Effect of potassium and calcium deficiency on the monophasic action potential, electrocardiogram and contractility of isolated rabbit hearts

Optical detection of lead and potassium ions using a quantum-dot-based aptamer nanosensor

Quantum-dot (QD) based nanosensors can be used to detect a wide range of molecules. This study examined a nanosensor comprised of thrombin binding aptamer (TBA) with 700NC InGaP QD on the 5 (') terminus and an Au nanoparticle quencher on the 3 (') terminus. Both K(+) and Pb(2+) bind to TBA, resulting in a conformational change that brings the Au quencher closer to the QD. Photoluminescence measurements indicated a decrease in fluorescence corresponding to an increase in either K(+) or Pb(2+) concentration. For healthy blood serum K(+) concentrations (3.5-5 mM), the beacon exhibited 15-17% quenching efficiency. Pb(2+) concentration of 0.48 μM, the threshold for toxicity in serum, yielded 14% quenching. The beacon's ability to detect changes in ion levels in a critical range of concentrations can make it an effective diagnostic tool.

Prolongation of the QT interval in primary aldosteronism

1. Only limited information is available concerning the changes in the electrocardiogram in primary aldosteronism. The aim of the present study was to determine factors influencing the QTc interval in patients with primary aldosteronism. 2. Nineteen patients with primary aldosteronism caused by a Conn's adenoma and 69 patients with essential hypertension, in whom all possible causes of secondary hypertension had been excluded, were included in the present study. Before and 10-20 days after adrenalectomy, blood and electrocardiographic examinations were conducted. 3. Systolic and diastolic blood pressures in primary aldosteronism were found to be comparable to those in essential hypertension. However, the QTc interval was significantly prolonged and serum potassium concentrations were significantly decreased in patients with primary aldosteronism compared with patients with essential hypertension (492.7+/-20.3 vs 428.5+/-3.1 msec for QTc interval, respectively (P<0.01); 3.07+/-0.12 vs 4.07+/-0.05 mEq/L for serum potassium concentrations, respectively (P<0.01)). The QTc interval was significantly correlated with serum potassium concentrations in primary aldosteronism (P=0.0011; r=-0.6902), but not in patients with essential hypertension. 4. Blood pressure significantly decreased after adrenalectomy. Furthermore, serum potassium concentrations increased significantly and did not correlate with the QTc interval after adrenalectomy (P=0.54; r=-0.1500). 5. Our results indicate that the QTc interval is prolonged in patients with primary aldosteronism, probably owing to hypokalaemia.

Electrophysiologic Effects of Salbutamol, a β 2 ‐Selective Agonist

INTRODUCTION

A positive chronotropic effect of beta2 stimulation is well known. Case reports of ventricular arrhythmias during beta2-inhalation therapy have been published. The aim of this study was to asses the overall electrophysiologic effects of the beta2-agonist salbutamol.

METHODS AND RESULTS

Electrophysiologic and hemodynamic variables were measured in 10 healthy volunteers during atrial pacing at baseline and during infusion of salbutamol at two different rates (0.1 and 0.2 microg/kg/min). To characterize beta2-agonist effects, a comparison was made with the beta1-selective agonist dobutamine. Salbutamol infusion produced significant changes in electrophysiologic properties in both myocardial and nodal tissues, with significantly greater effects on nodal properties. The proportional decreases in AV nodal parameters were more pronounced than in the sinus node (P < 0.001). An interesting result was a significant increase in the duration of the QS interval, which in the presence of an unchanged His-Purkinje conduction (HV) represents slower depolarization of the ventricle. QT dispersion also increased.

CONCLUSION

Infusion of salbutamol results in significant electrophysiologic effects on most heart structures, proportionally most pronounced in the AV node. Discordant effects on ventricular conduction, which slowed, and the refractoriness of the ventricular myocardium, which shortened, were seen. QT dispersion was increased.

Asthma medications and their potential adverse effects in the elderly: recommendations for prescribing

