide on two arrhythmia models. On ouabain-induced ventricular tachycardia (VT), L-disopyramide 3 mg/kg decreased the arrhythmic ratio (number of ectopic beats/total heart rate), whereas the same dose of the D-isomer was ineffective and a higher dose (5 mg/kg) was needed to suppress the arrhythmia. The effective plasma concentrations (IC50) decreasing the arrhythmic ratio to 50% of the control were 5.3 and 11.3 mu g/ml for L- and D-disopyramide, respectively. We obtained similar results using 24-h two-stage coronary ligation VT. The IC50 were 8.9 and 22.2 mu g/ml for the L- and D-isomers, respectively. Our results indicate that L-disopyramide is about twice as strong an antiarrhythmic drug as the D-isomer.

Electrophysiological basis for antiarrhythmic efficacy, positive inotropy and low proarrhythmic potential of (-)-caryachine

1. (-)-Caryachine, isolated from the plant (Cryptocarya chinensis), increased the contractility of atrial and right ventricular strips and significantly suppressed the reperfusion arrhythmias in adult rabbit heart (ED50 = 1.27 microM). 2. Data obtained by the whole-cell voltage clamp technique has shown that (-)-caryachine causes a negative shift of the steady-state Na channel inactivation and a slower rate of recovery from inactivation. The maximal Na current amplitude decreased to 67 +/- 7%, 29 +/- 8% and 12 +/- 5% after 0.5, 1.5 and 4.5 microM (-)-caryachine, respectively. 3. This agent also had effects on the time- and voltage-dependent K currents. (-)-Caryachine markedly suppressed the 4-AP-sensitive transient outward current (I10). However, it produced very little voltage-dependent shift in inactivation. After 0.5, 1.5 and 4.5 microM of the compound, the respective value of I10 elicited at +60 mV was 80 +/- 7%, 45 +/- 8% and 15 +/- 3%. At higher concentrations, the inward rectifier K current (IK1) was also inhibited but to a much smaller extent. Its slope conductance after 0.5, 1.5 and 4.5 microM (-)-caryachine was reduced to 71 +/- 9%, 51 +/- 12% and 42 +/- 11%, respectively. The outward hump of inward rectification was not changed. 4. In contrast, the L-type Ca current was not significantly changed by (-)-caryachine. 5. Electrophysiological studies in perfused whole heart preparations revealed that (-)-caryachine increased the intra-atrial conduction interval and also prolonged the atrial refractory period. No proarrhythmic effects were induced during the infusion of this compound (up to 13.5 microM). 6. We conclude that (-)-caryachine predominantly blocks the Na and I10 currents. These changes alter the electrophysiological properties of the heart and terminate the induced ventricular arrhythmias. The relatively selective I10 inhibition, safety margin of Ik1 suppression and lack of effect on Ica-L will provide an opportunity to develop an effective antiarrhythmic agent with positive inotropy as well as low proarrhythmic potential.

Effects of the two enantiomers, S-16257-2 and S-16260-2, of a new bradycardic agent on guinea-pig isolated cardiac preparations

1. The electromechanical effects of two enantiomers, S-16257-2 (S57) and S-16260-2 (R60), were studied and compared in guinea-pig isolated atria and ventricular papillary muscles. The possible stereoselectivity of the interaction on the cardiac Na+ channel was analysed by comparing the effects of the two enantiomers on the onset and recovery kinetics of the frequency-dependent Vmax block. 2. In spontaneously beating right atria, S57 and R60 (10(-8)M-10(-4M) exerted a negative chronotropic effect (pIC50 = 5.07 +/- 0.19 and 4.76 +/- 0.18, respectively) and prolonged the sinus node recovery time, this effect being more marked with S57. In electrically driven left atria, S57 decreased (P < 0.05) contractile force only at 10(-4M) and R60 at concentrations > or = 5 x 10(-5M), whereas in papillary muscles the negative inotropic effect appeared at concentrations > 10(-5M). 3. In papillary muscles driven at 1 Hz, S57 and R60 at concentrations higher than 5 x 10(-6M) produced a concentration-dependent decrease in the maximum upstroke velocity (Vmax) and amplitude of the cardiac action potential without altering the resting membrane potential or the action potential duration. S57 and R60 had no effect on the characteristics of the slow action potentials elicited by isoprenaline in ventricular muscle fibres depolarized in high K+ (27 mM) solution. 4. At 5 x 10(-5M), S57 and R60 produced a small tonic Vmax block. However, in muscles driven at rates between 0.5 and 3 Hz both enantiomers produced an exponential decline in Vmax (frequency-dependent Vmax block) which augmented at higher rates of stimulation. The onset and offset rates of the frequency-dependent Vmax block were similar for both drugs. Both S57 and R60 prolonged the recovery time constant from the frequency-dependent block from 20.1 +/- 2.9 ms to 2-3 s.5. At 5 x 10-5 M, S57 and R60 shifted the membrane responsiveness curve in a hyperpolarizing direction.6. It can be concluded that S57 and R60, the two enantiomers of the new bradycardic agent, produced a similar frequency-dependent Vmax block which indicated that the interaction with the Na+ channel was not stereospecific. The analysis of the onset and offset kinetics of the frequency-dependent Vmax block suggested that both enantiomers can be considered as Na+ channel blockers with intermediate kinetics,e.g., class IA antiarrhythmic drugs.

