Basic concepts in cellular cardiac electrophysiology: Part II: Block of ion channels by antiarrhythmic drugs.

Antiarrhythmic drugs have relative specificity for blocking each of the major classes of ion channels that control the action potential. The kinetics of block is determined by the state of the channel. Those channel states occupied at depolarized potentials generally have greater affinity for the blocking drugs. The kinetics of the drug-channel interaction is important in determining the blocking profile observed clinically. The increased mortality resulting from drug treatment in CAST and several atrial fibrillation trials has resulted in a shift in antiarrhythmic drug development from the Na+ channel blocking (Class I) drugs to the K+ channel blocking (Class III) drugs. While both Classes of drugs have a proarrhythmic potential, this may be less for the Class III agents. Their lack of negative inotropy also make them more attractive. It is important that the potential advantages of these agents be evaluated in controlled clinical trials. In several laboratories, the techniques of molecular biology and biophysics are being combined to determine the block site of available drugs. This information will aid in the future development of agents with greater specificity, and hopefully greater efficacy and safety than those currently in clinical use.

Relationship between structure and sodium channel blockade by lidocaine and its amino-alkyl derivatives.

We examined the relationship between the physicochemical properties and the sodium channel-blocking actions of lidocaine and four of its amino-alkyl derivatives. The homologues differ in lipid solubility (log p 2.7-4.1), pKa (6.9-9.0), and molecular weight (248.5-290.7). Macroscopic sodium currents were measured in rabbit atrial myocytes by the whole-cell configuration of patch-clamp technique; single-channel currents were measured by the cell-attached configuration. Lidocaine and its homologues produced two patterns of block: tonic block and frequency-dependent block. Tonic block was highly correlated with lipid solubility and pKa. The single-channel studies suggest that tonic block results when the drug interacts with channel state(s) that precede opening. Block of open channels does not appear to play a prominent role in tonic block. The rate of recovery from block was the major determinant of the magnitude of frequency-dependent block. Highly lipid-soluble homologues showed rapid recovery from block and little frequency-dependent block. Drugs with lower lipid solubility and high pKa showed slower recovery from block and greater frequency-dependent block. The seemingly different requirements for tonic and frequency-dependent block can be explained by drug interaction at a single receptor site.

Voltage-independent effects of extracellular K+ on the Na+ current and phase 0 of the action potential in isolated cardiac myocytes.

A rise in [K+]o, by depolarizing the resting membrane potential and partially inactivating the inward Na+ current (INa), is believed to play a critical role in slowing conduction during myocardial ischemia. In multicellular ventricular preparations, elevation of [K+]o has been suggested to decrease Vmax to a greater extent than expected from membrane depolarization alone. The mechanism of this voltage-independent effect of [K+]o is currently unknown, and its significance in single cardiac cells has not been determined. We have examined the voltage-independent effects of elevated [K+]o on INa and the action potential upstroke in isolated rabbit atrial and ventricular myocytes under voltage- and current-clamp conditions. Superfusate [K+] was varied from 5 mmol/L to 14 or 24 mmol/L, whereas [Na+] was maintained at 150 mmol/L. In cultured atrial cells and excised outside-out patches from freshly isolated atrial and ventricular cells, the amplitude and kinetics of INa were unchanged by elevation of [K+]o. In atrial cells, action potentials elicited from a holding potential of -70 mV had a similar Vmax (114.9 +/- 5.7 versus 112.2 +/- 4.8 V/s, mean +/- SEM, n = 6) and action potential amplitude (115.0 +/- 2.4 versus 113.4 +/- 3.9 mV) in 5 and 24 mmol/L [K+]o. In contrast, in ventricular cells at a holding potential of -70 mV, increasing [K+]o fro 5 to 14 mmol/L decreased Vmax from 161.8 +/- 18.0 to 55.3 +/- 5.0 V/s (n = 7, P < .001) and action potential amplitude from 128.1 +/- 1.3 to 86.6 +/- 5.4 mV (P < .001). This voltage-independent decrease in Vmax and action potential amplitude induced by elevated [K+]o was abolished in the presence of 1 mmol/L Ba2+, suggesting that it is attributable to an increased background K+ conductance. We conclude that elevation of [K+]o to levels expected during ischemia causes a marked voltage-independent depression of Vmax in ventricular cells, which may, in turn, contribute to the slowing of myocardial conduction characteristic of early ischemia.

Kinetics of interaction of disopyramide with the cardiac sodium channel: fast dissociation from open channels at normal rest potentials.