The incidence of drug-induced adverse effects is likely to increase as a result of advanced age and exposure of elderly patients to polypharmacy. Therefore, pharmacological therapy of asthma and chronic obstructive pulmonary disease (COPD) in the elderly patient can be potentially hazardous. beta(2)-agonists, administered as therapy for asthma and COPD, have recognised systemic sequelae, such as hypokalaemia and chronotropic effects, which may be life-threatening in susceptible patients. Adverse effects such as hypokalaemia can be aggravated by concomitant treatment with other drugs promoting potassium loss including diuretics, corticosteroids and theophyllines. In addition, relatively minor adverse events associated with the administration of beta(2)-agonists, such as tremor and blood pressure changes, may be of significance to the elderly patient leading to impairment in the quality of life. However, long-term treatment with beta(2)-agonists may reduce the incidence of drug-induced adverse effects as a result of beta-receptor subsensitivity. Oral and inhaled corticosteroids have been used for the treatment of acute asthma and COPD in the elderly patient. Long-term treatment with oral corticosteroids can result in serious systemic adverse effects such as suppressed adrenal function, bone loss, skin thinning and cataract formation. In contrast to beta(2)-agonists, oral corticosteroids can upregulate beta(2)-adrenoceptors and thereby potentiate the systemic sequelae of beta(2)-agonists. Hence, oral corticosteroids should be administered with caution for as short a duration as possible. Inhaled corticosteroids appear to be relatively well tolerated when administered at doses below approximately 1000 microg. However, larger doses of inhaled corticosteroids may affect hypothalamic-pituitary-adrenal function and bone turnover. In the case of inhaled corticosteroids, spacer devices, often used in older patients who cannot operate metered dose inhalers, can potentiate the systemic sequelae of both corticosteroids and beta(2)-agonists. The use of theophyllines in the treatment of COPD or chronic asthma is controversial. Theophyllines have a wide adverse effect profile and are prone to drug-drug interactions. The adverse effects may be mild or life threatening and include nausea and vomiting or sinus and supraventricular tachycardias. Therefore, theophyllines should be prescribed with extreme caution to elderly patients with asthma or COPD. In contrast, inhaled anticholinergic drugs such as ipratropium bromide and oxitropium bromide are generally safe in elderly patients and have useful bronchodilator function. Commonly reported adverse effects are an unpleasant taste and dryness of the mouth. When used as first-line therapy, anticholinergic drugs may optimise the bronchodilator effects of low-dose inhaled beta(2)-agonists in patients with chronic airflow obstruction, and hence obviate the need for higher doses.

Drug-related torsades de pointes in the isolated rabbit heart: comparison of clofilium, d,l-sotalol, and erythromycin

Torsades de pointes is a potentially life-threatening form of polymorphic ventricular tachyarrhythmia typically seen in the presence of repolarization-prolonging agents. We investigated this particular form of tachyarrhythmia in the isolated, perfused rabbit heart. The experimental model was designed to reproduce conditions that are clinically known to be associated with an increased propensity to the development of torsades de pointes. The class III agent clofilium (1 microM) and d,l-sotalol (10 microM), as well as the antibiotic erythromycin (30-150 microM) were infused in the presence of either normal (5.88 mM) or low (1.5 mM) potassium concentration in sinus-driven or atrioventricular (AV)-blocked hearts. Ventricular tachyarrhythmias spontaneously emerged in the clofilium-, d,l-sotalol-, and erythromycin-treated AV-blocked hearts. The episodes showed typical features of torsades de pointes found in humans. They developed within 4-12 min after the onset of infusion, were normally nonsustained, and only rarely degenerated into ventricular fibrillation. Electrical stimulation at cycle lengths <600 ms and perfusion with MgSO4 suppressed arrhythmic activity. In the d,l-sotalol- and erythromycin-treated hearts, torsades de pointes occurred only in the presence of hypokalemia and bradycardia, whereas, in the presence of clofilium, bradycardia alone caused torsades de pointes. Monophasic action-potential recordings demonstrated early afterdepolarizations in endocardial and epicardial recordings. Thus the isolated AV-blocked rabbit heart represents a model for studying drug-related torsades de pointes and its mechanism.

Potassium and anaesthesia

Potassium is the principle intracellular ion, and its concentration and gradients greatly influence the electrical activity of excitable membranes. Because anaesthesia is so intimately involved with electrically active cells, potassium concentrations in surgical patients have received considerable attention in diagnostic and therapeutic applications. With the ongoing evolution in the indications for potassium, it is important to review the role of potassium in cellular activity, in storage and regulation, in diseases that alter potassium homeostasis, and in the therapeutic implications of perioperative alterations of potassium concentration. A rational approach to abnormal potassium values and the use of potassium in the operating room is sought, based on a physiological understanding of risks and benefits.

The effects of enalapril and spironolactone on terbutaline-induced hypokalemia

OBJECTIVE

To investigate whether enalapril (E) 10 mg and spironolactone (S) 100 mg attenuate the hypokalemic effect of inhaled terbutaline (T).

DESIGN

Randomized single-blind crossover. Subjects received the following treatment combinations: (a) placebo (P), (b) T alone, (c) T + E, or (d) T + S.

SETTING

University Department of Clinical Pharmacology.

PARTICIPANTS

Twenty healthy volunteers (ten male, ten female) of mean age 22.8 +/- 3.1 years.

MAIN OUTCOME MEASURES

Serum potassium, magnesium, ECG changes (R-R interval, T wave, and QTc interval) for 4 h after terbutaline inhalation.