Electrophysiologic mechanisms of the long QT interval syndromes and torsade de pointes

PURPOSE

To review the current understanding of the mechanisms and treatment of the long QT interval syndromes and torsade de pointes.

DATA SOURCES

Personal databases of the authors and a search of the MEDLINE database from 1966 to 1994.

STUDY SELECTION

Experimental and clinical studies and topical reviews on the electrophysiologic mechanisms and treatment of torsade de pointes were analyzed.

RESULTS

The long QT interval syndromes have been classified into acquired and hereditary forms, both of which are associated with a characteristic type of life-threatening polymorphic ventricular tachycardia called torsade de pointes. The acquired form is caused by various agents and conditions that reduce the magnitude of outward repolarizing K+ currents, enhance inward depolarizing Na+ or Ca2+ currents, or both, thereby triggering the development of early afterdepolarizations that initiate the tachyarrhythmia. The hereditary form appears to result from an abnormal response to adrenergic or sympathetic nervous system stimulation. At least some cases of the hereditary long QT interval syndromes may result from a single gene defect that alters the intracellular regulatory proteins responsible for the modulation of K+ channel function. Treatment of the acquired form is primarily directed at identifying and withdrawing the offending agent, although emergent therapy using maneuvers and agents that favorably modulate transmembrane ion currents can be lifesaving. In torsade de pointes associated with the hereditary long QT interval syndromes, early diagnosis leading to treatments designed to both shorten the QT interval and block the beta-adrenergic-induced instability of the QT interval is essential.

CONCLUSIONS

The long QT interval syndromes and torsade de pointes are potentially life-threatening conditions caused by various agents, conditions, and genetic defects. The mechanisms responsible for these conditions and available treatment options for them are reviewed.

Utilization of an isolated, blood-perfused canine papillary muscle preparation as a model to assess efficacy and adversity of class I antiarrhythmic drugs

To develop a model to predict the efficacy and adversity of class I antiarrhythmic drugs, intraventricular conduction time (IVCT), coronary blood flow (CBF), developed tension of papillary muscle (DT) and idioventricular automaticity rate (VR) were measured following drug administration in an isolated canine papillary muscle preparation cross-circulated with the heparinized blood of a donor dog. Tetrodotoxin, the prototypic fast Na+ channel blocker, and class I drugs increased IVCT and CBF, but decreased DT and VR, in a dose-dependent manner. The profiles of known class I drugs, procainamide, disopyramide, lidocaine, mexiletine and flecainide were similar, but the potencies of each drug were different. Two new class I drugs, ME3202 and AN-132, were also tested and found to have effects that were similar to that of tetrodotoxin. There was a good correlation between the doses of drugs prolonging IVCT by 50% and the canine antiarrhythmic plasma concentrations in our previous study. This model can also be used to estimate the use-dependency and the kinetics of use-dependent sodium channel block; however, it is not suitable for extensive investigation of cellular and molecular mechanisms. Thus, the use of this model facilitates the comparison of multiple cardiac effects of class I drugs and may be an effective way to better assess new antiarrhythmic drugs.

