The influence of pH on th electrophysiological effects of lidocaine in guinea pig ventricular myocardium

Pharmacological and toxicological activity of RSD921, a novel sodium channel blocker

BACKGROUND

RSD921, the R,R enantiomer of the kappa (k) agonist PD117,302, lacks significant activity on opioid receptors.

METHODS

The pharmacological and toxicological actions were studied with reference to cardiovascular, cardiac, antiarrhythmic, toxic and local anaesthetic activity.

RESULTS

In rats, dogs and baboons, RSD921 dose-dependently reduced blood pressure and heart rate. In a manner consistent with sodium channel blockade it prolonged the PR and QRS intervals of the ECG. Furthermore, in rats and NHP, RSD921 increased the threshold currents for induction of extra-systoles and ventricular fibrillation (VFt), and prolonged effective refractory period (ERP). In rats, RSD921 was protective against arrhythmias induced by electrical stimulation and coronary artery occlusion. Application of RSD921 to voltage-clamped rat cardiac myocytes blocked sodium currents. RSD921 also blocked transient (ito) and sustained (IKsus) outward potassium currents, albeit with reduced potency relative to sodium current blockade. Sodium channel blockade due to RSD921 in myocytes and isolated hearts was enhanced under ischaemic conditions (low pH and high extracellular potassium concentration). When tested on the cardiac, neuronal and skeletal muscle forms of sodium channels expressed in Xenopus laevis oocytes, RSD921 produced equipotent tonic block of sodium currents, enhanced channel block at reduced pH (6.4) and marked use-dependent block of the cardiac isoform. RSD921 had limited but quantifiable effects in subacute toxicology studies in rats and dogs. Pharmacokinetic analyses were performed in baboons. Plasma concentrations producing cardiac actions in vivo after intravenous administration of RSD921 were similar to the concentrations effective in the in vitro assays utilized.

CONCLUSIONS

RSD921 primarily blocks sodium currents, and possesses antiarrhythmic and local anaesthetic activity.

Mechanisms of Drug Binding to Voltage-Gated Sodium Channels

Voltage-gated sodium (Na+) channels are expressed in virtually all electrically excitable tissues and are essential for muscle contraction and the conduction of impulses within the peripheral and central nervous systems. Genetic disorders that disrupt the function of these channels produce an array of Na+ channelopathies resulting in neuronal impairment, chronic pain, neuromuscular pathologies, and cardiac arrhythmias. Because of their importance to the conduction of electrical signals, Na+ channels are the target of a wide variety of local anesthetic, antiarrhythmic, anticonvulsant, and antidepressant drugs. The voltage-gated family of Na+ channels is composed of α-subunits that encode for the voltage sensor domains and the Na+-selective permeation pore. In vivo, Na+ channel α-subunits are associated with one or more accessory β-subunits (β1-β4) that regulate gating properties, trafficking, and cell-surface expression of the channels. The permeation pore of Na+ channels is divided in two parts: the outer mouth of the pore is the site of the ion selectivity filter, while the inner cytoplasmic pore serves as the channel activation gate. The cytoplasmic lining of the permeation pore is formed by the S6 segments that include highly conserved aromatic amino acids important for drug binding. These residues are believed to undergo voltage-dependent conformational changes that alter drug binding as the channels cycle through the closed, open, and inactivated states. The purpose of this chapter is to broadly review the mechanisms of Na+ channel gating and the models used to describe drug binding and Na+ channel inhibition.

Effects of Na+ channel blockers on the restitution of refractory period, conduction time, and excitation wavelength in perfused guinea-pig heart

Na⁺ channel blockers flecainide and quinidine can increase propensity to ventricular tachyarrhythmia, whereas lidocaine and mexiletine are recognized as safe antiarrhythmics. Clinically, ventricular fibrillation is often precipitated by transient tachycardia that reduces action potential duration, suggesting that a critical shortening of the excitation wavelength (EW) may contribute to the arrhythmic substrate. This study examined whether different I_Na blockers can produce contrasting effects on the rate adaptation of the EW, which would explain the difference in their safety profile. In perfused guinea-pig hearts, effective refractory periods (ERP), conduction times, and EW values were determined over a wide range of cardiac pacing intervals. All I_Na blockers tested were found to flatten the slope of ERP restitution, indicating antiarrhythmic tendency. However, with flecainide and quinidine, the beneficial changes in ERP were reversed owing to the use-dependent conduction slowing, thereby leading to significantly steepened restitution of the EW. In contrast, lidocaine and mexiletine had no effect on ventricular conduction, and therefore reduced the slope of the EW restitution, as expected from their effect on ERP. These findings suggest that the slope of the EW restitution is an important electrophysiological determinant which can discriminate I_Na blockers with proarrhythmic and antiarrhythmic profile.

