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Olleik F, Kamareddine MH, Spears J, Tse G, Liu T, Yan GX. Mexiletine: Antiarrhythmic mechanisms, emerging clinical applications and mortality. Pacing Clin Electrophysiol 2023; 46:1348-1356. [PMID: 37846818 DOI: 10.1111/pace.14846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/19/2023] [Accepted: 10/07/2023] [Indexed: 10/18/2023]
Abstract
Mexiletine, a class Ib antiarrhythmic drug, exhibits its major antiarrhythmic effect via inhibition of the fast and late Na+ currents in myocardial tissues that are dependent on the opening of Na+ channels for their excitation. Through a comprehensive examination of mexiletine's therapeutic benefits and potential risks, we aim to provide valuable insights that reinforce its role as a vital therapeutic option for patients with ventricular arrhythmias, long QT syndrome, and other heart rhythm disorders. This review will highlight the current understandings of the antiarrhythmic effects and rationales for recent off-label use and address the mortality and proarrhythmic effects of mexiletine utilizing published basic and clinical studies over the past five decades.
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Affiliation(s)
- Farah Olleik
- Lankenau Medical Center and Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | | | - Jenna Spears
- Lankenau Medical Center and Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Gary Tse
- Tianjin Key Laboratory of Ion-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, PR China
- Kent and Medway Medical School, Canterbury, Kent, UK
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, PR China
| | - Tong Liu
- Tianjin Key Laboratory of Ion-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, PR China
| | - Gan-Xin Yan
- Lankenau Medical Center and Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
- Fuwai Huazhong Hospital, Chinese Academy of Medical Sciences, Zhengzhou, PR China
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Rahm AK, Hackbarth J, Müller ME, Pfeiffer J, Gampp H, Petersenn F, Rivinius R, Frey N, Lugenbiel P, Thomas D. Differential Effects of the Betablockers Carvedilol, Metoprolol and Bisoprolol on Cardiac K v4.3 (I to) Channel Isoforms. Int J Mol Sci 2023; 24:13842. [PMID: 37762145 PMCID: PMC10530285 DOI: 10.3390/ijms241813842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Cardiac Kv4.3 channels contribute to the transient outward K+ current, Ito, during early repolarization of the cardiac action potential. Two different isoforms of Kv4.3 are present in the human ventricle and exhibit differential remodeling in heart failure (HF). Cardioselective betablockers are a cornerstone of HF with reduced ejection fraction therapy as well as ventricular arrhythmia treatment. In this study we examined pharmacological effects of betablockers on both Kv4.3 isoforms to explore their potential for isoform-specific therapy. Kv4.3 isoforms were expressed in Xenopus laevis oocytes and incubated with the respective betablockers. Dose-dependency and biophysical characteristics were examined. HEK 293T-cells were transfected with the two Kv4.3 isoforms and analyzed with Western blots. Carvedilol (100 µM) blocked Kv4.3 L by 77 ± 2% and Kv4.3 S by 67 ± 6%, respectively. Metoprolol (100 µM) was less effective with inhibition of 37 ± 3% (Kv4.3 L) and 35 ± 4% (Kv4.3 S). Bisoprolol showed no inhibitory effect. Current reduction was not caused by changes in Kv4.3 protein expression. Carvedilol inhibited Kv4.3 channels at physiologically relevant concentrations, affecting both isoforms. Metoprolol showed a weaker blocking effect and bisoprolol did not exert an effect on Kv4.3. Blockade of repolarizing Kv4.3 channels by carvedilol and metoprolol extend their pharmacological mechanism of action, potentially contributing beneficial antiarrhythmic effects in normal and failing hearts.