MAIN RESULTS

Baseline serum potassium levels were higher following prior treatment with E and S; P, 3.78 mmol/L (3.67 to 3.88); T + E, 3.93 mmol-1 (3.82 to 4.03); and T + S, 4.03 mmol/L (3.93 to 4.14) (p less than 0.05). Mean potassium concentrations over 4 h were also higher following prior treatment with E and S; T, 3.58 mmol/L (3.54 to 3.63); T + E, 3.68 mmol/L (3.64 to 3.72) (p less than 0.05); and T + S, 3.73 mmol/L (3.68 to 3.78) (p less than 0.01).

CONCLUSIONS

Enalapril and spironolactone protect against the fall in serum potassium over 4 h by elevating baseline potassium concentration. These potassium-sparing drugs, however, should not be used to prevent the hypokalemic and electrocardiographic sequelae of inhaled beta 2-agonists.

Inhaled beta 2-adrenoceptor agonists in asthma: help or hindrance?

Conventional low doses of inhaled beta 2-adrenoceptor agonists produce effective bronchodilation without systemic effects. Higher doses of inhaled beta 2-adrenoceptor agonists may produce substantial improvements in bronchodilator response, which may be helpful to patients with more severe airway obstruction. At higher than recommended doses, in asthmatic patients, fenoterol appears to cause greater dose-related systemic beta 2-responses compared with salbutamol or terbutaline, although there is no evidence to suggest that fenoterol is any less beta 2-selective in vivo. Furthermore, tolerance develops to systemic but not to bronchodilator effects during chronic treatment with inhaled beta 2-adrenoceptor agonists. The link between asthma mortality and systemic adverse effects of inhaled beta 2-adrenoceptor agonists at present remains unproven. A critical reappraisal of the regular use of inhaled beta 2-adrenoceptor agonists including long-acting drugs is now indicated in the light of their possible adverse effects on disease control. Patients requiring regular use of inhaled beta 2-adrenoceptor agonists should be given additional anti-inflammatory therapy with inhaled corticosteroids.

Risks versus benefits of inhaled beta 2-agonists in the management of asthma

The therapeutic goal for the treatment of asthma should be to suppress bronchial mucosal inflammation with preventive drugs such as inhaled corticosteroids, and to relieve symptoms of wheezing and breathlessness with bronchodilator drugs. The lower recommended doses of inhaled beta 2-agonists produce rapid effective bronchodilatation without systemic adverse effects; higher doses may produce substantial improvements in airway response which may help patients with more severe airflow obstruction. Higher doses of inhaled beta 2-agonists also cause dose-related systemic adverse beta 2 effects including tremor, tachycardia, hypokalaemia and associated electrocardiographic sequelae. In this respect, although fenoterol appears to cause greater extrapulmonary beta 2-mediated adverse effects at higher doses, there is no evidence to suggest that it is any less beta 2-selective. There is also some evidence to suggest that use of regular inhaled beta 2-agonists may cause increased bronchial hyperreactivity and possibly deterioration in disease control. Patients who require such regular use should therefore be given additional anti-inflammatory therapy with inhaled corticosteroids. The recent availability of novel, longer-acting inhaled beta 2-agonists such as salmeterol and formoterol will also make necessary a careful reappraisal of their long term use in patients with asthma.

Methods and limitations of an experimental model of long QT syndrome

An experimental model of the long QT syndrome has been developed in conscious dogs. This report discusses the methods used in its preparation and the strengths and weaknesses of the model. This new model is suitable for screening the bradycardia-dependent proarrhythmic effects of drugs and for studying the electrophysiology of "torsades de pointes." Permanent bradycardia (RR: 1558 +/- 83 ms) was obtained in 37 dogs by chemically-induced complete atrioventricular block. A 10% further increase of ventricular repolarization (QT: 306 +/- 7.0 ms to 331 +/- 5.5 ms) was obtained in 28 of these dogs by diuretic-induced hypokalemia. Diuretics, despite saline replacement, induced some degree of functional renal failure and extracellular volume losses. The QT interval increased although ventricular cycle length decreased slightly. These biological and electrophysiological parameters were reproducible except for a slow increase in plasma creatinine. Cardiac failure and sudden death rarely occurred. The most severe, but reversible, renal failure occurred in some dogs given the highest diuretic doses. Hypokalemia resulted in ventricular arrhythmias in only 6 dogs, 2 of them exhibiting runs of ventricular tachycardia and even "torsade de pointes" as their potassium levels fell below 2 mmol/L. The results of studies with several drugs using the model, with or without hypokalemia, or with bradycardia worsened by propranolol are analysed.