Role of voltage-gated sodium, potassium and calcium channels in the development of cocaine-associated cardiac arrhythmias

Cocaine is a highly active stimulant that alters dopamine metabolism in the central nervous system resulting in a feeling of euphoria that with time can lead to addictive behaviours. Cocaine has numerous deleterious effects in humans including seizures, vasoconstriction, ischaemia, increased heart rate and blood pressure, cardiac arrhythmias and sudden death. The cardiotoxic effects of cocaine are indirectly mediated by an increase in sympathomimetic stimulation to the heart and coronary vasculature and by a direct effect on the ion channels responsible for maintaining the electrical excitability of the heart. The direct and indirect effects of cocaine work in tandem to disrupt the co-ordinated electrical activity of the heart and have been associated with life-threatening cardiac arrhythmias. This review focuses on the direct effects of cocaine on cardiac ion channels, with particular focus on sodium, potassium and calcium channels, and on the contributions of these channels to cocaine-induced arrhythmias. Companion articles in this edition of the journal examine the epidemiology of cocaine use (Wood & Dargan) and the treatment of cocaine-associated arrhythmias (Hoffmann).

Exploring the role of pH in modulating the effects of lidocaine in virtual ischemic tissue

Lidocaine is a class I antiarrhytmic drug that blocks Na(+) channels and exists in both neutral and charged forms at a physiological pH. In this work, a mathematical model of pH and the frequency-modulated effects of lidocaine has been developed and incorporated into the Luo-Rudy model of the ventricular action potential. We studied the effects of lidocaine on Na(+) current, maximum upstroke velocity, and conduction velocity and demonstrated that a decrease of these parameters was dependent on pH, frequency, and concentration. We also tested the action of lidocaine under pathological conditions. Specifically, we investigated its effects on conduction block under acute regional ischemia. Our results in one-dimensional fiber simulations showed a reduction of the window of block in the presence of lidocaine, thereby highlighting the role of reduced conduction velocity and safe conduction. This reduction may be related to the antifibrillatory effects of the drug by hampering wavefront fragmentation. In bidimensional acute ischemic tissue, lidocaine increased the vulnerable window for reentry and exerted proarrhythmic effects. In conclusion, the present simulation study used a newly formulated model of lidocaine, which considers pH and frequency modulation, and revealed the mechanisms by which lidocaine facilitates the onset of reentries. The results of this study also help to increase our understanding of the potential antifibrillatory effects of the drug.

Multiscale modelling of drug-induced effects on cardiac electrophysiological activity

Many drugs fail in the clinical trials and therefore do not reach the market due to adverse effects on cardiac electrical function. This represents a growing concern for both regulatory and pharmaceutical agencies as it translates into important socio-economic costs. Drugs affecting cardiac activity come from diverse pharmacological groups and their interaction with cardiac electrophysiology can result in increased risk of potentially life threatening arrhythmias, such as Torsade de Pointes. The mechanisms of drug interaction with the heart are very complex and the effects span from the ion channel to the whole organ level. This makes their investigation using solely experimental in vitro and in vivo techniques very difficult. Computational modelling of cardiac electrophysiological behaviour has provided insight into the mechanisms of cardiac arrhythmogenesis, with high spatio-temporal resolution, from the ion channel to the whole organ level. It therefore represents a powerful tool in investigating mechanisms of drug-induced changes in cardiac behaviour and in their pro-arrhythmic potential. This article presents a comprehensive review of the recent advances in detailed models of drug action on cardiac electrophysiological activity.

