Cardiac Repolarization Process Research Articles

Sex hormonal regulation of cardiac ion channels in drug-induced QT syndromes.

Female sex is an independent risk factor for development of torsade de pointes (TdP) arrhythmias not only in congenital long QT syndromes but also in acquired long QT syndromes. Clinical and experimental evidences suggest that the gender differences may be due to, at least in part, gender differences in regulation of rate-corrected QT (QTC) interval between men and women. In adult women, both QTC interval and arrhythmic risks in TdP alter cyclically during menstrual cycle, suggesting a critical role of female sex hormones in cardiac repolarization process. These gender differences in fundamental cardiac electrophysiology result from variable ion channel expression and diverse sex hormonal regulation via long term genomic and acute non-genomic actions, and sex differences in drug responses and metabolisms. In particular, non-genomic actions of testosterone and progesterone on cardiac ion channels are likely to contribute to the gender differences in cardiac repolarization processes. This review summarizes current knowledge on sex hormonal regulation of cardiac ion channels which contribute to cardiac repolarization processes and its implication for gender differences in drug-induced long QT syndromes.

Joint influence of transmural heterogeneities and wall deformation on cardiac bioelectrical activity: A simulation study

The aim of this work is to investigate, by means of numerical simulations, the influence of myocardial deformation due to muscle contraction and relaxation on the cardiac repolarization process in presence of transmural intrinsic action potential duration (APD) heterogeneities. The three-dimensional electromechanical model considered consists of the following four coupled components: the quasi-static transversely isotropic finite elasticity equations for the deformation of the cardiac tissue; the active tension model for the intracellular calcium dynamics and cross-bridge binding; the anisotropic Bidomain model for the electrical current flow through the deforming cardiac tissue; the membrane model of ventricular myocytes, including stretch-activated channels. The numerical simulations are based on our finite element parallel solver, which employs Multilevel Additive Schwarz preconditioners for the solution of the discretized Bidomain equations and Newton-Krylov methods for the solution of the discretized non-linear finite elasticity equations. Our findings show that: (i) the presence of intrinsic transmural cellular APD heterogeneities is not fully masked by electrotonic current flow or by the presence of the mechanical deformation; (ii) despite the presence of transmural APD heterogeneities, the recovery process follows the activation sequence and there is no significant transmural repolarization gradient; (iii) with or without transmural APD heterogeneities, epicardial electrograms always display the same wave shape and discordance between the polarity of QRS complex and T-wave; (iv) the main effects of the mechanical deformation are an increase of the dispersion of repolarization time and APD, when computed over the total cardiac domain and over the endo- and epicardial surfaces, while there is a slight decrease along the transmural direction.

The relationship between repolarization parameters and serum electrolyte levels in patients with J wave syndromes.

Intravenous administration of magnesium (Mg(2+)) is effective for polymorphic ventricular tachycardia via homogenization of transmural ventricular repolarization. Mg(2+) likely plays some role in the heterogeneity of repolarization in J wave syndromes. To investigate the relationship between the repolarization parameters and serum Mg(2+), potassium (K(+)), and calcium (Ca(2+)) levels in J wave syndromes. Thirteen J-wave syndrome patients (Brugada and early repolarization [ER] syndromes), with documented episodes of ventricular fibrillation (VF), and 13 ER pattern (ERP) or Brugada type ECG patients were enrolled (25 males, mean age 48 ± 15 years). The 12-lead ECG-derived parameters including the QT, QT dispersion (QTd), Tpeak-Tend (Tp-e) interval, Tp-e dispersion (Tp-ed), Tp-e/QT ratio, and activation recovery interval (ARI) dispersion were calculated; the correlations between these parameters and electrolytes including Mg(2+), K(+), and Ca(2+) were analyzed. Although there was no association between serum K(+) or Ca(2+) and QTd, there was a strong negative correlation between serum Mg(2+) and QTd in J wave syndrome patients with a history of VF (r = -0.715, p = 0.006). Also, there was a tendency for a negative correlation between Mg(2+) and Tp-ed or ARI dispersion in J wave syndrome patients with a history of VF (r = -0.513, p = 0.072 and r = -0.53, p = 0.063, respectively). On the other hand, in 13 patients with a Brugada type ECG or ERP, no correlation was observed between serum Mg(2+) and the QTd, Tp-ed or ARI dispersion. Serum Mg(2+) may play an important role in the cardiac repolarization process in J wave syndromes.