Hypokalemic and ECG sequelae of combined beta-agonist/diuretic therapy. Protection by conventional doses of spironolactone but not triamterene

Salbutamol (Albuterol) and diuretics are commonly prescribed together in patients with airflow obstruction and are associated with electrocardiographic effects. We have now investigated whether the use of potassium-sparing drugs might prevent the ECG sequelae of such combined therapy. Ten healthy subjects received seven days of randomized treatments with: placebo, bendrofluazide (5 mg), bendrofluazide plus triamterene 50 mg (conventional dose), or triamterene 200 mg (high dose), and bendrofluazide plus spironolactone (100 mg). Potassium and ECG responses to inhaled salbutamol, 2 mg, were measured after each treatment period. The T-wave flattening in response to bendrofluazide and salbutamol (0.24[CI, 0.19 to 0.29]mV) was attenuated by the addition of triamterene, 200 mg (0.33[CI, 0.28 to 0.37]mV; p less than 0.05) and spironolactone 100 mg (0.42[CI, 0.37 to 0.47]mV; p less than 0.01), but not by triamterene 50 mg (0.25[CI, 0.20 to 0.30]mV). Spironolactone and high dose triamterene also diminished the frequency of U waves and ST depression. The ECG effects mirrored hypokalemic responses which were also blunted by high dose (p less than 0.01) but not low dose triamterene, as well as by spironolactone (p less than 0.001). Thus, the use of high dose triamterene and spironolactone protected against the hypokalemic and ECG sequelae of combined beta-agonist/diuretic therapy, whereas a conventional dose of triamterene had no effect. These findings may be important in the prevention of a potentially dangerous interaction in susceptible patients taking this combination of drugs.

Comparison of the effects of prolonged treatment with low and high doses of inhaled terbutaline on beta-adrenoceptor responsiveness in patients with chronic obstructive pulmonary disease

Eleven patients with chronic obstructive pulmonary disease (age, 61 +/- 2 yr; FEV1, 1.36 +/- 0.24 L, 46 +/- 7% predicted) were given 4 wk of treatment with either a conventional low dose of inhaled terbutaline (LDT), 500 micrograms four times a day, or a high dose of inhaled terbutaline (HDT), 2,000 micrograms four times a day, delivered by a spacer. A randomized double-blind crossover design was used with 2-wk run-in and washout periods, when ipratropium bromide was substituted for inhaled beta-agonists. Dose response curves (DRC) to cumulative doubling doses of inhaled terbutaline (125 to 4,000 micrograms) were constructed after each treatment period, and baseline spirometry, finger tremor (Tr), plasma potassium (K), plasma cAMP, and ECG (HR and T wave) were measured at each dose step of the DRC. Daily PEFR measurements (A.M. and P.M.) and Holter ECG were performed during run-in and treatment periods. Baseline values for FEV1 were not significantly different during run-in, treatment, or washout periods. There were dose-related increases in FEV1 (p less than 0.0001) with no significant differences between DRC after treatment with HDT compared with those with LDT: delta FEV1 max, 0.46 +/- 0.14 L, 15.5 +/- 3.7% predicted (HDT); 0.50 +/- 0.11 L, 16.0 +/- 3.1% predicted (LDT). There were also no differences between DRC for delta FVC: 1.08 +/- 0.22 L, 31.1 +/- 5.4% predicted (HDT); 0.99 +/- 0.14 L, 28.5 +/- 3.8% predicted (LDT). There were no significant changes in K or HR in response to cumulative doses of terbutaline after either treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Magnesium treatment of ventricular arrhythmias

The association between marked hypomagnesemia and arrhythmias, particularly those associated with digitalis intoxication, has long been recognized. More recently, acute intervention with magnesium in patients who are not hypomagnesemic has demonstrated arrhythmia suppression in 3 settings: digitalis intoxication, long QT-related arrhythmias and arrhythmias after acute myocardial infarction. Although the electrophysiologic effects of magnesium are not clearly understood, magnesium treatment is emerging as an important adjunct in managing certain serious ventricular arrhythmias.

Electrocardiographic findings and frequency of arrhythmias in Bartter's syndrome

Twenty four hour electrocardiograms in 20 patients with Bartter's syndrome, a disorder associated with chronic potassium deficiency, were analysed for atrial and ventricular extrasystoles, pauses (RR interval greater than 2 s), and heart rate. The 12 lead resting electrocardiogram was also evaluated. There were slight electrocardiographic changes with ST segment depression (greater than or equal to - 0.5 mm) in seven patients, flat or low amplitude T waves in seven, and U waves (greater than or equal to + 1.0 mm) in three patients. The QT interval was prolonged in 18 patients. Nine patients had one or more ventricular extrasystoles in 24 hours. Only two patients had more than 200 ventricular extrasystoles in 24 hours. No patient had ventricular tachycardia. A total of nine patients had one or more atrial extrasystoles in 24 hours, but only one patient had more than 200 in 24 hours. One patient had an attack of non-sustained supraventricular tachycardia. No patient had pauses. Dangerous tachycardia was rare in these patients with chronic potassium deficiency caused by Bartter's syndrome. The general pattern of slight electrocardiographic changes may reflect an adaptation of the myocardium to hypokalaemia. Further studies are, however, needed to determine whether these findings are relevant to long term prognosis.