Can Nifekalant Hydrochloride be Used as a First-Line Drug for Cardiopulmonary Arrest (CPA)?

BACKGROUND

Early defibrillation of ventricular tachycardia and fibrillation (VT/VF) is an urgent and most important method of resuscitation for survival in cardiopulmonary arrest (CPA). We have previously reported that nifekalant (NIF), a specific I(Kr) blocker developed in Japan, is effective for lidocaine (LID) resistant VT/VF in out-of-hospital CPA (OHCPA). However, little is known about the differences in the effect of NIF on OHCPA with acidosis and in-hospital CPA (IHCPA) without acidosis.

METHODS AND RESULTS

The present study enrolled 91 cases of DC shock resistant VT/VF among 892 cases of CPA that occurred between June 2000 and May 2003. NIF was used (0.15-0.3 mg/kg) after LID according to the cardiopulmonary resuscitation (CPR) algorithm of Tokai University. The defibrillation rate was higher in the NIF group for both OHCPA and IHCPA than for LID alone, and the VT/VF rate reduction effect could be maintained even with acidosis. However, sinus bradycardia in OHCPA, and torsades de pointes in IHCPA were occasionally observed. These differences in adverse effects might be related to the amount of epinephrine, serum potassium levels, serum pH, and interaction with LID.

CONCLUSIONS

NIF had a favorable defibrillating effect in both CPA groups, and it shows promise of becoming a first-line drug for CPR.

Nifekalant Hydrochloride Administration During Cardiopulmonary Resuscitation Improves the Transmural Dispersion of Myocardial Repolarization Experimental Study in a Canine Model of Cardiopulmonary Arrest

BACKGROUND

Because nifekalant hydrochloride (NIF) displayed a superior defibrillating effect on ventricular tachycardia/fibrillation (VT/VF) in cardiopulmonary arrest (CPA) patients, despite some QT prolongation, its effect on transmural dispersion of repolarization (TDR) in the left ventricle (LV) in an animal model of CPA was investigated.

METHODS AND RESULTS

Eight beagle dogs were created with a myocardial infarction under anesthesia, and then VT/VF induction by continuous stimulation and cardiopulmonary resuscitation (CPR) were repeated. NIF (0.3 mg/kg) was administered under acidotic conditions (pH 7.26). The QTc interval measured by Y-lead ECG showed no significant prolongation before and after NIF. The activation recovery interval (ARI) measured by 64-lead LV surface mapping showed minimum ARI prolongation (40%) by NIF without maximum ARI prolongation, and as a result the ARI dispersion decreased by 67%. The repolarization time (RPT) with the plunge electrode showed 13-19% prolongation in the subendocardium and subepicardium with CPR, but NIF prolonged the RPT in the middle layer alone (17%), and as a result Plunge-TDR decreased by 82% (n=8, p<0.05).

CONCLUSIONS

Administration of NIF during CPR decreased the TDR by RPT prolongation selectively in the middle layer. Because the subendocardial and subepicardial RPTs after CPR were already prolonged before NIF administration, it may have been the reason why the QT-prolonging effect of NIF was not reflected in the body surface ECG.

Ischaemia selectivity confers efficacy for suppression of ischaemia-induced arrhythmias in rats

Eight novel and three reference antiarrhythmics were investigated in anaesthetised rats for antiarrhythmic actions, as well as for effects on the electrocardiogram (ECG) under normal and "simulated ischaemic" conditions. In rats subjected to coronary artery occlusion lidocaine, (+/-)-trans-[2-(4-morpholinyl)-cyclohexyl]naphthyl-1-acetate, RSD1000 and (+/-)-trans-[2-(4-morpholinyl)-cyclohexyl]-2-(1-naphthyl)propionate, RSD1030, (Group A) produced dose-related and complete antiarrhythmic protection. Group B compounds, such as (+/-)-trans-N-methyl-N-[2-(1-pyrrolidinyl)-cyclohexyl]-3, 4-dichlorocinnamamide, RSD995, produced complete antiarrhythmic protection but had aberrant dose-response curves. Group C compounds, such as quinidine and flecainide, failed to give full antiarrhythmic protection and had shallow dose-response curves. The potency of Group A compounds, but not Group B or C compounds, for ECG actions indicative of Na(+) channel blockade (prolongation of PR and QRS intervals) were significantly increased under "simulated ischaemic" conditions ([K(+)] 10 mM and pH 6.4) in isolated rat hearts. Thus, compounds with ischaemia-selective actions provided superior protection against ischaemia-induced arrhythmias in rats.