A Novel Approach for Evaluation of Drug-Induced QT Prolongation using Human Induced Pluripotent Stem Cell-Derived Cardiomyocytes

Drug-induced cardiac arrhythmias characterized by QT prolongation have been a major reason for drug withdrawal at late stage of clinical trials. Species difference is a cause of insufficient predictability of current drug safety models. Therefore, human induced pluripotent stem cell-derived cardiomyocytes (hiPS-CMs) have great promise for application of cardiac drug safety testing as a human cardiac model. Our perforated patch-clamp recordings from hiPS-CMs revealed that the cells exhibited diverse shapes of spontaneous action potentials (APs) with relatively small upstroke velocity (∼10V/s) and depolarized maximum diastolic potential (MDP; >-50 mV), which represents rather immature forms of cardiac cells. Actually, a selective hERG blocker, E4031,depolarized significantly MDP and stopped spontaneous beatings on a monolayer of hiPS-CMs, which makes it difficult to evaluate the effects on AP durations.Thus, in order to improve evaluation of risks for drug-induced QT prolongation in hiPS-CMs, we generated ventricular-like hiPS-CMs by over-expressing protein-X into hiPS-CMs and characterized the utility for evaluation of drug effects on cardiac repolarization process. The protein-X over-expression made hiPS-CMs quiescent with hyperpolarized MDP (−67 mV), and were excitable with rapid upstroke velocity (∼95 V/s) by electrical field stimulation. When E4031 was applied to hiPS-CMs overexpressing protein-X, both AP durations of single myocytes and extracellular field potential durations of cardiac sheets were prolonged in a dose dependent manner. These results suggest that hiPS-CMs engineered with gene X would be a novel approach for evaluation of drug-induced alternation of repolarization processes in the human cardiomyocytes.

KvLQT1 and KCNE1 K+ Channel Gene Polymorphisms in Long QT Syndrome

Long QT Syndrome (LQTS), a disorder of the cardiac repolarization process with prolongation of the QT interval (QTc e0.46 seconds), is an ion -channelopathy. Mutations

Non-genomic Action of Sex Steroid Hormones and Cardiac Repolarization

Gender differences play a major role in the manifestation of cardiovascular disease including cardiac arrhythmias. In particular, female sex is an independent risk factor for development of torsade de pointes (TdP) arrhythmias not only in congenital long QT syndromes but also in acquired long QT syndromes which occur as adverse effects of existing drugs. Recent clinical and experimental studies suggest that the gender differences may stem, at least in part, from gender differences in cardiac repolarization process, that is longer rate-corrected QT (QT(C)) interval in women than in men. In women, QT(C) interval and arrhythmic risks in TdP alter cyclically during menstrual cycle, suggesting a critical role of female sex hormones in cardiac repolarization process. These gender differences in fundamental cardiac electrophysiology result from variable ion channel expression and diverse sex hormonal regulation via long term genomic and acute non-genomic pathways, and sex differences in drug responses and metabolisms. In particular, non-genomic actions of testosterone and progesterone on cardiac ion channels likely to contribute to the gender differences in cardiac repolarization processes.

Drug-induced block of cardiac HERG potassium channels and development oftorsade de pointesarrhythmias: the case of antipsychotics

The prolongation of the cardiac repolarization process, a result of the blocking of the Human Ether-ago-go Related Gene potassium channel, is an undesired accessory property shared by many pharmacological classes of non-cardiovascular drugs. Often the delayed cardiac repolarization process can be identified by a prolongation of the QT interval of the electrocardiograph. In these conditions, premature action potentials can trigger a dangerous polymorphic ventricular tachyarrhythmia, known as torsade de pointes, which occasionally can result in lethal ventricular fibrillation. In this work, brief descriptions of the electrophysiological basis of torsade de pointes and of the several pharmacological classes of torsadogenic drugs are given. Attention is focused on antipsychotics, with a deeper overview on the experimental and clinical reports about their torsadogenic properties.

MinK: a double-hearted partner in cardiac repolarization

Tight control of the cardiac repolarization process is essential to ensure adequate action potential duration. When cardiac repolarization is disturbed—e.g. by ion-channel mutations, drugs, or disease-related defects—rhythm disturbances may ensue. Thus, a delay in repolarization, apparent in the ECG as a long QT interval, may induce early afterdepolarizations that give rise to Torsades de Pointes and can lead to life-threatening arrhythmias.1 On the other hand, a premature repolarization, resulting in a short QT interval, has also been associated with a high rate of sudden cardiac death.2 Two important players in controlling repolarization and duration of the cardiac action potential are the delayed rectifying outward potassium currents, the fast activating I Kr and the slowly activating I Ks. In most species, repolarization seems to be dominated by activation of I Kr, since I Ks normally activates slowly and with a delay such that its magnitude is minute at the end of the action potential. Hence, I Ks is supposed to act as a safety net for repolarization,3 coming into play when repolarizing currents like I Kr fail. I Ks, therefore, acts as a repolarization reserve.4 In the control of the repolarization process, different time scales can … *Corresponding author. Tel: +3120-5664644. E-mail address: a.c.vanginneken{at}amc.uva.nl

