Pharmacokinetic and Pharmacodynamic Comparison of Sildenafil-Bosentan and Sildenafil-Ambrisentan Combination Therapies for Pulmonary Hypertension.

To elucidate whether the pharmacokinetics (PK) and pharmacodynamics (PD) of sildenafil are influenced differently when it is coadministered with bosentan (S+B) or with ambrisentan (S+A), we evaluated the PK and PD profiles of sildenafil before and after 4-5 weeks of S+A or S+B treatment in patients with pulmonary arterial hypertension. The area under the plasma concentration-time curve of sildenafil was significantly higher in S+A treatment than in S+B treatment (165.8 ng•h/mL vs. 396.8 ng•h/mL, P = 0.018) and the oral clearance of sildenafil was significantly lower after S+A treatment than after S+B treatment (120.6 L/h/kg vs. 50.4 L/h/kg, P = 0.018). In the PD study, incremental shuttle walking distance was superior during treatment with S+A than during treatment with S+B (S+B; 280 m vs. S+A; 340 m, P = 0.042). There were no concerns about safety with either combination therapy regime.

Immunological abnormalities in splenic marginal zone cell lymphoma.

The clinical features of patients with splenic marginal zone cell lymphoma (SMZCL) have rarely been reported. In the present study, immunological abnormalities, particularly hematological abnormalities, observed in SMZCL were described. Autoimmune hemolytic anemia, immune thrombocytopenia, and appearance of lupus anticoagulant were observed in 2 of 3 patients with SMZCL. Other abnormal data including monoclonal gammopathy and cold agglutinin were also observed in 2 of the 3 patients. Immunological abnormalities may be characteristic complications in patients with SMZCL and must be followed carefully, since they may be a reliable marker of this type of lymphoma activity.

[Syphilitic thoracic aortic aneurysm with destruction of vertebral body, producing numbness of lower extremities and paraplegia].

Numbness and paraplegia are uncommon complaints in patient with thoracic aortic aneurysm (TAA). The patient was a 64-year-old man. He suffered numbness and gait disturbance (paraplegia). The blood examination showed no positive findings except a Wassermann was positive. Roentgen examination of the chest showed two abnormal shadows like tumors. The CT and MRI revealed destruction of the vertebral bodies and TAAs adjacent to the spinal cord. After the graft replacement was performed, numbness and paraplegia disappeared. This suggests that in our patient the TAAs destruct the vertebral body and produce pressure on the spinal cord, causing numbness and paraplegia. We experienced a rare case of the syphilitic TAA producing bone destruction, numbness and paraplegia.

Stretch-activated anion currents of rabbit cardiac myocytes.

1. Stretch-activated anion currents were studied in sino-atrial and atrial cells using the whole-cell patch clamp technique. With continuous application of positive pressure (5-15 cmH2O) through the patch clamp electrode, the cell was inflated and the membrane conductance was increased. 2. Voltage clamp steps revealed that the stretch-activated currents had time-independent characteristics. The increase in membrane conductance was reversible on subsequent application of negative pressure to the electrode. 3. The reversal potential of the stretch-activated currents was shifted by 60 mV for a 10-fold change in intracellular Cl- concentration, while it was unaffected by replacement of Na+ in the extracellular solution by N-methyl-D-glucamine. Cell superfusion with Cl(-)-deficient solution (10 mM Cl-) reduced the amplitude of outward current. These findings indicate that the stretch-activated conductance is Cl- selective. 4. The sequence of anion permeability through the stretch-activated conductance was determined to be I-(1.7) > NO3-(1.5) > Br-(1.2) > Cl-(1.0) > and F-(0.6). SCN- appeared to be more permeant than I-. 5. The stretch-activated conductance was reduced by the Cl- channel blockers, 4,4'-dinitrostilbene-2,2'-disulphonic acid disodium salt, 4-acetamido-4'-isothiocyanatostilbene-2,2'-disulphonic acid or anthracene-9-carboxylate (9-AC). Administration of furosemide or bumetanide had no effect. 6. The stretch-activated Cl- current was recorded even though intracellular Ca2+ ions were chelated by including 10 mM EGTA in the pipette solution. Neither the specific peptide inhibitor of cyclic AMP-dependent protein kinase (50 microM), nor the non-selective blocker of protein kinases, H-7 (20 microM), was effective in reducing the stretch-activated Cl- current, suggesting that the stretch-activated Cl- current is a novel type of cardiac Cl- current, which shows a different modulatory mechanism from that of other cardiac Cl- currents.