Block of cardiac sodium channels is enhanced by repetitive depolarization. It is not clear whether the changes in drug binding result from a change in affinity that is dependent on voltage or on the actual state of the channel. This question was examined in rabbit ventricular myocytes by analyzing the kinetics of block of single sodium channel currents with normal gating kinetics or channels with inactivation and deactivation slowed by pyrethrin toxins. At -20 and -40 mV, disopyramide 100 microM blocked the unmodified channel. Mean open time decreased 45 and 34% at -20 and -40 mV during exposure to disopyramide. Exposure of cells to the pyrethrin toxins deltamethrin or fenvalrate caused at least a tenfold increase in mean open time, and prominent tail currents could be recorded at the normal resting potential. The association rate constant of disopyramide for the normal and modified channel at -20 mV was similar, approximately 10 x 10(6)/M/sec. During exposure to disopyramide, changes in open and closed times and in open channel noise at -80 and -100 mV are consistent with fast block and unblocking events at these potentials. This contrasts with the slow unbinding of drug from resting channels at similar potentials. We conclude that the sodium channel state is a critical determinant of drug binding and unbinding kinetics.

pH dependence of kinetics and steady-state block of cardiac sodium channels by lidocaine.

The local anesthetic-class antiarrhythmic drugs produce greater depression of conduction in ischemic compared with normal myocardium. The basis for this relatively selective action is uncertain. A model of the pH-dependent interaction of tertiary amine drugs with the sodium channel suggests that the low pH occurring during ischemia slows drug dissociation from the channel by changing the drug's protonation. The importance of the proton exchange reaction and the effect of overall slowing of drug dissociation on steady-state sodium channel blockade is uncertain. We have measured whole cell sodium channel current in rabbit atrial myocytes during control and exposure to lidocaine while external pH was varied between 6.8 and 7.8 at membrane potentials of -140, -120, and -100 mV. Tonic blockade was little influenced by external pH. Decreasing the external pH from 7.8 to 6.8 slowed both the rate of development of phasic block and recovery from the block. Decreasing the membrane potential from -140 to -100 mV increased the degree of phasic block attained in the steady state. Block was further enhanced when low pH was combined with membrane depolarization. Experiments in which deuterium ions were substituted for protons suggest that the kinetics of proton exchange is not rate limiting in the dissociation of drugs from the sodium channel. We conclude that it is the combined effect of low pH and membrane depolarization that may be critical in the enhanced blocking action of local anesthetic-class drugs during ischemia.

Na channel kinetics remain stable during perforated-patch recordings.

The results of studies on modulation of Na channel function are often difficult to interpret due to time-dependent changes in channel kinetics. Although the "tight-seal" whole cell voltage-clamp technique has proved very useful in studying the properties of the cardiac Na current, the spontaneous shift of parameters of inactivation and activation gating to more negative potential is a serious limitation to the use of the technique. The shifts are believed to result from changes in the intracellular milieu effected by dialysis; moreover, use of a variety of different anions and cations in the internal micropipette solution has not obviated the problem. The perforated-patch technique permits low-resistance intracellular access without free dialysis between the intracellular solution and the recording micropipette. We have compared steady-state inactivation and peak current-voltage relationship of whole cell Na currents measured with the conventional whole cell and perforated-patch techniques in rabbit atrial myocytes at 17 degrees C. Although gating parameters shifted to more negative potentials when recorded with the conventional technique, stable kinetics could be observed for up to 150 min with the perforated-patch technique. The potential for one-half Na channel inactivation was -73 +/- 5.1 mV and is consistent with measurements made using indirect techniques such as upstroke velocity measurements. The fact that the intracellular milieu is left relatively intact makes the approach attractive for studying modulation of the Na current by neurotransmitters and hormones.

Block and modulation of cardiac Na+ channels by antiarrhythmic drugs, neurotransmitters and hormones.

The Na+ channel is an important target for the action of antiarrhythmic drugs. Application of contemporary biophysical, biochemical and molecular biological techniques have added considerably to our knowledge of its structure, function, modulation and block by antiarrhythmic drugs. The increased mortality from the use of these drugs for prophylaxis of cardiac arrhythmias has forced a re-evaluation of their use and of the entire pharmacological strategy of arrhythmia management. Gus Grant and David Wendt review recent studies on the block and modulation of cardiac Na+ channels and the place of Na+ channel blockers in future antiarrhythmic drug development.

Blockade of cardiac sodium channels. Competition between the permeant ion and antiarrhythmic drugs.