Differential response to right and left ansae subclaviae stimulation of early afterdepolarizations and ventricular tachycardia induced by cesium in dogs

Early afterdepolarizations (EADs) are depolarizing potentials that occur before complete repolarization. They may be important in the acquired and possibly the idiopathic long QT syndrome and associated ventricular tachycardia (VT). The purpose of these experiments was to study in 20 open-chest dogs the effects of sympathetic stimulation on EADs and VT produced with cesium chloride (84 mg/kg i.v.) alone or combined with left (LAS), right (RAS), or bilateral (BAS) ansae subclaviae stimulation (2 Hz, 4 msec, 2 mA). We compared the EAD amplitude and area as a percentage of monophasic action potential amplitude and area, respectively, recorded simultaneously with contact electrodes from right (RV) and left ventricular (LV) endocardium and recorded the prevalence of VT induction during each intervention. Both LAS and BAS produced left ventricular EADs with larger amplitudes and areas than did RAS or cesium alone. BAS and LAS produced larger EADs recorded from the LV than from the RV. Cesium produced VT in six of 20 dogs, RAS in three of 20, BAS in 12 of 20, and LAS in 16 of 20. Norepinephrine (0.1-1.5 micrograms/kg/min) caused VT in all dogs by producing a dose-related increase in EAD amplitude that was similar in RV and LV, suggesting that the response of RV and LV EADs to catecholamine stimulation was not intrinsically different. During stimulation of left ansae subclaviae at increasing frequencies (1, 2, 4, and 6 Hz), EADs were significantly larger in LV than in RV at all stimulus frequencies, and the amplitude of EADs in both ventricles increased with increasing stimulus frequencies. Based on the increased LV amplitude and area of cesium chloride-induced EADs during LAS and BAS, with EAD amplitude dependent on the frequency of LAS but with an equal RV and LV EAD amplitude during norepinephrine infusion, it is possible that more norepinephrine released into the LV during LAS and BAS compared with RAS causes larger amplitude LV EADs that reach threshold to cause VT more often. Thus, quantitative differences between the effects of left and right stellate ganglia stimulation rather than qualitative differences or imbalance may account for the arrhythmogenic potential of the left stellate ganglion.

QTU prolongation and polymorphic ventricular tachyarrhythmias due to bradycardia-dependent early afterdepolarizations. Afterdepolarizations and ventricular arrhythmias

Polymorphic ventricular tachyarrhythmias occurred spontaneously during bradycardia in dogs given the inotropic polypeptide anthopleurin-A (AP-A). The arrhythmia was investigated in in vitro and in vivo experiments. In in vitro experiments, AP-A (50 micrograms/l) produced bradycardia-dependent prolongation of action potential duration that was more pronounced in Purkinje than in muscle fibers. Only Purkinje fibers developed early afterdepolarizations (EAD) and triggered activity. These effects could be abolished by rapid pacing, lidocaine (4 mg/l), or tetrodotoxin (1 mg/l). In vivo experiments were conducted in anesthetized healthy dogs with simultaneous recording of surface ECG, monophasic action potentials from the endocardial and epicardial surface of the left ventricle by contact electrode catheter technique, and transmembrane action potentials from the epicardial surface of the left ventricle with a floating microelectrode technique. AP-A in a dose comparable to that used in vitro (4 micrograms/kg, i.v. bolus) resulted in bradycardia-dependent marked prolongation of both monophasic and transmembrane action potentials. An EAD gradually appeared on both recordings but was more marked in endocardial monophasic action potentials. Eventually, a premature ventricular depolarization arose from or very close to the peak of the EAD. The prolongation of action potentials was associated with similar prolongation of the QTU interval in surface ECG, and in some experiments, the EAD corresponded to a distinct prominent U wave. A ventricular premature depolarization arose from the U or TU complex and initiated polymorphic ventricular tachyarrhythmias that terminated spontaneously or degenerated into ventricular fibrillation. These effects were reversed by rapid pacing or lidocaine (1 mg/kg). The present study provides evidence in support of the hypothesis that AP-A-induced ventricular tachyarrhythmias are due to bradycardia-dependent EAD and triggered activity.