Famotidine neither affects action potential parameters nor inhibits human ether-a-go-go-related gene (hERG) K<sup>+</sup> current

The direct effects of famotidine, a selective histamine H(2) receptor antagonist, on the cardiac repolarization process were assessed using two in vitro test systems. Neither famotidine (0.1 and 1 microM), nor its solvent, dimethylsulfoxide (0.1%), affected any of the action potential parameters of guinea-pig papillary muscles, whereas the positive control, dl-sotalol (30 microM), significantly prolonged the action potential duration. Moreover, neither famotidine (0.1, 1 and 10 microM) nor dimethylsulfoxide affected the human ether-a-go-go-related gene (hERG) K(+) current expressed in Chinese hamster ovary-K1 cells, whereas the positive control, E-4031 (0.1 microM), significantly decreased the current. These results indicate famotidine does not directly affect the cardiac repolarization process.

Effects of Acute Intravenous Administration of Pentamidine, a Typical hERG-Trafficking Inhibitor, on the Cardiac Repolarization Process of Halothane-Anesthetized Dogs

Although acute treatment of pentamidine does not directly modify any ionic channel function in the heart at clinically relevant concentrations, its continuous exposure can prolong QT interval. Recent in vitro studies have indicated that hERG trafficking inhibition may play an important role in the onset of pentamidine-induced long QT syndrome. In this study, we examined acute in vivo electropharmacological effects of pentamidine using the halothane-anesthetized canine model (n = 5). The clinically relevant total dose of 4 mg/kg of pentamidine (namely, 1 mg/kg, i.v. over 10 min followed by 3 mg/kg, i.v. over 10 min with a pause of 20 min) decreased the mean blood pressure, ventricular contraction, preload to the left ventricle, and peripheral vascular resistance. Pentamidine also enhanced the atrioventricular conduction in parallel with its cardiohemodynamic actions, but it gradually prolonged both the ventricular repolarization period and effective refractory period, whereas no significant change was detected in the intraventricular conduction. Thus, acute administration of a clinically relevant dose of pentamidine can suppress cardiac function and vascular tone with reflex-mediated increase of sympathetic activity, whereas it may delay the repolarization process, suggesting that inhibition of potassium-channel trafficking might be induced more acutely in vivo than those previously expected in vitro.

Alterations of Autonomic Nervous Activity and Energy Metabolism by Capsaicin Ingestion during Aerobic Exercise in Healthy Men

We investigated whether capsaicin ingestion (150 mg) enhances substrate oxidation associated with thermogenic sympathetic activity as an energy metabolic modulator without causing prolongation of the cardiac OT interval during aerobic exercise in humans. Ten healthy males [24.4 (4.3) y] volunteered for this study. The cardiac autonomic nervous activities evaluated by means of heart rate variability of power spectral analysis, energy metabolism, and ECG QT interval were continuously measured during 5-min rest and 30-min exercise at 50% of maximal ventilatory threshold (50% VT(max)) on a stationary ergometer with placebo or capsaicin oral administration chosen at random. The results indicated that there were no significant differences in heart rate during rest or exercise between the two trials. Autonomic nervous activity increased in the capsaicin tablet trial during exercise, but the difference did not reach statistical significance. Capsaicin, however, significantly induced a lower respiratory gas exchange ratio [0.92 (0.02) vs. 0.94 (0.02), means (SE), p < 0.05] and higher fat oxidation [0.17 (0.04) vs. 0.12 (0.04) g/min, means (SE), p < 0.05] during exercise. On the other hand, the data on the cardiac OT interval showed no significant difference, indicating that oral administration of capsaicin did not cause any adverse effect on cardiac depolarization-repolarization. In conclusion, it may be considered that capsaicin consumption 1 h before low intensity exercise (50% VT(max)) is a valuable supplement for the treatment of individuals with hyperlipidemia and/or obesity because it improves lipolysis without any adverse effects on the cardiac depolarization and repolarization process.

Spectrum of pathogenic mutations and associated polymorphisms in a cohort of 44 unrelated patients with long QT syndrome

Long QT syndrome (LQTS) is a rare and clinically heterogeneous inherited disorder characterized by a long QT interval on the electrocardiogram, increased risk of syncope and sudden death caused by arrhythmias. This syndrome is mostly caused by mutations in genes encoding various cardiac ion channels. The clinical heterogeneity is usually attributed to variable penetrance. One of the reasons for this variability in expression could be the coexistence of common single nucleotide polymorphisms (SNPs) on LQTS-causing genes and/or unknown genes. Some synonymous and nonsynonymous exonic SNPs identified in LQTS-causing genes may have an effect on the cardiac repolarization process and modulate the clinical expression of a latent LQTS pathogenic mutation. We report the molecular pattern of 44 unrelated patients with LQTS using denaturing high-performance liquid chromatography analysis of the KCNQ1, KCNH2, SCN5A, KCNE1 and KCNE2 genes. Forty-five disease-causing mutations (including 24 novel ones) were identified in this cohort. Most of our patients (84%) showed complex molecular pattern with one mutation (and even two for four patients) associated with several SNPs located in several LQTS genes.

