Electrophysiologic effects of blocking and stimulating the opioid system in patients with unexplained heart palpitations

Cardiovascular effects of intravenous pentazocine and cyclazocine in conscious, curarized-conscious, and anesthetized dogs

The cardiovascular effects of intravenous pentazocine and cyclazocine in dogs were studied under conscious, curarized-conscious (paralyzed by gallamine), and anesthetized states. In the conscious state, blood pressure and heart rate were dose-dependently increased by pentazocine (1, 2, 3 mg/kg) and to a lesser extent by cyclazocine (0.3 mg/kg). In all subsequent experiments on dogs, the results were obtained using 3 mg/kg pentazocine and 0.3 mg/kg cyclazocine. Pentazocine accelerated breathing, peaking at about 10 min, whereas cyclazocine reduced breathing to a minimum in 1 min, followed by a gradual recovery thereafter. In the curarized-conscious state, the blood pressure response to pentazocine was biphasic, namely an initial decrease followed by an increase; chronotrophic activity was stimulated. Pretreatment with either ganglionic or alpha andrenergic blocking agents not only significantly antagonized the pressory responses to the drug but also potentiated the initial decreases in blood pressure and unmasked a bradycardic component, but these parameters were not altered by 0.3 mg/kg naxalone. In open-chest anesthetized dogs, blood pressure, heart rate, contractility, and mean peripheral vascular resistance were simultaneously decreased by both pentazocine and cyclazocine, initially accompanied by increases in aortic blood flow. During the later stages of drug action, only the blood pressure and contractility were increased above control levels (biphasic effect). A comparison of blood pressure and heart rate responses to pentazocine in dogs kept under differing experimental conditions revealed that conscious dogs were more sensitive than curarized conscious and anesthetized animals to pentazocine action. In isolated guinea pig atria, the effect of adrenaline (0.1, 0.3, or 1 mg/mL) on the spontaneous breathing rate was significantly augmented by 10 mg/mL pentazocine (p < 0.02 for 0.3 g/mL; p < 0.01 for 0.1 g/mL adrenaline). In dogs, however, adrenaline (1 mg/kg)-induced increases in heart contractility, aortic blood flow, and blood pressure remained almost unaltered in the presence of pentazocine. We concluded that the abovementioned cardiovascular responses to pentazocine and cyclazocine are a consequence of the sum of the two following opposing effects: (i) an indirect reflex activation of sympathetic neuromediation in the periphery, and (ii) a direct membrane effect on the heart leading to bradycardia and a depression in myocardial contractility.

Electrophysiological mechanisms for the antiarrhythmic activities of naloxone on cardiac tissues

It has been reported that naloxone, an opioid antagonist, has antiarrhythmic activity in vivo. In Langendorff perfused rat hearts, we found that ischemia-reperfusion-induced ventricular tachyarrhythmia reverted to normal sinus rhythm after the treatment with naloxone (3 approximately 10 microM). The method of voltage and current clamp were used to study the underlying mechanism of its antiarrhythmic activity on isolated cardiac myocytes. In isolated rat ventricular and in guinea-pig and human atrial myocytes, naloxone prolonged the action potential duration reversibly. In rat ventricular myocytes, naloxone (1 approximately 30 microM) inhibited sodium current (I(Na)), transient outward potassium current (I(to)), and calcium current (I(Ca)). On the contrary, the addition of naloxone significantly increased inward rectifier potassium current (I(K1)). For the effect on I(Na), naloxone did not shift the inactivation curve of I(Na) but retarded the I(Na) recovery rate from inactivation state. Naloxone suppressed I(to) with a significant left-shift of the inactivation curve, however, the time course of I(to) recovery from inactivation was not affected. In guinea pig atrial myocytes, naloxone (10 microM) decreased the delayed rectifier K+ current (IK). These results show that naloxone exert various extent of inhibition on I(Na), I(to), IK and I(Ca). The prolongation of cardiac action potential is related to the inhibition of I(to) and IK. The antiarrhythmic activity of naloxone is more closely related to the inhibition of Na+ and K+ currents rather than the blockade of myocardial opioid receptors.

Failure to reproduce the in vitro cardiac electrophysiological effects of naloxone in humans

1. Opioid receptor antagonists such as naloxone have shown antiarrhythmic activity in animal models of coronary artery occlusion. Studies have indicated that these effects are stereospecific but both isomers of naloxone prolong action potential duration and refractoriness in guinea-pig and rabbit isolated ventricular myocardium (Class III effect). 2. This study was performed to identify whether this Class III effect of naloxone could be reproduced in human myocardium in vivo. Twenty patients with coronary artery disease received intravenous racemic naloxone (1-40 micrograms kg-1 min-1). Surface electrocardiographic parameters were measured and refractory periods were determined during fixed rate pacing by programmed stimulation. 3. The corrected QT interval during sinus rhythm (SR-QTc) was prolonged by 5(3)% (P = 0.06) at a dose of 20 micrograms kg-1 min-1 and by 9(10)% at 40 micrograms kg-1 min-1 (P = 0.03). These small changes were lost at higher paced heart rates. No significant effects on atrial, atrioventricular nodal or ventricular refractoriness were seen. 4. Plasma naloxone concentrations well into the micromolar range were achieved with both of the higher doses of naloxone administered. Plasma beta-endorphin concentrations invariably increased following naloxone infusion. There was no statistical relationship between peak plasma naloxone concentrations and the absolute or percent prolongation of SR-QTc. 5. It seems unlikely that racemic naloxone would have any clinical utility as an antiarrhythmic agent. Racemic naloxone may enhance cardiac adrenergic nerve activity and this receptor mediated effect may have prevented the demonstration of any nonreceptor mediated prolongation of cardiac refractoriness. Studies with the individual stereoisomers of naloxone would be of interest.

Stereospecific antiarrhythmic effects of naloxone against myocardial ischaemia and reperfusion in the dog

1. The effects of both the (-)- and (+)-stereoisomers of naloxone in anaesthetized dogs with arrhythmias induced by acute coronary artery occlusion followed by reperfusion were investigated. 2. Following coronary artery occlusion and reperfusion, all dogs in the control group developed ischaemia- and reperfusion-induced cardiac arrhythmias, bradycardia and hypotension. 3. The opiate antagonist (-)-naloxone prevented the arrhythmias, bradycardia and hypotension due to myocardial ischaemia and reperfusion. 4. The (+)-stereoisomer of naloxone, which is inactive as an opiate antagonist, was without beneficial effects. 5. These results indicate a possible involvement of endogenous opioid peptides in the cardiac effects due to myocardial ischaemia and reperfusion, mediated by opiate receptors through opiate antagonism.