Magnesium suppression of early afterdepolarizations and ventricular tachyarrhythmias induced by cesium in dogs

The mechanism by which magnesium therapy suppresses some ventricular tachyarrhythmias characterized by a prolonged QT interval (e.g., torsades de pointes) is unknown. Since early afterdepolarizations have been proposed as a cause of the long QT syndrome and the related ventricular tachyarrhythmias, we hypothesized that magnesium therapy would suppress both the early afterdepolarizations and the ventricular arrhythmias. The present study was performed to test that hypothesis. Using monophasic action potentials (MAP) recorded with a contact electrode from the right ventricular endocardium to demonstrate early afterdepolarizations, cesium chloride (168 mg/kg iv) was administered before, during, and 1 to 2 hr after discontinuation of a magnesium infusion (1 to 2 mg/kg/min for 20 to 30 min). Before magnesium infusion, cesium induced early afterdepolarizations that were 49.7 +/- 1.6% (mean +/- SE) of the amplitude of the corresponding monophasic action potential. The amplitude of the early afterdepolarization decreased to 31.2 +/- 3.8% of the MAP amplitude during magnesium infusion (p less than .003) and increased to 48.0 +/- 4.0% 1 to 2 hr after termination of the magnesium infusion (p less than .003). Cesium induced sustained monomorphic ventricular tachycardia, torsades de pointes, or ventricular fibrillation in 12 of 13 dogs before magnesium infusion, and in eight of 11 dogs 1 to 2 hr after stopping infusion, but in only three of 13 dogs during magnesium infusion. Cesium prolonged the corrected QT interval from 338 +/- 16 msec (control) to 387 +/- 14 msec before (p less than .003), 356 +/- 12 msec during (p less than .003), and 406 +/- 16 msec after stopping the magnesium infusion (p less than .003).(ABSTRACT TRUNCATED AT 250 WORDS)

Contributions of cellular electrophysiology to the understanding of the electrocardiogram

The understanding of cardiac action potential and membrane currents has broadened the theoretical foundation and enhanced the clinical usefulness of the electrocardiogram. An improved understanding of the morphology of the electrocardiographic waveform has resulted from: correlations between Vmax of depolarization and QRS complex, plateau of the ventricular action potential and S-T segment, terminal repolarization and T-wave, from definitions of action potential differences responsible for the T-wave, and recordings of action potential alternans. Cellular electrophysiology has contributed to the understanding of certain mechanisms of cardiac standstill. Many disturbances of conduction and refractoriness associated with ventricular arrhythmias can be attributed to the following derangements at the cellular level: slowing of terminal repolarization, development of diastolic depolarization in fibers with stable resting membrane potential, after-depolarizations, currents of injury resulting from non-uniform polarization, increased dispersion of action potential durations, and co-existence of slow conduction and short premature action potentials.

Effects of low potassium or magnesium concentrations on isolated cardiac tissue

Low potassium and magnesium concentrations not only cause cardiac arrhythmias, but also interfere with the efficacy or enhance the toxicity of drugs commonly used to treat patients with heart disease. Arrhythmias may develop in hypokalemia due to enhanced normal automaticity, abnormal automaticity, or slowed conduction; moreover, hypokalemia is associated with enhanced digitalis toxicity, quinidine-related Torsades de pointes, and interference with the antiarrhythmic activity of quinidine. Hypomagnesemia, especially in the presence of other electrolyte abnormalities, also affects automaticity and is associated with decreased efficacy of digitalis and with quinidine-related Torsades de pointes. Therefore, treatment that controls hypertension without causing electrolyte abnormalities is preferable for patients who are at risk of arrhythmias, or who are receiving drugs such as digitalis or quinidine.

Mechanism of cardiac arrhythmias induced by epinephrine in dogs with hypokalemia

To investigate the mechanism of ventricular arrhythmias induced by epinephrine in dogs with hypokalemia, 30 adult mongrel dogs were separated into a control group (n = 13) and a hypokalemia group (n = 17). In the hypokalemia group, sodium polystyrene sulfonate (5 g/kg body weight) was infused into the colon. In both groups, the serum concentrations of sodium, potassium and calcium were measured every 15 minutes for 60 minutes. The mean (+/- standard deviation) serum potassium level of the hypokalemia group decreased significantly from 3.81 +/- 0.21 to 2.92 +/- 0.36 mEq/liter; there were no significant changes in other electrolytes. After 60 minutes, epinephrine (10 micrograms/kg) was injected intravenously in the hypokalemia and control groups, and the arrhythmia ratio (the number of ventricular ectopic beats divided by the total heart rate) was calculated for 5 minutes. Each group was further classified into subgroups of dogs with an arrhythmia ratio higher or lower than 10%. An arrhythmia ratio over 10% was observed in 7.7% of the control group and 53% of the hypokalemia group. Immediately after 5 minutes of epinephrine injection, myocardial mitochondria and plasma membrane fraction were prepared from each group. Mitochondrial calcium content and phospholipase activity of plasma membrane fraction were determined. Significant increases in both mitochondrial calcium content and phospholipase activity were observed in the dogs with hypokalemia and an arrhythmia ratio greater than 10%.(ABSTRACT TRUNCATED AT 250 WORDS)

