Marked QRS complex abnormalities and sodium channel blockade by propoxyphene reversed with lidocaine.

The opiate analgesic propoxyphene produces cardiac toxicity when taken in overdose. We recently observed a patient with propoxyphene overdose in whom marked QRS widening was reversed by lidocaine. The reversal is apparently paradoxical as both agents block the inward sodium current (INa). We examined possible mechanisms of the reversal by measuring INa in rabbit atrial myocytes during exposure to propoxyphene and the combination of propoxyphene and lidocaine (60 and 80 microM, respectively). Propoxyphene caused use-dependent block of INa during pulse train stimulation. Block recovered slowly with time constants of 20.8 +/- 3.9 s. Block during lidocaine exposure recovered with time constants of 2-3 s. During exposure to the mixture, block recovered as a double exponential. The half time for recovery during exposure to the mixture was 1.6 +/- .9 s compared with a half-time of 14.3 +/- 2.9 s during exposure to propoxyphene alone. During pulse train stimulation, less steady-state block was observed during exposure to the mixture than during exposure to propoxyphene alone when the interval between pulses was greater than 0.95 s. Both drugs compete for a common receptor during the polarizing phase. The more rapid dissociation of lidocaine during the recovery period leads to less block during the mixture than during exposure to propoxyphene alone. The experiments suggest a mechanism for reversal of the cardiac toxicity of drugs which have slow unbinding kinetics.

Cardiac resynchronization therapy and the relationship of percent biventricular pacing to symptoms and survival.

BACKGROUND: With the advent of cardiac resynchronization therapy, it was unclear what percentage of biventricular pacing would be required to obtain maximal symptomatic and mortality benefit from the therapy. The optimal percentage of biventricular pacing and the association between the amount of continuous pacing and survival is unknown. OBJECTIVE: The purpose of this study was to assess the optimal percentage of biventricular pacing and any association with survival in a large cohort of networked patients. METHODS: A large cohort of 36,935 patients followed up in a remote-monitoring network, the LATITUDE Patient Management system (Boston Scientific Corp., Natick, Massachusetts), was assessed to determine the association between the percentage of biventricular pacing and mortality. RESULTS: The greatest magnitude of reduction in mortality was observed with a biventricular pacing achieved in excess of 98% of all ventricular beats. Atrial fibrillation and native atrial ventricular condition can limit a high degree of biventricular pacing. Incremental increases in mortality benefit are observed with an increasing percentage of biventricular pacing. CONCLUSION: Every effort should be made to reduce native atrioventricular conduction with cardiac resynchronization therapy systems in an attempt to achieve biventricular pacing as close to 100% as possible.

Changes in epicardial coronary arterial diameter following intracoronary papaverine in man.

The effect of intracoronary papaverine administration on epicardial coronary arterial diameter was examined in 18 male patients. Coronary-artery cineangiograms were acquired with a power injector before intervention, 20 sec after intracoronary saline (control), and 20 sec after administration of papaverine into either the left (12 mg) or right (8 mg) coronary artery. Absolute coronary arterial diameter of a normal-appearing segment was quantified using a previously validated, fully automated digital edge detection program with an ADAC digital radiographic unit. Baseline coronary arterial diameter of 3.1 +/- 0.8 mm did not significantly change after saline administration (3.1 +/- 0.9 mm) but did significantly increase (p less than .001) to 3.4 +/- 0.9 mm after papaverine administration. No significant percent change in diameter occurred in either the left anterior descending (-.5 +/- 1.7%), left circumflex (-.2 +/- 1.1%), or right (-3.0 +/- 3.8%) coronary arteries with saline, but significant (p less than .001) increases occurred with papaverine (7.2 +/- 4.1%, 7.0 +/- 4.5%, 6.8 +/- 2.7%, respectively). The response of 7 coronary arteries examined immediately proximal to a significant lesion was not significantly different from the response of the remaining 11 coronary arteries. In conclusion, intracoronary papaverine causes a significant increase in coronary arterial diameter. This has clinical implications for assessing coronary flow reserve with devices that defect flow velocity.

Blockade of rabbit atrial sodium channels by lidocaine. Characterization of continuous and frequency-dependent blocking.