Automated microanalysis of creatinine by coupled enzyme reactions.

Hydrogen peroxide was generated from creatinine by the sequential enzyme reactions of creatinine amidohydrolase, creatine amidinohydrolase and sarcosine oxidase. Hydrogen peroxide was, in turn, used stoichiometrically for the condensation of 4-aminoantipyrine and N-ethyl-N-(2-hydroxy-3-sulfopropyl)-m-toluidine catalyzed by horse-radish peroxidase, resulting in the formation of quinone dye with maximum absorbance at 546 nm. The optimized assay conditions for the enzymatic determination of creatinine in a HITACHI 7250 autoanalyzer was established. This system, which requires less than 5 microliters of sample, was found to be the most economical for laboratories equipped with autoanalyzers.

Background current in sino-atrial node cells of the rabbit heart.

1. The Ca2+ current, K+ current, hyperpolarization-activated current, Na(+)-K+ pump current and the Na(+)-Ca2+ exchange current were all blocked by appropriate blockers and the remaining time-independent currents were investigated in single pacemaker cells of the rabbit sino-atrial node using the whole-cell patch clamp technique. 2. Exchanging the bathing solution from Tris-hydroxymethyl-aminomethane hydrochloride (Tris) Na+ free to 150 mM-Na+ induced an inward current and the slope conductance of the current-voltage relationship increased from 0.45 +/- 0.18 to 0.87 +/- 0.33 nS (n = 71) at -50 mV. The remaining conductance in Tris Na(+)-free solution was essentially the same when Tris was substituted with tetraethylammonium (TEA) or N-methyl-D-glucamine (NMG). The current density of the Na(+)-dependent inward current obtained by subtracting the current in Tris Na(+)-free from that in 150 mM-Na+ solution was 0.73 +/- 0.21 pA/pF (n = 71) at -50 mV. We called this current the Na(+)-dependent background current. 3. The membrane conductance was reduced by lowering the temperature of the external solution from 36 to 23 degrees C. In Tris Na(+)-free solution, the temperature-sensitive component was outward at all potentials, whereas it showed a reversal potential at around -20 mV in 150 mM-Na+ solution. This reversal potential was interpreted as a sum of the Cs+ efflux and Na+ influx, by comparing the Na(+)-dependent inward currents obtained at 36 degrees C and those at 23 degrees C. 4. Divalent cations (2 mM-Ni2+, 1 mM-Ba2+ or 2 mM-Ca2+) reduced only the outward current in the Tris Na(+)-free solution, while in the 150 mM-Na+ solution, they reduced both the inward and outward components of the current which had a reversal potential of around -10 mV. 5. Amiloride depressed the membrane conductance in 150 mM-Na+, Cs+ or Rb+ external solution, though only at negative membrane potentials, which suggests amiloride has a voltage-dependent effect on the background current. 6. Removal of Cl- from the external solution or the addition of a Cl- channel blocker (4,4'-dinitrostilbene-2,2'-disulphonic acid disodium salt, DNDS) failed to affect the membrane conductance. 7. When the monovalent cation-dependent inward current was measured by subtracting the current in the Tris solution from those recorded in the various monovalent cation solutions, the current amplitude decreased in the order: Rb+ greater than K+ greater than Cs+ greater than Na+ greater than Li+, which suggests a poor cation selectivity of this current system.(ABSTRACT TRUNCATED AT 400 WORDS)

Regulation of spontaneous opening of muscarinic K+ channels in rabbit atrium.