A number of basic and clinical studies suggest that elevation of external sodium concentrations, [Na]o, may reverse the cardiotoxic effect of local anesthetic-class drugs. The mechanisms of reversal are uncertain. The blocking action of lidocaine and disopyramide were studied over a range of [Na]o. Both whole-cell voltage clamp and single-channel recordings were performed on isolated rabbit myocytes at 17 and 22 degrees C, respectively. In the presence of lidocaine, an inactivated channel blocker, the level of steady-state block in response to pulse train stimulation was not affected by variations in [Na]o from 20 to 150 mM. Estimates of the rate of dissociation of drug from the channel also were unaffected. In contrast, steady-state block by disopyramide, a drug that blocks open channels, was decreased as [Na]o was increased. Single-channel measurements suggest that the influence of [Na]o on channel current amplitude was small, 12% for a 25 mM increase in [Na]o. This increase in single-channel current amplitude would affect drug-free channels only, in that our studies suggest that drug-associated channels do not conduct. The association rate constant of disopyramide with open single sodium channels was decreased from 10 x 10(6) to 5 x 10(6)/M per s by an increase in [Na]o from 120 to 180 mM. Elevation of [Na]o may reverse the blocking action of local anesthetic-class drugs by an increase in single-channel current amplitude or by a decrease in drug association rate with the sodium channel. The occurrence of the latter action depends on the mode of block of the specific agent.

Kinetics of interaction of the lidocaine metabolite glycylxylidide with the cardiac sodium channel. Additive blockade with lidocaine.

The recovery of the sodium channel from blockade by local anesthetic antiarrhythmic drugs is voltage dependent. Recovery from lidocaine-induced blockade is accelerated by hyperpolarization, whereas that from glycylxylidide (GX) blockade has been reported to be slowed by hyperpolarization. This striking difference occurs despite similarities in chemical structure. The fast recovery from GX block at depolarized potentials may lead to a partial reversal of lidocaine blockade when the two drugs are combined. We have examined the kinetics of interaction of GX with the cardiac sodium channel over a range of membrane potentials by measuring whole-cell currents in isolated rabbit myocytes under voltage clamp at 15 degrees C. In the absence of drug, slow inactivation developed with a time constant of 10.7 +/- 5.1 seconds (n = 6). During exposure to 74 mumol/l GX, block developed with a time constant of 7.0 +/- 3 seconds (n = 6). Because of the similar time course of slow inactivation and block, we used a high concentration of GX to induce a level of block sufficient for analysis. The onset of block was slower than that induced by lidocaine and was unaffected by variation of external sodium from 20 to 75 mmol/l. Use-dependent blockade of sodium channels was greater when pulse trains were applied from a holding potential of -100 than -140 mV. This suggested that recovery from GX block might be slower at -100 than -140 mV. Direct measurements gave time constants of recovery of 10.3 +/- 4.2 seconds at -100 mV (n = 6) and 4.1 +/- 0.4 seconds at -140 mV (n = 4). The combination of GX with lidocaine produced only additive blocking effects when pulse trains were applied from both holding potentials. Computer simulations of the requirements for the competitive displacement of a sodium channel blocker with slow kinetics by one with fast kinetics suggest that the recovery time constant of the fast drug must be 10-100-fold smaller than that of the slow drug. Rapid association kinetics effected by a large binding rate constant or a higher concentration of the fast blocking drug is also important. The simulations suggest that, for the interaction of GX and lidocaine, only additive blocking action should be observed over the range of stimulus frequencies used in these experiments.

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).

Autonomic neural regulation of intact Purkinje system of dogs.

To characterize autonomic influences on the Purkinje system in vivo, we measured Purkinje relative refractory period (PRRP) in response to sympathetic (SNS) and vagal nerve stimulation (VNS). Effects of SNS on PRRP were primarily mediated via beta-adrenergic mechanisms because shortening of PRRP during SNS [from 215 +/- 7 (SE) to 202 +/- 8 ms, P less than 0.01] was entirely blocked by metoprolol (1 mg/kg). Vagal influences in the ambient state did not prolong PRRP, even when effective refractory period of adjacent muscle did prolong. When VNS was augmented with physostigmine, PRRP prolonged from 205 +/- 12 to 212 +/- 13 ms, P less than 0.05. Similar provocation of parasympathetic effects on PRRP occurred when VNS was performed during SNS; PRRP prolonged from 188 +/- 9 to 193 +/- 9 ms, P less than 0.05. Also, when alpha-adrenergic stimulation was produced by phenylephrine infusion (25 micrograms.kg-1.min-1) in the presence of metoprolol (1 mg/kg), which prolonged PRRP from 242 +/- 8 to 246 +/- 9 ms, P less than 0.05, the addition of VNS further prolonged PRRP from 246 +/- 9 to 253 +/- 9 ms, P less than 0.05. Thus some refractory period responses in the Purkinje system were similar to adjacent muscle, because beta-adrenergic activation shortened refractory period and vagal stimulation antagonized the shortening. Findings unique to Purkinje tissue were refractory period prolongation by vagal stimulation when facilitated by concurrent prolongation of refractory period during alpha-adrenergic stimulation.

Alpha-adrenergic effects on relative refractory period in Purkinje system of intact canine left ventricles.