The electrophysiological effects of antiarrhythmic potential of a secoaporphine, N-allylsecoboldine

1. A satisfactory antiarrhythmic potential of N-allylsecoboldine, a synthetic derivative of secoaporphine, has been documented. Its effects on the ionic currents of cardiac myocytes and the influence on the electrophysiological properties of the conduction system in Langendorff perfused hearts were investigated. 2. Ionic currents were studied by voltage clamp in the whole cell configuration. N-allylsecoboldine blocked the Na channel with a leftward-shift of its half voltage-dependent inactivation and a slower rate of recovery from the inactivation state. Similarly, calcium inward currents were inhibited but to a much smaller extent. 3. N-allylsecoboldine inhibited the 4-AP-sensitive transient outward K current. Currents through the K1 channels were also reduced. 4. As compared with quinidine, N-allylsecoboldine caused a comparable degree of block on Na and K1 currents but blocked to a lesser extent the Ca and Ito currents. 5. In the perfused whole-heart model, N-allylsecoboldine caused a dose-dependent prolongation in sinoatrial, atrioventricular and His-Purkinje system conduction intervals and prolonged the effective refractory periods of the atrium, AV node, His-Purkinje system and ventricle. However, the basic cycle length was not significantly affected. As compared to quinidine, N-allylsecoboldine exerted less pronounced effects on both the basic cycle length and the atrial and AV nodal refractory periods. 6. We conclude that N-allylsecoboldine predominantly blocks Na and K1 channels and in similar concentrations partly blocks Ca channels and Ito. These effects result in a modification of the electrophysiological properties of the conduction system which provides a satisfactory therapeutic potential for the treatment of cardiac arrhythmias.

The electrophysiological effects of dicentrine on the conduction system of rabbit heart

1. The electrophysiological effects of dicentrine, an aporphine alkaloid isolated from the root of Lindera megaphylla, were examined in the Langendorff perfused rabbit heart and rabbit isolated cardiac cells. 2. Standard electrophysiological characters were measured in the Langendorff perfused rabbit heart (control study) and after 5 min exposure to 1, 3 and 9 microM of dicentrine and during the subsequent recovery phase sequentially (n = 7). The same study protocols were performed in 0.5 to 4.5 microM quinidine (n = 7), 18 to 162 microM procainamide and N-acetylprocainamide (n = 7) for comparison. 3. The results showed that the spontaneously beating heart rate and the sinoatrial (SA) and atrioventricular nodal (AH) conduction time were not significantly affected by dicentrine but were significantly suppressed by the higher doses of quinidine (4.5 microM) and procainamide (162 microM). 4. The His-Purkinje conduction time was significantly increased by the higher dose of dicentrine, quinidine and procainamide. 5. The ventricular repolarization time and its effective refractory period were significantly increased by the higher dose of dicentrine and the other agents. 6. The effective refractory period of the atrium, AV node and His-Purkinje system were also significantly increased by dicentrine and the other agents. 7. A voltage clamp study revealed that the prolongation of atrial action potential duration by dicentrine (9 microM) was associated with a significant inhibition of the transient potassium outward current. As well as inhibition of the transient outward current, a significant inhibition of the sodium inward current by dicentrine was found. 8.We conclude that (1) dicentrine is potentially a useful antiarrhythmic agent with type Ia and type III antiarrhythmic action; (2) the relative potency of dicentrine on the electrophysiological function of cardiac tissue is 10-20 times more than that of procainamide.

Regulation of the action potential configuration by taurine in guinea-pig ventricular muscles

1. Effects of taurine on the action potentials in guinea-pig ventricular muscle were examined at different extracellular Ca2+ concentrations ([Ca]o). Experiments were exerted by conventional microelectrode technique at 36 degrees C. 2. At normal Tyrode solution ([Ca]o = 1.8 mM), taurine (10 and 20 mM) had little or no effect on the 50%, 75% and 90% repolarizations of action potential duration (APD). 3. When [Ca]o was 3.6-10.8 mM [Ca]o, the APD shortening was produced [Ca]o-dependently, which was potentiated by addition of taurine. 4. To the contrary, at low [Ca]o (0.9 mM), the APD was prolonged. Taurine (10 and 20 mM) potentiated to prolong the APD. 5. The amplitude of action potential was depressed by taurine. The resting potential was unaffected. The responses to taurine were almost reversible. 6. Under the calcium overload condition ([Ca]o = 10.8 mM) in which a delayed afterdepolarization and spontaneous action potentials occurred, taurine (10 mM) abolished them completely. 7. These results indicate that taurine causes a dual action on the APD dependent on [Ca]o, and simultaneously reduces the cellular Ca2+ level in calcium overloading muscles.