Antiarrhythmic drugs and cardiac ion channels: mechanisms of action

In this review a description and an analysis are given of the interaction of antiarrhythmic drugs with their molecular target, i.e. ion channels and receptors. Our approach is based on the concept of vulnerable parameter, i.e. the electrophysiological property which plays a crucial role in the genesis of arrhythmias. To prevent or stop the arrhythmia a drug should modify the vulnerable parameter by its action on channel or receptor targets. In the first part, general aspects of the interaction between drugs channel molecules are considered. Drug binding depends on the state of the channel: rested, activated pre-open, activated open, or inactivated state. The change in channel behaviour with state is presented in the framework of the modulated-receptor hypothesis. Not only inhibition but also stimulation can be the result of drug binding. In the second part a detailed and systematic description and an analysis are given of the interaction of drugs with specific channels (Na+, Ca2+, K+, "pacemaker") and non-channel receptors. Emphasis is given to the type of state-dependent block involved (rested, activated and inactivated state block) and the change in channel kinetics. These properties vary and determine the voltage- and frequency-dependence of the change in ionic current. Finally, the question is asked as to whether the available drugs by their action on channels and receptors modify the vulnerable parameter in the desired way to stop or prevent arrhythmias.

Molecular mechanisms of the reversal of imipramine-induced sodium channel blockade by alkalinization in human cardiac myocytes

BACKGROUND

Alkalinizing agents reverse cardiotoxicity of a variety of sodium channel blockers, including tricyclic antidepressants, but their mechanisms of action are poorly understood.

PURPOSE

To establish the mechanisms by which alkalinization diminishes the sodium channel blocking action of imipramine.

METHODS

The whole-cell voltage-clamp technique was used to measure INa during a variety of depolarizing pulse protocols in isolated human atrial myocytes, in the presence and absence of imipramine. A three-state model was used to analyze state-dependent INa block.

RESULTS

Imipramine (1 and 5 microM) strongly inhibited INa. Experimental data and piecewise exponential analysis suggested significant binding to both activated and inactivated states. Alkalosis antagonized imipramine-induced INa blockade by increasing the unbinding rate, with intracellular alkalosis being more effective than extracellular alkalosis. The dissociation constant (Kd) for the inactivated state was increased from 0.55 to 1.40 microM by extracellular alkalosis and to 2.51 microM by intracellular alkalosis. Along with the reversal of drug-induced shifts in the inactivation curve, these data indicate that alkalosis on either side of the membrane antagonized drug interactions with the inactivated state. On the other hand, only intracellular alkalosis antagonized activated state block, increasing the Kd from 0.67 microM to 2.18 microM, while extracellular alkalosis left the activated state Kd unaltered at 0.67 microM.

CONCLUSIONS

Alkalinization antagonizes the INa-blocking action of imipramine by promoting unbinding from the receptor. Intracellular alkalosis has a particularly important effect related to the activated-state interaction. The lipid-soluble, uncharged moiety appears to be a critical determinant of imipramine's ability to dissociate from the Na+ channel receptor.

Influence of extracellular H+ and Ca2+ on Ro 22-9194-induced block of sodium current in cardiac myocytes

1. Ro 22-9194 reduced the Na current in ventricular myocytes in either a tonic block or phasic block manner. 2. Ro 22-9194 had a higher affinity to the inactivated state (Kdi = 10.3 microM) than to the rested state (Kdrest = 180 microM). 3. Extracellular acidification enhanced the tonic block but reduced the phasic block. 4. Elevation of extracellular Ca2+ inhibited the enhancing effects of extracellular acidification. 5. These findings suggest that Ro 22-9194 strongly inhibits Na+ channels of the ventricular myocytes of the diseased hearts, characterized by the depolarized cell membranes and by acid conditions.