Lidocaine block of the cardiac sodium channel is believed to be primarily a function of channel state. For subthreshold potentials, block is limited to the inactivated state, whereas above threshold, block results from the combination of open- and inactivated-state block. Since, in the absence of drug, inactivation develops with time constants that vary from several hundred milliseconds to a few milliseconds as potential is varied from subthreshold to strongly depolarized levels, we would predict a similar voltage dependence of at least a fraction of block. Prior theoretical analyses from our laboratory suggest that there should be a direct parallel between blockade determined with a single pulse and trains of pulses. We tested these predictions by measuring the blockade of sodium current in cultured atrial myocytes during exposure to 80 microM lidocaine. We selected two test potentials for most of our studies, -80 mV, which was clearly in the subthreshold range of potentials, and -20 mV, which was close to the peak of the current-voltage curve. With single pulses of increasing duration, block developed with a single exponential time course and with time constants that decreased from 694 +/- 117 msec at -80 mV to 373 +/- 54 msec at -20 mV. In the absence of drug, inactivation developed with a time constant 176 +/- 17 at -80 mV and 2.9 +/- .5 msec at -20 mV. Despite the much slower onset of inactivation at -80 mV, no second-order delay in block development was observed. This suggests that at -80 mV block is occurring to a channel conformation that is accessed without delay rather than the classical inactivated state. We compared the kinetics of block during a single continuous pulse with trains of pulses at -20 mV. The rate of block onset was faster during the pulse trains, suggesting an element of "activated state" block. We computed shifts in apparent inactivation from observed steady-state blockade. The computed shifts agree well with those observed, indicating that shifts in apparent inactivation result largely from voltage-sensitive equilibrium blockade. The classical states described in the Hodgkin-Huxley formalism may be too restrictive to fully describe the voltage- and time-dependent block of cardiac sodium channels.

Blockade of cardiac sodium channels by lidocaine. Single-channel analysis.

The mechanism of interaction of lidocaine with cardiac sodium channels during use-dependent block is not well defined. We examined the blockade of single cardiac sodium channels by lidocaine and its hydrophobic derivative RAD-242 in rabbit ventricular myocytes. Experiments were performed in cell-attached and inside-out patches. Use-dependent block was assessed with trains of ten 200-msec pulses with interpulse intervals of 500 msec and test potentials of -60 to -40 mV. Single-channel kinetics sometimes showed time-dependent change in the absence of drug. During exposure to 80 microM lidocaine, use-dependent block during the trains was associated with a decrease in the average number of openings per step. At -60 mV, mean open time was not significantly changed (control, 1.4 +/- 0.6 msec; lidocaine, 1.2 +/- 0.3 msec, p greater than 0.05). Greater block developed during trains of 200-msec pulses compared with trains of 20-msec pulses at the same interpulse interval at test potentials during which openings were uncommon later than 20 msec (-50 and -40 mV). Prolonged bursts of channels showing slow-gating kinetics were observed both in control and the presence of 80 microM lidocaine. However, lidocaine may decrease the late sodium current by altering the kinetics of slow gating. The hydrophobic lidocaine derivative RAD-242, which has a 10-fold greater lipid solubility than lidocaine, decreased the peak averaged current during pulse train stimulation by 60% without a change in the mean open time. Our results suggest that the major effect of lidocaine during use-dependent block involves the interaction with a nonconducting state of the sodium channel followed by a failure to open during subsequent depolarization.

Use of ionic currents to identify and estimate parameters in models of channel blockade.

Models of ion channel blockade are frequently validated with observations of ionic currents resulting from electrical or chemical stimulation. Model parameters for some models (modulated receptor hypothesis) cannot be uniquely determined from ionic currents. The time course of ionic currents reflects the activation (fraction of available channels that conduct in the presence of excitation) and availability of channels (the ability of the protein to make a transition to a conducting conformation and where this conformation is not complexed with a drug). In the presence of a channel blocking agent, the voltage dependence of availability appears modified and has been interpreted as evidence that drug-complexed channels exhibit modified transition rates between channel protein conformations. Because blockade and availability both modify ionic currents, their individual contributions to macroscopic conductance cannot be resolved from ionic currents except when constant affinity binding to a bindable site is assumed. Experimental studies of nimodipine block of calcium channels and lidocaine block of sodium channels illustrate these concepts.

Extracellular pH modulates block of both sodium and calcium channels by nicardipine.

Slowing of the recovery of the Na channel from local anesthetic block at low external pH has been well described. In contrast the Ca channel has been reported not to show such an effect. Because of the absence of this response, a two-site model for the interaction of Ca antagonists with the Ca channel has been proposed. We sought to determine whether these results were a consequence of utilizing the poorly lipid-soluble Ca antagonist diltiazem as the test drug. We have measured the time constants of recovery (tau r) of Na (INa) and Ca currents (ICa) recorded from rabbit atrial myocytes during control and exposure to the lipid-soluble Ca antagonist nicardipine as external pH was reduced from 7.8 to 6.9. In the absence of drug, tau r for INa decreased from 19 +/- 1.3 to 12.1 +/- 0.6 ms for the pH reduction. Similarly, tau r for ICa decreased from 53 +/- 7 to 33.6 +/- 7 ms. During exposure to nicardipine tau r for INa increased from 2.24 +/- 0.8 to 5.96 +/- 0.8 s as external pH was reduced. For ICa, tau r also increased from 1.43 +/- 0.55 to 2 +/- 0.32 s. For each channel type, the results are well explained by a single blocking site model with hydrophobic and hydrophilic pathways to a single membrane binding site as proposed by Hille (J. Gen. Physiol. 69: 497-517, 1977).