The monophasic action potential upstroke: a means of characterizing local conduction

The upstrokes of monophasic action potentials (MAPs) recorded with an extracellular pressure electrode were characterized in isolated canine tissue preparations in vitro. The characteristics of the MAP upstroke were compared with those of the local action potential foot as well as with the characteristics of approaching electrical activation during uniform and asynchronous conduction. The upstroke of the MAP was exponential during uniform conduction. The time constant of rise of the MAP upstroke (TMAP) correlated with that of the action potential foot (Tfoot): TMAP + 1.01 Tfoot + 0.50; r2 = .80. Furthermore, changes in Tfoot with alterations in cycle length were associated with similar changes in TMAP: Tfoot = 1.06 TMAP - 0.11; r2 = .78. In addition, TMAP and Tfoot both deviated from exponential during asynchronous activation; the inflections that developed in the MAP upstroke correlated in time with intracellular action potential upstrokes that were asynchronous in onset in these tissues. Finally, the field of view of the MAP was determined and was found to be dependent in part on tissue architecture and the space constant. Specifically, the field of view of the MAP was found to be greater parallel compared with transverse to fiber orientation (6.02 +/- 1.74 vs 3.03 +/- 1.10 mm; p less than .01). These data suggest that the MAP upstroke may be used to define and characterize local electrical activation. The relatively large field of view of the MAP suggests that this technique may be a sensitive means to record focal membrane phenomena in vivo.

Arrhythmias in patients with drug toxicity, electrolyte, and endocrine disturbances

The common rhythm disturbances related to electrolyte imbalance are due predominantly to abnormalities of potassium. An understanding of the mechanism underlying these abnormalities is facilitated by a brief review of normal electrical activity during impulse propagation in cardiac tissue. Also discussed are the actions of all cardioactive and antiarrhythmic drugs on membrane permeability to ions. Lastly, the nonspecific arrhythmias associated with endocrine disturbances are outlined.

Hypopotassemia-induced U wave in electrocardiogram (an experimental study for possible mechanism)

To define the mechanism of hypopotassemia-induced U wave change, we performed open-chest experiments in 20 dogs and obtained following results: (1) During hemodialysis U wave amplitude of epicardial electrogram increased significantly (p less than 0.05) from 0.4 +/- 0.3 (mean +/- SD) to 1.2 +/- 0.5 mV with lowering serum potassium (K) concentrations from 3.4 +/- 0.4 to 2.2 +/- 0.2 mEq/l (p less than 0.001) in 6 dogs. (2) These hypopotassemia-induced U waves disappeared after instillation of high K+ solution into the regional coronary artery, without detectable increase in systemic plasma K+ concentration. (3) In 10 dogs, huge (0.5-1.0 mV), delayed (corrected Q-U apex = 0.66 +/- 0.16) positive U waves were induced at the epicardial surface by infusion of K+-free, Ca++-rich Tyrode solution into the regional coronary artery, whereas no appearance of negative U waves was shown at the endocardial surface. (4) In all of 6 dogs with infusion of K+-free, Ca++-rich solution, monophasic action potential registered with suction electrode showed early afterhyperpolarization, which corresponded to appearance of huge positive U waves. These data indicate that hypopotassemia-induced U wave may reflect early afterhyperpolarization developed in the ventricular muscle.

Cardiovascular function in dogs with acute hypokalemia

The effects of acute hypokalemia on plasma electrolytes, cardiovascular function, osmolality, and hematocrit were investigated in anesthetized dogs for 2 hours. There was progressive increase in the total systemic vascular resistance, but no change in the osmolality and blood hematocrit. All of the hemodynamic parameters decreased except the preferred index of myocardial contractility, [dp/dt]/IIP, which increased during hypokalemia. The changes in this index of myocardial contractility were associated with changes in the plasma potassium but not the plasma sodium. The results suggest that hypokalemia-induced increases in myocardial contractility might be associated with an increased influx of Ca++ as a result of hypokalemia-induced inhibition of sarcolemmal Mg++ -dependent, Na+-K+-ATPase.

The prominent electrocardiographic conduction aspects of hypokalemia in a patient with periodic paralysis

This article documents striking atrioventricular and intraventricular conduction disturbances in marked hypokalemia, in a Negro male with periodic paralysis. The authors discuss cardiac conduction in hypokalemia.