Famotidine does not induce long QT syndrome: experimental evidence from in vitro and in vivo test systems

The effects of famotidine on the cardiac repolarization process were assessed using four different levels of test systems described in the draft stage guideline ICH S7B. A supratherapeutic concentration of famotidine (10 −5 M), which is >8 times higher than C max obtained after its therapeutic dose, neither inhibited human ether-a-go-go-related gene (HERG) K + current expressed in human embryonic kidney 293 (HEK293) cells nor affected any of the action potential parameters of guinea pig papillary muscles. Therapeutic (0.3 mg/kg, i.v.) to supratherapeutic doses (3–10 mg/kg, i.v.) of famotidine did not affect the repolarization process of the halothane-anesthetized canine model, while only supratherapeutic doses exerted the positive chronotropic, inotropic and dromotropic effects without affecting the mean blood pressure. Moreover, supratherapeutic doses of famotidine (1–10 mg/kg, i.v.) neither induced torsades de pointes nor prolonged QT interval in the canine chronic atrioventricular conduction block model. These results suggest that famotidine possesses no cardiovascular effects at a therapeutic dose, while it may exert cardiostimulatory actions after drug overdoses that might potentiate the proarrhythmic potential of co-administered cardiotonic agents by increasing the intracellular Ca 2+ concentration.

Prolongation of QT interval in isolated feline hearts by antipsychotic drugs.

Some antipsychotic drugs have been found to prolong the QT interval on electrocardiographic (ECG) recordings, a phenomenon which, when severe, may facilitate the occurrence of complex ventricular arrhythmias such as torsade de pointes. However, the effects of these drugs on the cardiac repolarization process have not been evaluated extensively. This study was designed to examine the potency of five antipsychotic drugs in lengthening the QT interval of the perfused feline heart: haloperidol, risperidone, sertindole, clozapine, and olanzapine. The hearts were infused with increasing concentrations of drugs (0.1-20 micromol/L) for 40-minute intervals at each concentration. ECG recordings were made, with signals amplified and data recorded on a strip chart recorder. Four representative beats from each set of three signal recordings were chosen for QT interval measurement. Our data indicated that all tested drugs prolonged the QT interval in a concentration-dependent manner (p < 0.01). Haloperidol and risperidone were significantly more potent than sertindole, clozapine, and olanzapine (p < 0.001). At a concentration of 0.5 micromol/L over a 40-minute infusion interval, haloperidol lengthened the interval by 26.2+/-0.7%, risperidone by 19.4+/-2.2%, and sertindole by 8.9+/-3.5% (p < 0.05 compared with baseline); clozapine and olanzapine were less potent. Although species differences may limit extrapolation of our findings to humans, the cardiac potassium channels of felines clearly resemble those of humans. This model may serve as the basis for further studies of drug-induced prolongation of the QT interval and precipitation of ventricular arrhythmias.

Effect of Phosphamidon and Obidoxime on the QT‐RR Relationship of Isolated Rat Heart

We studied the effects of phosphamidon (an organophosphate compound), obidoxime (a cholinesterase reactivator), and their combination, phosphamidon/obidoxime (PD/OB) on cardiac cycle length (RR), QT interval, and on QT-RR relationship of isolated rat heart. Cardiac cycle length did not change significantly following perfusion with phosphamidon or obidoxime alone; however, following perfusion with PD/OB, RR significantly increased at high concentrations (10(-3) M) of both drugs. The QT interval lengthened by 5% following perfusion with phosphamidon, did not change following perfusion with obidoxime, and increased by 10% following perfusion with PD/OB. The QT-RR relationship without drugs was positive and linear. Following perfusion with phosphamidon alone, the slope of the relationship decreased significantly, while perfusion with obidoxime alone did not change the QT-RR relationship. Perfusion with PD/OB at low concentrations decreased the slope of the relationship; however, at the highest concentration (10(-3) M) the QT-RR relationship was inverted and became negative. Ventricular arrhythmias as premature ventricular beats, or bigeminies, were noted with increasing frequency following perfusion with increasing doses of phosphamidon. Perfusion with obidoxime did not cause arrhythmias, whereas perfusion with PD/OB caused premature ventricular beats, bigeminies, and ventricular tachycardias at high doses. We suggest that obidoxime modulates the direct effects of phosphamidon on the cardiac repolarization process. PD/OB at high concentrations invert the normal depolarization-repolarization coupling and may therefore potentiate arrhythmias.