Dual actions of procainamide on batrachotoxin-activated sodium channels: open channel block and prevention of inactivation

We have investigated the action of procainamide on batrachotoxin (BTX)-activated sodium channels from bovine heart and rat skeletal muscle. When applied to the intracellular side, procainamide induced rapid, open-channel block. We estimated rate constants using amplitude distribution analysis (Yellen, G. 1984. J. Gen. Physiol. 84:157). Membrane depolarization increased the blocking rate and slowed unblock. The rate constants were similar in both magnitude and voltage dependence for cardiac and skeletal muscle channels. Qualitatively, this block resembled the fast open-channel block by lidocaine (Zamponi, G. W., D. D. Doyle, and R. J. French. 1993. Biophys. J. 65:80), but procainamide was about sevenfold less potent. Molecular modeling suggests that the difference in potency between procainamide and lidocaine might arise from the relative orientation of their aromatic rings, or from differences in the structure of the aryl-amine link. For the cardiac channels, procainamide reduced the frequency of transitions to a long-lived closed state which shows features characteristic of inactivation (Zamponi, G. W., D. D. Doyle, and R. J. French. 1993. Biophys J. 65:91). Mean durations of kinetically identified closed states were not affected. The degree of fast block and of inhibition of the slow closures were correlated. Internally applied QX-314, a lidocaine derivative and also a fast blocker, produced a similar effect. Thus, drug binding to the fast blocking site appears to inhibit inactivation in BTX-activated cardiac channels.

Evidence for a reexcitability gap in man after treatment with type I antiarrhythmic drugs

The intention of this study was to determine whether type IA antiarrhythmic drugs cause a disparity between refractoriness and repolarization, and if so, its magnitude. We simultaneously measured monophasic action potential duration (MAPD) and effective refractory period (ERP) at a right ventricular site in 11 patients without overt right ventricular disease. The pacing protocol, which included sinus rhythm and a 600 and 400 msec cycle length of ventricular drive, was performed at baseline and after the intravenous administration of 15 mg/kg of procainamide in nine patients, and of 10 mg/kg of quinidine in two patients. Despite trivial changes in sinus rates, drug therapy caused a 10% to 17% increase in MAPD and ERP that shortened with decreasing drive cycle lengths. At baseline there was a small gap (10 to 13 msec) between MAPD and ERP in sinus rhythm and with a 600 or 400 msec drive. However, the type IA drug caused a significant widening of this gap that was most profound in sinus rhythm (45 msec) and that shortened but was not abolished with a 600 and 400 msec drive (28 and 29 msec, respectively). The disparity was caused in one third of cases by postrepolarization refractoriness. Type I drugs increase the difference between repolarization and refractoriness, and this effect is partially reversed with increases in heart rate. The clinical implications of these findings are discussed.

Lidocaine cardioplegia for prevention of reperfusion ventricular fibrillation

Lidocaine addition to crystalloid cardioplegic solution for prevention of reperfusion ventricular fibrillation after the release of the aortic cross-clamp was studied in 50 patients undergoing coronary artery bypass grafting and in 30 patients undergoing mitral or aortic valve replacement. Twenty-six of the patients undergoing coronary artery bypass grafting received lidocaine, 100 mg/L of cardioplegia, whereas a control group of 24 patients received cardioplegia without lidocaine. In the group undergoing valve replacement, 14 patients received lidocaine cardioplegia and 16 patients served as control. In the coronary artery bypass grafting group, lidocaine cardioplegia reduced significantly the incidence of reperfusion ventricular fibrillation from 100% to 42%. In the valve group, lidocaine cardioplegia also reduced significantly the incidence of reperfusion ventricular fibrillation from 93% to 42%. In both groups, lidocaine cardioplegia decreased the number of direct-current countershocks required to defibrillate the heart, with no significant increase in the incidence of high-grade atrioventricular block.