1. Intracellular mechanism(s) for controlling the opening of muscarinic K+ channels in the absence of an applied muscarinic agonist were studied in rabbit atrium by applying the patch clamp technique to isolated single myocytes. 2. In the cell-attached patch configuration, currents due to the activity of both the muscarinic K+ channel and the inward rectifying K+ channel were recorded. However, while the inward rectifying K+ channel currents were observed in only ten patches of 211 examined, spontaneous opening (i.e. in the absence of a muscarinic agonist) of the muscarinic K+ channel currents was observed in all patches examined in these atrial cells. 3. The single-channel currents due to spontaneous opening of muscarinic K+ channels were identified on the basis of their very similar conductance and gating properties to the unitary events which have been recorded when 0.5 microM-acetylcholine is included in the pipette and 10 microM-GTP is present in the internal side of the patch membrane. 4. Although the spontaneous opening of the muscarinic K+ channels disappeared soon after excision of the patch membrane, this type of channel activity reappeared following application of ATP and MgCl2 to the internal side of the torn-off patch, as expected from previous publications. 5. The K+ channel activity induced by the ATP and Mg2+ (measured as the product of the number of channels, N, times the probability of opening, Po) was strongly dependent upon concentration of free Mg2+; it was half-maximal at 2.2 x 10(-4) M [Mg2+]i. However, after the muscarinic K+ channels had been activated by 100 microM-guanosine 5'-O-3-thiotriphosphate (GTP gamma S) together with ATP and Mg2+, an increase in the Mg2+ concentration from 5.5 x 10(-5) to 2 x 10(-3) M failed to enhance this channel activity. 6. Pertussis toxin, which is known to uncouple muscarinic receptors from associated G-proteins (G(i) or G(o)), failed to inhibit the ATP- and Mg(2+)-induced activation of this K+ channel in the absence agonists. 7. In experiments made to test whether the Mg(2+)-ATP requirement results from an obligatory phosphorylation reaction, ATP was replaced with adenylyl-imidodiphosphate (AMP-PNP), an analogue of ATP which is resistant to hydrolysis. This K+ channel activity was not present when ATP was replaced with AMP-PNP.(ABSTRACT TRUNCATED AT 400 WORDS)

Inhibition of the muscarinic receptor-activated K+ current by N-ethylmaleimide in rabbit heart.

The effects of N-ethylmaleimide (NEM), a sulfhydryl alkylating agent, on the ACh-activated K+ current were examined in single cells from rabbit hearts using whole-cell and single channel patch clamp techniques. Bath application of NEM (50 microM) or the muscarinic antagonist, atropine (1 microM) completely inhibited the ACh-activated K+ current in whole-cell recordings. In cell-attached patch conditions, the inhibitory effect of NEM was still observed; in contrast, atropine was ineffective when the agents were bath applied, indicating that the site of action of NEM is different from that of atropine. Inside-out patch recordings confirmed that GTP was required on the internal side of the membrane for activation of this K+ channel when ACh was present in the pipette. NEM abolished this GTP-activated K+ channel activity. GTP gamma S, a non-hydrolysable GTP analogue, was able to activate this K+ channel in the absence of a muscarinic agonist, an effect thought to be due to the direct activation of GTP-binding proteins. Pretreatment with NEM almost completely prevented this effect of GTP gamma S. In contrast, after the activation of the K+ channel by GTP gamma S had reached a steady-state, NEM failed to show a significant inhibitory effect. These results demonstrate that NEM prevents the activation of muscarinic receptor-regulated K+ channel and suggest an involvement of alkylation of the GTP-binding proteins which are coupled to this type of K+ channel.

Mechanism of acetylcholine-induced inhibition of Ca current in bullfrog atrial myocytes.

The mechanism of the anti-beta-adrenergic action of acetylcholine (ACh) on Ca current, ICa, was examined using the tight-seal, whole-cell voltage clamp technique in single atrial myocytes from the bullfrog. Both isoproterenol (ISO) and forskolin increased ICa dose dependently. After ICa had been enhanced maximally by ISO (10(-6) M), subsequent application of forskolin (50 microM) did not further increase ICa, suggesting that ISO and forskolin increase ICa via a common biochemical pathway, possibly by stimulation of adenylate cyclase. ACh (10(-5) M) completely inhibited the effect of low doses of forskolin (2 x 10(-6) M), as well as ISO, but it failed to block the effects of high doses of forskolin (greater than 5 x 10(-5) M). Intracellular application of cyclic AMP (cAMP) also increased ICa. ACh (10(-5) M) failed to inhibit this cAMP effect, indicating that the inhibitory action of ACh occurs at a site proximal to the production of cAMP. ACh (10(-5) M) also activated an inwardly rectifying K+ current IK(ACh). Intracellular application of a nonhydrolyzable GTP analogue, GTP gamma S (5 X 10(-4) M), activated IK(ACh) within several minutes; subsequent application of ACh (10(-5) M) did not increase IK(ACh) further. These results demonstrate that a GTP-binding protein coupled to these K+ channels can be activated maximally by GTP gamma S even in the absence of ACh. Intracellular application of GTP gamma S also strongly inhibited the effect of ISO on ICa in the absence of ACh. Pertussis toxin (IAP) completely prevented both the inhibitory effect of ACh on ICa and the ACh-induced activation of IK(ACh). GTP gamma S (50 microM-1 mM) alone did not increase ICa significantly; however, when ISO was applied first, GTP gamma S (5 x 10(-4) M) gradually inhibited the ISO effect on ICa. These results indicate that ACh antagonizes the effect of ISO on ICa via a GTP-binding protein (Gi and/or Go). This effect may be mediated through a direct inhibition by the alpha-subunit of Gi which is coupled to the adenylate cyclase.