Modulation of the Electrophysiologic Actions of E-4031 and Dofetilide by Hyperkalemia and Acidosis in Rabbit Ventricular Myocytes

BACKGROUND: E-4031 and dofetilide are new class III antiarrhythmic agents that inhibit the rapid component of the delayed rectifier potassium channel (I(Kr)); however, the effectiveness of many antiarrhythmic drugs in ischemic conditions is uncertain. METHODS AND RESULTS: We modeled two components of ischemia, hyperkalemia (9.6 mM) and acidosis (pH 6.8), in voltage-clamped single rabbit ventricular myocytes to help determine the effect of ischemia on the action of these two drugs. In physiologic solution both E-4031 and dofetilide blocked I(Kr) and significantly reduced total outward current. In hyperkalemic solution, both E-4031 and dofetilide showed significantly reduced blockade of I(Kr), while in acidotic solution dofetilide showed significantly reduced blockade of I(Kr) and E-4031 showed a trend to reduced blockade. Neither drug significantly reduced total outward current in hyperkalemic or acidotic solutions. CONCLUSIONS: In these conditions, E-4031 and dofetilide demonstrate reduced blockade of I(Kr), resulting in loss of class III effect. Furthermore, the complete loss of blocking effect on total outward current during simulated ischemia suggests increases of other repolarizing currents also contribute to loss of class III effect.

Sematilide blocks the inward rectifier potassium channel in isolated guinea pig ventricular myocytes

1. In whole-cell patch recording, the relative potency of the blocking action of sematilide on IK1 was found to be constant at each potential level of IK1 activation. Under more acidic condition, the degree of block was decreased. These results strongly suggested that the neutral form of sematilide may penetrate the cardiac cell membrane via hydrophobic pathway. 2. In cell-attached patches, sematilide prolonged the interburst interval and reduced the opening probabilities of the IK1 channel without affecting either the mean open time or the mean closed time within a burst.

Ischemia enhances use-dependent sodium channel blockade by pilsicainide, a class IC antiarrhythmic agent

OBJECTIVES

The aim of this study was to elucidate whether the electrophysiologic properties of pilsicainide, a novel class IC drug with slow kinetic properties, could be altered in the presence of acute myocardial ischemia.

BACKGROUND

An increase in the rate of sudden death in patients taking flecainide and encainide has been reported by the Cardiac Arrhythmia Suppression Trial (CAST), implying a proarrhythmic effect that may be due to the interaction between ischemia and class IC antiarrhythmic drugs.

METHODS

Thirty-five patients and 16 age-matched control patients performed a treadmill exercise test and were assigned to four study groups: group A = 16 control patients; group B = 15 patients with ischemic ST segment depression; group C = 11 patients receiving pilsicainide without ST segment depression; and group D = 9 patients receiving pilsicainide with ischemic ST segment depression. The QRS duration was measured at rest and at heart rates of 80, 100 and 120 beats/min.

RESULTS

There were no changes in the QRS duration as heart rates increased to 120 beats/min in the control patients. Ischemia, however, independently caused a significant increase in QRS duration at a heart rate of 120 beats/min. Pilsicainide produced a rate-dependent prolongation of the QRS duration in patients without ST segment depression as the heart rate increased to 100 beats/min. The combination of ischemia and pilsicainide led to a much greater rate-dependent prolongation of the QRS duration.

CONCLUSIONS

Combination of a class IC drug and acute ischemia could lead to additive rate-dependent ventricular conduction slowing. This may be one plausible mechanism for the induction of proarrhythmias noted in the CAST study.

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.

Influence of pH on the uptake and pharmacodynamics of quinidine in the isolated perfused rat heart