Effects of low and high concentrations of potassium on the simultaneously recorded Purkinje and ventricular action potentials of the perfused pig moderator band

The use of the perfused pig moderator band has allowed us to study the rapid simultaneous changes in Purkinje and ventricular action potentials induced by perfusing solutions of high (10 to 12 m M ) and low (0.6 to 0.8 m M ) K concentrations. High K shortened the plateau more in Purkinje fibers than in ventricular fibers and decreased the difference between the action potential durations of the two fiber types. Low K prolonged the plateau in Purkinje fibers but shortened it in ventricular fibers and increased the difference between the action potential durations. Low K initially hyperpolarized both Purkinje and ventricular fibers. However, the resting potential of the Purkinje fiber subsequently decreased as phase-4 depolarization increased. The decreased maximum repolarization potential associated with low K-induced pacemaker activity was time rather than voltage dependent. When the perfusate was changed from low K to control (K = 4.8 m M ), phase-4 depolarization was rapidly suppressed and the action potential of the Purkinje fiber was shortened to less than that produced by high K, and then changes in amplitude of the resting and action potentials occurred. Our observations help to explain some of the effects of low and high K on rhythm and conduction.

Effects of cell density and low K on action potentials of cultured chick heart cells

Hearts from 7-day-old chick embryos were separated by 0.05% trypsin and subsequently cultured in a medium containing low (1.4 mM) and normal (4.4 to 5.6 mM) potassium (K) concentration. A method was developed for controlling environmental conditions (pH, temperature, osmolarity) of 1- to 3-day. old cultured heart cells during intracellular recording with microelectrodes. No apparent differences were noted in the measurement of the several components of the action potential as a function of incubation time. Action potential configurations recorded from cells in dense areas of a culture were noticeably different from those potentials obtained in sparse areas of the same culture; the latter were similar to those of the slowly conducting cardiac junctional tissues. This difference was observed both in the presence of normal and low K. The transmembrane potential recorded from cells in densely populated areas in the normal K medium was characterized by large amplitude and steady, high resting potential whereas that recorded from cells in similar areas in the low K medium had a small amplitude, low resting potential and prominent diastolic depolarization. The tissue cultured in low K also showed a tendency to fibrillate and spontaneously defibrillate.

Effect of calcium concentration on the transmembrane potentials of Purkinje fibers

The effects of variation in calcium concentration on the action potential of Purkinje fibers isolated from the dog heart were studied. Action potentials recorded during perfusion with Tyrode solution containing 2.7 mM calcium chloride were compared with those recorded during subsequent perfusion with solutions containing 0.675 (1/4X), 1.35 (1/2X), 5.4 (2X), or 10.8 (4X) mM calcium chloride. In both 1/2X and 1/4X solutions, the time required to repolarize to minus 60 mv and the duration of the action potential were increased. There were significant decreases in the slopes of phases 2 and 3 and the terminal phase of repolarization, while the slope of phase 1 increased. In 2X or 4X solutions, repolarization was speeded mainly by an earlier onset of phase 3. As a result the time to repolarize to minus 60 mv and the duration of the action potential were decreased significantly. The slope of phase 1 decreased significantly in 4X solution. In both high calcium solutions the rate and magnitude of diastolic depolarization increased. It was shown that the rate of the calcium-enhanced diastolic depolarization was dependent on the stimulus rate. The possible role of these changes in transmembrane potential in causing the ventricular arrhythmias following CaCl 2 infusion in intact animals is discussed.

Oxygen cost of electrical activation of the heart

The present study was undertaken to define the O 2 requirements of electrical activation of the heart. Thirteen isolated canine hearts were perfused with whole blood from which calcium had been removed with an exchange resin and to which the disodium salt of ethylenediaminetetraacetic acid had been added. Spontaneous depolarizations were suppressed by raising the plasma potassium to an average concentration of 7.5 mEq/liter, and the right ventricle was stimulated electrically at controlled frequencies. Although the stimuli produced propagated depolarizations, neither high-sensitivity strain gauge arches sutured to both ventricles, nor careful visual observation, showed any evidence of associated contractile activity. Ten of the hearts were studied with repetitive single stimuli applied in the conventional fashion, while the remaining three hearts were subjected to paired electrical stimulation. Changes of myocardial O 2 consumption (MV · O 2 ) were measured at a constant coronary blood flow and arterial O 2 content by determining changes of venous O 2 content from a continuous recording of venous PO 2 . Increases of the frequency of depolarization were uniformly accompanied by small increases of MV · O 2 , averaging 0.40 ± 0.04 (SEM) µliter/activation/100 g. The increases were of the same order of magnitude in the hearts subjected to paired electrical stimulation as in the hearts studied with single stimulation, suggesting that the altered frequency and rhythm of depolarization in paired electrical stimulation cannot account for the marked increase of MV · O 2 which this intervention produces in the intact heart. It is concluded that the amount of O 2 required for electrical activation of the heart is less than 1% of the total O 2 consumption of the normally working heart.