Use-dependent block of Ca2+ current by moricizine in guinea-pig ventricular myocytes: a possible ionic mechanism of action potential shortening

1. Whole cell patch clamp techniques were used to study the effects of moricizine on membrane currents in guinea-pig ventricular myocytes. 2. Application of moricizine caused reversible depression of the time-dependent outward K+ current. 3. The Na+/Ca2+ exchange current was not directly affected by moricizine. 4. Although moricizine hardly affected the L-type Ca2+ current when cells were stimulated at a frequency of 0.1 Hz, it suppressed the current at depolarized holding potentials in a use-dependent manner at 1 Hz. 5. Developments of use-dependent block of the Ca2+ current in the presence of moricizine were best expressed by two exponentials. Binding to both activated and inactivated states of the Ca2+ channel were supported from the binding kinetics study. 6. We concluded that moricizine suppressed the L-type Ca2+ current in a use-dependent manner and this might explain, at least in part, action potential shortening by the drug.

Differential effects of quinidine and flecainide on plateau duration of human atrial action potential

Quinidine and flecainide, two class-I antiarrhythmics increase action potential duration (APD) at 90% repolarization and cellular refractory period in human atrial fibers without significant change in resting potential. On the other hand, quinidine decreases APD at 50%, whereas flecainide slightly increases, which suggests different effects on Ca2+ current. Using isolation cell procedure and whole cell recording, we found that 10 microM quinidine (34.77 +/- 6.5%, n = 5) and 0.5 microM flecainide (50.46 +/- 6.2%, n = 4) decrease calcium current in human atrium. It is concluded that, at therapeutical concentrations, quinidine and flecainide modify the action potential plateau phase in a different manner, which is not only related to the calcium current decrease.

Comparative mechanical and electrical actions of A23187 and X-537A in canine Purkinje fibers

1. At concentrations lower than 10(-5) M, A23187 did not affect the contractile force in canine Purkinje fibers, but at 2 x 10(-5) M, decreased it significantly. 2. X-537A (10(-6) M) slightly increased the contractile force. The increase was not modified by 10(-7) M pindolol. 3. At 20 min after application both ionophores (2 x 10(-5) M) affected little or no changes in the action potential configurations, except for a marked shortening of the action potential duration. A delayed afterdepolarization and an aftercontraction occurred. 4. The electrophysiological effects were potentiated with an increase in extracellular Ca2+ and further by isoproterenol (1-3 x 10(-7) M). 5. A post-rest potentiation was depressed in the presence of these Ca2+ ionophores. 6. When the stimulation frequency was stepped up from 120 to 180 beats/min, the negative staircase of the contractile force was reversed to positive one in the presence of A23187, high Ca2+ and isoproterenol. 7. These results indicate that in canine Purkinje fibers, X-537A produces cellular Ca2+ overload, but A23187 alone does not cause it. Mechanical and electrophysiological effects induced by these ionophores are potentiated by addition of high Ca2+ and isoproterenol.

Modelling of frequency-dependent effects of lignocaine homologues on the maximum upstroke velocity of action potentials in guinea-pig papillary muscles

1. The effects of 14 lignocaine homologues on the maximum upstroke velocity (Vmax) of the action potentials (AP) were studied in guinea-pig papillary muscles. These drugs possess one, two or three methyl groups in different positions: an ortho-chloro, -carbomethoxy or -ethyl group instead of an ortho-methyl group; or an N-butyl group instead of an N-diethyl group in lignocaine molecules. 2. At 50-100 mumol/L, six drugs possessing two ortho substituents (but not the other eight) reduced Vmax more prominently at 2-4 Hz than at 1 Hz, and slowed the time courses of recovery of the premature responses. None of the drugs affected resting potential. 3. Besides the two-state piecewise exponential model (models I and II) frequently used, a time-dependent and time-independent, two-state model (model III) was formulated and applied to these experimental data. The above two groups were effectively distinguished by the difference of the estimated association and dissociation rate constants (model II) and equilibrium constants for phasic state (model III) and for resting (model II) or tonic (model III) states. 4. The equilibrium constants for resting or tonic state correlated well with log P (where P = the n-octanol: water partition coefficients), but correlated better with an indicator variable that denotes the existence of two ortho substituents, suggesting the importance of the contribution of steric factors to the activity.