N-ethylmaleimide uncouples muscarinic receptors from acetylcholine-sensitive potassium channels in bullfrog atrium.

The effect of N-ethylmaleimide (NEM), a sulphydryl alkylating agent, on the acetylcholine-activated K+ current, IK(ACh), has been studied in single cells from bullfrog atrium using a tight-seal, whole-cell voltage clamp technique. Addition of NEM (5 x 10(-5) M) produced a time-dependent complete block of IK(ACh). Dialysis of guanosine-5'-O-(3-thiotriphosphate) (GTP gamma S, 5-10 x 10(-4) M), a nonhydrolyzable GTP analogue, into the myoplasm from the recording pipette gradually activated IK(ACh) even in the absence of acetylcholine. This effect is thought to be due to a GTP gamma S-induced dissociation of GTP-binding proteins (Gi and/or Go) into subunits that can directly activate these K+ channels. When NEM (5 x 10(-5) M) was applied after the GTP gamma S effect had fully developed, it failed to inhibit the GTP gamma S-induced K+ current, indicating that the NEM effect is unlikely to be on the dissociated subunits of the GTP-binding protein(s) or on the K+ channels. In contrast, pretreatment with NEM before GTP gamma S application markedly reduced the muscarinic K+ current, suggesting that NEM can block this K+ current by inhibition of the dissociation of the GTP-binding proteins into functional subunits. In NEM-treated cells the stimulatory effect of isoproterenol on ICa was present, but the inhibitory action of ACh on ICa was completely abolished. These results demonstrated that NEM can preferentially inhibit muscarinic receptor-effector interactions, probably by alkylating the GTP-binding proteins that are essential for these responses.

Calcitonin gene-related peptide regulates calcium current in heart muscle.

The influx of Ca2+ due to the transmembrane calcium current, ICa, has a fundamental role in cardiac pacemaker activity, in the action potential plateau and in excitation-contraction coupling. Both sympathetic and parasympathetic neurotransmitters can modulate ICa. Recent studies indicate that in both the cardiovascular and the central nervous systems, nerve varicosities exist that contain a novel non-adrenergic, non-cholinergic peptide--calcitonin gene-related peptide (CGRP). Although CGRP is known to exert strong positive inotropic and chronotropic effects, as well as to cause vasodilation, very little is known about the ionic mechanisms of these effects. Here we report that CGRP dramatically increases ICa in single heart cells. Although this CGRP-induced increase in ICa resembles the effect of beta-adrenergic agonists, our results demonstrate some significant differences between the effects of CGRP and these agonists: (1) the increase due to CGRP cannot be blocked by beta-adrenergic antagonists; (2) the CGRP-induced effect is transient; and, (3) CGRP can inhibit isoproterenol-stimulated ICa. Our results provide the first electrophysiological evidence that CGRP can significantly modulate ICa in the heart, and suggest a new additional mechanism for the neurogenic control of cardiac function.

Modulation by intracellular Ca2+ of the hyperpolarization-activated inward current in rabbit single sino-atrial node cells.