Using the single-pass isolated perfused rat heart preparation we examined the effect of perfusate pH (pH 7.05, 7.46, 7.71, 7.92) on quinidine output concentration (C(out)) and delta QT. Eight hearts were perfused at 2.5 ml/min. with quinidine (20 microM) for 35 min. followed by a 35-40 min. washout period with drug-free perfusate. This procedure was repeated four times in each preparation with the pH sequence varied and the same pH used in the first and last phases. Increasing pH slowed the rate of equilibration of C(out), the equilibration rate constant (k) decreasing from 0.273 min.-1 at pH 7.05 to 0.095 min.-1 at pH 7.92. A modified Kety-Renkin-Crone equation was fitted to the C(out) versus time data for each pH. The estimated volume of distribution (V) increased significantly with pH from 11.5 +/- 1.1 to 32.5 +/- 2.9 ml/g, but the permeability surface product did not change with pH (mean 17.7 ml/min./g). There was a linear relationship between V and calculated un-ionised quinidine C(out), with an intercept of 5.70 ml/g corresponding to the V of ionised drug. This indicates that ionised and un-ionised drug readily enter the heart and that the slower equilibration with pH is due to the increased V which results from increased partitioning of un-ionised quinidine into myocardial tissue. Perfusion pH did not directly affect baseline QT interval, but the rate of attainment of maximum delta QT decreased with increasing perfusate pH. Plots of delta QT versus calculated coronary output quinidine concentration did not change with pH, showing that this drug effect was due to both ionised and un-ionised moieties. This study shows that myocardial permeability and pharmacodynamic effect (delta QT) of quinidine are not influenced by perfusion pH over the range 7.0 to 7.9, although rate of equilibration of both C(out) and effect vary with pH.

The influence of pH on the use-dependent effects of lidocaine in adult and neonatal canine Purkinje fibers

We used microelectrode techniques to examine the influence of pH on the effects of lidocaine on neonatal and adult canine Purkinje fiber action potentials. Lidocaine, 5 mg/l and 10 mg/l, significantly decreased overshoot, Vmax, and action potential duration in neonatal and adult fibers (basic cycle length 1300 and 300 ms) at pH 7.3 and 6.8. The effects were similar except for that on action potential duration which was greater in adults. Lidocaine, 5 mg/l, caused a comparable tonic block in adults and neonates at pH 7.3 (12 +/- 2 and 11 +/- 2%, respective decreases of Vmax) and at pH 6.8. Onset of use-dependent block (UDB) (pH 7.3) was faster in adults than neonates, 2 +/- 0.3 vs. 6 +/- 0.8 beats (P < 0.05); and tau off was slower in adults (133 +/- 10 ms) than neonates (81 +/- 8 ms; P < 0.05). At pH 6.8 the 'on' rates were 5 +/- 0.8 and 7 +/- 1 beats for adults and neonates, respectively (P > 0.05), and tau off increased to 210 +/- 15 ms for adults and 193 +/- 10 ms for neonates (P > 0.05). Thus, developmental differences in lidocaine action may be modified by the degree of protonation.

Sodium lactate reversal of electrophysiological effects of imipramine in guinea-pig ventricular myocardium

Overdose cardiac effects of imipramine are due to fast Na channel blockade and are clinically reversed by administration of sodium lactate which induces alkalosis (about pH 7.50) and hypernatremia (about 8 mM). The mechanisms of this beneficial effect of Na lactate were explored in vitro on guinea-pig ventricular myocardium using the microelectrode technique. The time-course effects of the clinically relevant concentration of 10 microM imipramine on action potential characteristics were examined at pH 7.20 and pH 7.50. To test whether alkalinisation per se is important or whether an increase in Na concentration plays a major role in the reversal effect, preparations were exposed to increasing concentrations (1, 3, 10, 30, 100 mM) of either Na lactate, bicarbonate or chloride in the absence or in the presence of 10 microM imipramine at pH 7.50. The influence of elevating osmolality was evaluated with equivalent concentrations of sucrose. Imipramine alone significantly depressed Vmax and shortened action potential duration at all phases of repolarisation. All three high sodium solutions reversed imipramine effects. However the reversal effect was already obvious with 10 mM Na lactate and 10 mM NaHCO3 but not 10 mM NaCl. Osmolality did not reverse the imipramine-induced Vmax depression. The results suggest that at the clinically relevant 10 mM concentration, sodium lactate and bicarbonate may displace imipramine from its receptor site on the Na channel by causing alkalosis at the membrane level without profoundly affecting the driving force of the Na current, whereas at the upper concentrations, the increase in Na ion concentrations is predominantly involved in the reversal of imipramine effects.