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Affiliation(s)
- Ann-Kathrin Rahm
- Heidelberg Center for Heart Rhythm Disorders, Heidelberg University Hospital, 69120 Heidelberg, Germany (M.E.M.); (R.R.); (P.L.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Juline Hackbarth
- Heidelberg Center for Heart Rhythm Disorders, Heidelberg University Hospital, 69120 Heidelberg, Germany (M.E.M.); (R.R.); (P.L.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Mara E. Müller
- Heidelberg Center for Heart Rhythm Disorders, Heidelberg University Hospital, 69120 Heidelberg, Germany (M.E.M.); (R.R.); (P.L.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Julia Pfeiffer
- Heidelberg Center for Heart Rhythm Disorders, Heidelberg University Hospital, 69120 Heidelberg, Germany (M.E.M.); (R.R.); (P.L.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Heike Gampp
- Heidelberg Center for Heart Rhythm Disorders, Heidelberg University Hospital, 69120 Heidelberg, Germany (M.E.M.); (R.R.); (P.L.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Finn Petersenn
- Heidelberg Center for Heart Rhythm Disorders, Heidelberg University Hospital, 69120 Heidelberg, Germany (M.E.M.); (R.R.); (P.L.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Rasmus Rivinius
- Heidelberg Center for Heart Rhythm Disorders, Heidelberg University Hospital, 69120 Heidelberg, Germany (M.E.M.); (R.R.); (P.L.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Norbert Frey
- Heidelberg Center for Heart Rhythm Disorders, Heidelberg University Hospital, 69120 Heidelberg, Germany (M.E.M.); (R.R.); (P.L.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Patrick Lugenbiel
- Heidelberg Center for Heart Rhythm Disorders, Heidelberg University Hospital, 69120 Heidelberg, Germany (M.E.M.); (R.R.); (P.L.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Dierk Thomas
- Heidelberg Center for Heart Rhythm Disorders, Heidelberg University Hospital, 69120 Heidelberg, Germany (M.E.M.); (R.R.); (P.L.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
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Tian G, Sun Y, Liu S, Li C, Chen S, Qiu R, Zhang X, Li Y, Li M, Shang H. Therapeutic Effects of Wenxin Keli in Cardiovascular Diseases: An Experimental and Mechanism Overview. Front Pharmacol 2018; 9:1005. [PMID: 30233380 PMCID: PMC6134428 DOI: 10.3389/fphar.2018.01005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/16/2018] [Indexed: 02/05/2023] Open
Abstract
Cardiovascular diseases (CVDs) are the major public health problem and a leading cause of morbidity and mortality on a global basis. Wenxin Keli (WXKL), a formally classical Chinese patent medicine with obvious efficacy and favorable safety, plays a great role in the management of patients with CVDs. Accumulating evidence from various animal and cell studies has showed that WXKL could protect myocardium and anti-arrhythmia against CVDs. WXKL exhibited its cardioprotective roles by inhibiting inflammatory reaction, decreasing oxidative stress, regulating vasomotor disorders, lowering cell apoptosis, and protection against endothelial injure, myocardial ischemia, cardiac fibrosis, and cardiac hypertrophy. Besides, WXKL could effectively shorten the QRS and Q-T intervals, decrease the incidence of atrial/ventricular fibrillation and the number of ventricular tachycardia episodes, improve the severity of arrhythmias by regulating various ion channels with different potencies, mainly comprising peak sodium current (INa), late sodium current (INaL), transient outward potassium current (Ito), L-type calcium current (ICaL), and pacemaker current (If).