1. The sensitivity to internal Ca2+ of the hyperpolarization-activated inward current (Ih or If) in rabbit single sino-atrial node cells was investigated by the whole-cell voltage-clamp method. 2. When the patch pipette contained an internal solution of pCa 10, the amplitude of If decreased by 74.8 +/- 3.3% in 10 min (n = 7) after rupture of the patch membrane. When the pipette contained an internal solution of pCa 7, If increased by 43.7 +/- 8.7% within 10 min (n = 5). 3. Increase of If by the higher Ca2+ internal solution was confirmed in the same cell using the cell dialysis method. Both If and its tail current were increased at every membrane potential. The amplitude of If increased most markedly between pCa 8 and 7. 4. The reversal potential and kinetics of If were unaffected by the internal Ca2+ concentration. Increase of If by the high internal Ca2+ concentration was sensitively blocked by Cs+. These findings confirm that the increased current is indeed If and not a newly activated If-like current due to elevation of internal Ca2+. 5. The activation curve of If shifted approximately 13 mV in a positive direction by elevating Ca2+ from pCa 10 to 7 (n = 21), indicating that the voltage dependence of If was modulated by internal Ca2+. 6. beta-Agonists also modulated If, but the underlying mechanisms of their effects on If differed from those of the internal Ca2+. The former affected the If kinetics rather than its amplitude, whereas the latter acted on the If conductance rather than on its kinetics. 7. The increase in If by the internal Ca2+ was unaffected by protein kinase inhibitor or calmodulin inhibitor, suggesting that the internal Ca2+ directly modulates If. 8. When the patch pipette contained pCa 7 internal solution, the maximum diastolic potential shifted towards a positive potential but the heart rate remained almost constant.

Dual effects of intracellular magnesium on muscarinic potassium channel current in single guinea-pig atrial cells.

1. The effects of internal Mg2+ ions on the muscarinic acetylcholine (ACh) receptor-mediated K+ currents were investigated in single atrial cells of guinea-pigs, using the whole-cell and inside-out modes of the patch-clamp technique. 2. During cell dialysis in the whole-cell-clamp condition, the depletion of internal Mg2+ increased outward muscarinic K+ currents but decreased inward currents, thereby reducing the inwardly rectifying property of the channels. 3. When inside-out patches were prepared, channel availability was abolished and was reactivated by internal application of guanosine 5'-triphosphate (GTP) or its non-hydrolysable analogue, 5'-guanylyl imidodiphosphate (GppNHp), in the presence of Mg2+. GppNHp led to a recovery of the channels also in the nominal absence of Mg2+ (0[Mg2+]i). 4. The activation of single-channel currents by intracellular GTP and Mg2+ was dose-dependent. Both concentration-response curves were fitted by saturation kinetics with Hill coefficients of 1, and the half-maximum doses were 24 +/- 8 microM for GTP and 67 +/- 14 microM for Mg2+. The effects of Mg2+ on activation of K+ currents were additive with those of GTP, suggesting the presence of two independent binding sites for GTP and Mg2+. 5. The single-channel conductance became virtually ohmic when measured at nominally zero [Mg2+]i while GppNHp was used to recover the channel activity. Micromolar [Mg2+]i reduced the unitary amplitude of single open-channel currents in a dose- and voltage-dependent manner, showing half-blocking doses of 293 microM at +40 mV and 115 microM at +60 mV. 6. Voltage-dependent kinetics of Mg2+ block were described using equations based on Eyring rate theory (Woodbury, 1971; Hille, 1984), where the coefficient for voltage dependence (delta) was 0.63. 7. Intracellular Mg2+, at a physiological concentration, has a dual action on the muscarinic K+ channel: first Mg2+ activates the channel in the presence of GTP through GTP-binding proteins (G proteins), and secondly it blocks outward currents through the channel, thereby causing the inwardly rectifying property.

Contribution of two types of calcium currents to the pacemaker potentials of rabbit sino-atrial node cells.