To investigate the electrophysiological effects of alpha-agonists, we studied 23 chloralose-anesthetized sinoaortic and vagotomized dogs, measuring epicardial and endocardial effective refractory period and relative refractory period of the Purkinje system during graded infusions of norepinephrine and phenylephrine. In group 1, epicardial and endocardial effective refractory periods shortened equivalently with norepinephrine. These effects were blocked with metoprolol. In group 2, epicardial and endocardial refractory periods did not prolong with phenylephrine despite addition of metoprolol. In group 3, phenylephrine, after the addition of metoprolol, prolonged the relative refractory period of Purkinje only at the highest phenylephrine dose of 50 micrograms.kg-1.min-1. In group 4, these latter effects were not produced by raising pressure with descending aortic occlusion. However, the effects of phenylephrine were blocked with prazosin (1.0 mg/kg). Taken together, these data demonstrate that alpha-adrenergic influences prolong Purkinje but not muscle refractory period in the intact canine ventricle. The high dose of phenylephrine and resulting hypertension suggest that this may be a pharmacological and not a physiological response.

Sinus of Valsalva aneurysm presenting with complete heart block.

An elderly woman presented with sudden unresponsiveness and complete heart block and subsequently expired. Postmortem examination revealed an aneurysm of the right sinus of Valsalva impinging on the cardiac conducting tissue. Only a few cases associated with complete heart block have been previously reported.

Enhanced efficacy of oral sotalol for sustained ventricular tachycardia refractory to type I antiarrhythmic drugs.

Sotalol is a nonselective beta-adrenergic blocking agent with Vaughn-Williams class III activity. Its efficacy was tested in 9 patients with sustained ventricular tachycardia (VT) that had previously remained inducible during electrophysiologic testing of type I drugs (procainamide or quinidine). Eight patients had coronary artery disease with remote myocardial infarction and 1 had cardiomyopathy (ejection fraction 0.34 +/- 0.08, mean +/- standard deviation). Type I drugs prolonged the effective refractory period of the right ventricle 12 +/- 14% and prolonged the VT cycle length 41 +/- 24%. In contrast, despite an equivalent effect on the effective refractory period, a sustained VT could no longer be initiated in any of the 8 patients ultimately tested while taking oral sotalol. Daily doses averaged 600 +/- 103 mg and blood levels associated with VT suppression in electrophysiologic studies were generally greater than 3,000 ng/ml. In addition, sotalol was moderately effective at reducing ventricular ectopic activity measured by ambulatory electrocardiography. Over a mean follow-up of 23 months (range 1 to 37), mild heart failure (3 patients), symptomatic brady-cardia requiring pacemaker (1) and drug-related polymorphous VT (1) have occurred. Sudden death occurred in 1 patient and nonfatal VT recurrence was noted in 2. Five of 8 chronically treated patients currently are successfully treated with minimal side effects. Sotalol appears to be a promising antiarrhythmic drug in the treatment of serious ventricular arrhythmias, even in patients refractory to type I antiarrhythmic agents.

Chronic intracarotid cannulation of pigeons for administration of behaviorally active peptides.

Chronic intracarotid cannulation of the common carotid artery was performed in the pigeon. The catheter system of polyethylene tubing consisted of an indwelling component and an injection component. The indwelling component was exteriorized at the occiput so the bird could not reach the catheter with its beak. Following surgery, the pigeons were housed individually and received food and water ad libitum and no special care was necessary. The catheter was flushed daily with heparin in 0.9% NaCl solution to maintain patency. 30 pigeons were continuously or intermittently infused with bioactive peptides for up to 60 days after cannulation.

Permeability to ions of bovine retinal disk membrane vesicles in the bleached state.

The permeability of the bleached disk membrane of retinal rod outer segments to univalent and divalent ions is studied by light scattering. The membranes are isolated from frozen dark-adapted bovine retinae, swollen into spherical vesicles in a hypotonic medium and bleached in dilute suspension and their size is determined by elastic and quasi-elastic light scatterings. Various electrolytes are then added to the suspending medium in order to examine their osmotic activity relative to the vesicles deformation characteristics. By following the deformation behavior of the membrane vesicles by elastic light scattering in terms of the oblate ellipsoidal shell model, the osmotic activity of a given electrolyte is qualitatively deduced and thereby the permeability of the membrane to the electrolyte is ranked in reference to a chosen standard, i.e., sucrose. By this method, we show that the permeabilities to Na+, K+, Mg2+ and Ca2+ are all alike, and those to halides (F-, Cl-, Br-, I-), nitrate and phosphates (HPO4(2-)/H2PO4-) are similar. Acetate, however, is about 3-times more permeative, while sulfate is less permeative than the other anions by about the same factor. The viability of our method is checked with use of an ionophore, lasolocid (X-537A), by establishing partial recovery from the osmotic deformation through the suppression of the cation osmotic effect. Ion-induced aggregation and pH-dependent size and shape changes are both found to be insignificant.