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Affiliation(s)
- Guihua Tian
- Chinese Cochrane Center, West China Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yang Sun
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Shuo Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chengyu Li
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Shiqi Chen
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Ruijin Qiu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoyu Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Youping Li
- Chinese Cochrane Center, West China Hospital, Sichuan University, Chengdu, China
| | - Min Li
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute of Integration of Traditional Chinese and Western Medicine, Guangzhou Medical University, Guangzhou, China
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Abstract
Visible T-wave alternans (TWA), a beat-to-beat alternation in the morphology and amplitude of the ST segment or T wave, has been observed for over a century to occur in association with life-threatening arrhythmias in patients with acute coronary syndrome, heart failure, and cardiac channelopathies. This compelling linkage prompted development of quantitative techniques leading to FDA-cleared commercial methodologies for measuring nonvisible levels of TWA in the frequency and time domains. The first aim of this review is to summarize evidence from more than a hundred studies enrolling a total of >12,000 patients that support the predictivity of TWA for cardiovascular mortality and sudden cardiac death. The second focus is on the usefulness of TWA in guiding therapy. Until recently, TWA has been used primarily in decision making for cardioverter-defibrillator implantation. Its potential utility in guiding pharmacologic therapy has been underappreciated. We review clinical literature supporting the usefulness of TWA as an index of antiarrhythmic effects and proarrhythmia for different drug classes. Beta-adrenergic and sodium channel-blocking agents are the most widely studied drugs in clinical TWA investigations, with both reducing TWA magnitude; the exception is patients in whom sodium channel blockade discloses the Brugada syndrome and provokes macroscopic TWA. An intriguing possibility is that TWA may help to detect beneficial effects of nonantiarrhythmic agents such as the angiotensin II receptor blocker valsartan, which indirectly protects from arrhythmia through improving myocardial remodeling. We conclude that quantitative analysis of TWA has considerable potential to guide pharmacologic intervention and thereby serve as a therapeutic target.
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Affiliation(s)
- Tuomo Nieminen
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Department of Pharmacological Sciences, Medical School, University of Tampere, Finland, and Department of Internal Medicine, Päijät‐Häme Central Hospital, Lahti, Finland
| | - Richard L. Verrier
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Coronel R, Wilms-Schopman FJG, Janse MJ. Anti- or profibrillatory effects of Na(+) channel blockade depend on the site of application relative to gradients in repolarization. Front Physiol 2010; 1:10. [PMID: 21423353 PMCID: PMC3059930 DOI: 10.3389/fphys.2010.00010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/06/2010] [Indexed: 11/16/2022] Open
Abstract
Sodium channel blockers are associated with arrhythmic sudden death, although they are considered antiarrhythmic agents. The mechanism of these opposing effects is unknown. We used a model of induction of ventricular fibrillation (VF) based on selective perfusion of the vascular beds of isolated porcine hearts (n = 8). One bed was perfused with sotalol (220 μM), the adjacent bed with pinacidil (80 μM), leading to repolarization heterogeneity (late repolarization in the sotalol-, early in the pinacidil-area). Premature stimulation from the area with the short action potential was performed. Epicardial activation/repolarization mapping was done. In three of the eight hearts VF was inducible prior to infusion of flecainide. In those hearts the Fibrillation Factor (FF), the interval between the earliest repolarization of the premature beat (S2) in the early repolarizing (pinacidil) domain, and the last S2-activation in the late repolarizing (sotalol) domain, was significantly shorter than in the hearts without VF (33 ± 22 vs 93 ± 11 ms, m ± SEM, p < 0.05). In the three hearts with VF flecainide was infused in the pinacidil domain after defibrillation. This led to shortening of the line of block, local delay of S2 activation and repolarization, an increase in FF and failure to induce VF. In the five hearts without VF, flecainide was subsequently infused in the sotalol domain. This led to a local delay of S2 activation, a shortening of FF (by 47 ± 3 ms) and successful induction of VF in three hearts. In the two remaining hearts FF did not decrease enough (maximally 13 ms) to allow re-entry. Sodium channel blockade applied to myocardium with a short refractory period is antifibrillatory whereas sodium channel blockade of myocardium with a long refractory period is profibrillatory. Our study provides a mechanistic basis for pro- and antiarrhythmic effects of sodium channel blockers in the absence of structural heart disease.
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Affiliation(s)
- Ruben Coronel
- Experimental Cardiology Group, Academic Medical Center Amsterdam, Netherlands.
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