1. Two types of calcium currents, the transient type and long-lasting type, were examined by both whole-cell and cell-attached patch-clamp modes in single isolated sino-atrial node cells of the rabbit. 2. In the whole-cell clamp mode, in response to a depolarizing pulse to -40 mV from a holding potential of -80 mV, a transient type calcium current with an amplitude of 2.1 +/- 0.7 pA/pF (mean +/- S.D.; n = 15) was recorded. The threshold potential was approximately -50 mV. 3. Nickel (40 microM) and tetramethrin (0.1 microM) blocked the transient type calcium current without appreciable effects on the long-lasting type. Nifedipine and D600 blocked the long-lasting type, but did not affect the transient type. Cadmium (20 microM) and cobalt (2 mM) inhibited both types of calcium currents equally. 4. Both types of calcium currents showed an increased amplitude with increasing extracellular calcium concentration. The values of the Michaelis constant, Km, were 0.95 mM for the transient type and 3.92 mM for the long-lasting type, indicating that these types represent two different classes of channels. 5. In the cell-attached patch-clamp mode, the single-channel conductance of the transient type calcium current was 8.5 pS, by using 100 mM-BaCl2 in the pipette, whereas that of the long-lasting type was 16.0 pS, under the same conditions. Each of these values was similar to those found in other cells, respectively. 6. In the whole-cell clamp mode, the transient type current began to inactivate at -70 mV and was fully inactivated at -40 mV. The steady-state inactivation curve of the transient type current was approximately 50 mV negative to that of the long-lasting type. The overlap of the membrane potential between the activation and inactivation curves was small. The time constant of the inactivation shortened from 20 to 5 ms as the potential became progressively positive over the range from -80 to +30 mV. 7. Isoprenaline (1 microM) increased the amplitude of the long-lasting type Ca2+ current, but was not effective on the transient type, suggesting that the long-lasting type calcium current may be responsible for the positive chronotropic effect of isoprenaline. 8. While recording spontaneous electrical activity of the cell, application of 40 microM-nickel induced bradycardia and this effect was enhanced when the membrane was constantly hyperpolarized.(ABSTRACT TRUNCATED AT 400 WORDS)

Membrane currents in cardiac pacemaker tissue.

The present work is a brief survey of the mechanism of the cardiac pacemaker in sinoatrial node cells. Information on the pacemaker mechanism in cardiac tissue has been greatly enhanced by the development of the single cell isolation technique and the patch clamp technique. These methods circumvent to a large extent the difficulties involved in voltage clamping multicellular preparations. The calcium current (ICa), delayed rectifier potassium current (IK), transient outward current (Ito;IA), and the hyperpolarization activated inward current (Ih or If) were found both in whole cell preparations and in single channel analysis. The physiological significance of these currents, together with the exchange current systems for the pacemaker depolarization are discussed.

Intracellular Ca2+ and protein kinase C modulate K+ current in guinea pig heart cells.

Effects of protein kinase C (PKC) and intracellular calcium ion (Cai2+) on the delayed rectifier K+ current (IK) were investigated in the single ventricular cells of guinea pig by use of an internal-dialysis method and a whole cell voltage-clamp technique. 12-O-tetradecanoylphorbol-13-acetate (TPA, 10(-9) M), an activator of PKC, increased the amplitude of IK in the presence of Cai2+ higher than 10(-10) M. This effect of TPA was mimicked by a synthetic diacylglycerol, 1-oleoyl-2-acetylglycerol (OAG), 50 micrograms/ml, 125 microM, and was blocked by 1-(5-isoquinolinylsulfonyl)-2-methylpiperazine (10 microM). The above findings suggest that IK channels were phosphorylated by PKC and thereby the amplitude of IK was increased. IK was also increased by elevating the concentration of Cai2+ in the absence of TPA. It is thus indicated that IK channels are modulated by Cai2+ not only through activation of PKC but also directly. Our observation may provide a possible mechanism by which Cai2+ mediates the link between the Ca2+ transients during contraction and the action potential duration.

Rectification of muscarinic K+ current by magnesium ion in guinea pig atrial cells.

Rectifying properties of the acetylcholine (ACh)-sensitive K+ channels were studied using a patch-clamp method in single atrial cells prepared enzymatically from adult guinea pig hearts. In the presence of micromolar concentration of nonhydrolyzable guanosine 5'-triphosphate (GTP) analogue 5'-guanylylimidodiphosphate (GppNHp) and the absence of Mg2+ at the inner surface of patch membrane [( Mg2+]i), the channel activity recovered in inside-out patch condition. The single channel conductance became ohmic between -80 and +80 mV (symmetrical 150 mM K+ solutions). The rapid relaxation of outward single channel currents was disclosed on a depolarization. [Mg2+]i blocked the outward current through the channel dose- and voltage-dependently and also induced a dose-dependent increase in the channel activation. The apparent paradoxical role of [Mg2+]i is important for the cholinergic control in the heart; voltage-dependent Mg block ensures a low K+ conductance of cell membrane at the plateau of action potentials during the exposure to ACh, thereby slowing the heart rate without unfavorable shortening of the action potentials.