Kinetics of local anesthetic inhibition of neuronal sodium currents. pH and hydrophobicity dependence

This study assesses the importance of local anesthetic charge and hydrophobicity in determining the rates of binding to and dissociation from neuronal Na channels. Five amide-linked local anesthetics, paired either by similar pKa or hydrophobicity, were chosen for study: lidocaine, two tertiary amine lidocaine homologs, a neutral lidocaine homolog, and bupivacaine. Voltage-clamped nodes of Ranvier from the sciatic nerve of Bufo marinus were exposed to anesthetic externally, and use-dependent ("phasic") block of Na current was observed. Kinetic analysis of binding (blocking) rates was performed using a three parameter, piecewise-exponential binding model. Changes in extracellular pH (pHo) were used to assess the role of drug protonation in determining the rate of onset of, and recovery from, phasic block. For those drugs with pKa's in the range of pHo tested (6.2-10.4), the forward binding rate during a depolarizing pulse increased at higher pH, consistent with an increase in either intracellular or intramembrane concentration of drug. The rate for unbinding during depolarization was independent of pHo. The dissociation rate between pulses also increased at higher pHo. The pHo dependence of the dissociation rate was not consistent with a model in which the cation is trapped relentlessly within a closed channel. Quantitative estimates of dissociation rates show that the cationic form of lidocaine dissociates at a rate of 0.1 s-1 (at 13 degrees C); for neutral lidocaine, the dissociation rate is 7.0 s-1. Furthermore, the apparent pKa of bound local anesthetic was found to be close to the pKa in aqueous solution, but different than the pKa for "free" local anesthetic accessible to the depolarized channel.

Selective effects of tocainide in canine acute myocardial infarction

We examined the in vivo electrophysiologic effects of tocainide in canine acute myocardial infarction. We compared the effects of tocainide in infarcted and non-infarcted zones. The left anterior descending coronary artery of 8 dogs was ligated and bipolar ventricular electrograms were recorded from a needle electrode placed transmurally in the infarcted zone and from electrodes in the non-infarcted zone. Conduction intervals were measured from the onset of the limb lead QRS to the major deflection of the recorded electrograms in the infarcted and non-infarcted zones. Effective refractory periods were also determined. Measurements were made before, during and after intravenous infusion of tocainide in therapeutic doses 2 hours after infarct. Tocainide prolonged conduction intervals by 26-31% in the infarcted zone at peak (P less than 0.001), but by only 6% in the non-infarcted zone. Similarly, tocainide prolonged the effective refractory period by 27% (P less than 0.001) on the infarcted, but by 8% the non-infarcted zone. Tocainide had very slight effects on QRS duration. The present study shows that tocainide had selective effects in the infarcted zone on both conduction and effective refractory period. These selective effects may explain its antiarrhythmic effects in acute myocardial infarction.

The influence of acidosis on the myocardial uptake and electrocardiographic effects of disopyramide

The time course for the ECG effects and myocardial uptake of disopyramide was studied in isolated perfused guinea pig hearts under different pH conditions. At pH 7.46 the drug depressed the overall AV conduction time (PR) by 16.64%, the His-ventriculum conduction time (HV interval) by 30.46% and delayed the ventricular repolarization (QT interval) by 8.08%, on average. The maximum intraventricular pressure (Pmax) was also depressed by 35.6%. The maximum effect on the QT interval (constant rate: 0.609 min-1) was reached faster than the maximum effect on the PR and HV intervals (constant rates: 0.399 and 0.400 min-1, respectively), while the myocardium uptake process was complete before any ECG parameter reached a steady state (uptake constant: 1.58 min-1). Under conditions of extracellular acidosis (pH 6.92), the disopyramide disposition parameters (uptake rate constant and myocardial concentration) were not modified. However, the drug exerted significantly smaller effects on the HV and QT intervals and on myocardial contractility. These results are in contrast with those obtained previously with lidocaine and quinidine, and indicate that the influence of acidosis on class 1 antiarrhythmic agents may also depend on the characteristics of the individual drug.

Effects of OPC-88117, a new antiarrhythmic agent, on the electrophysiological properties of rabbit isolated hearts

1. Effects of a new antiarrhythmic agent, OPC-88117, on the conduction properties and excitability of Langendorff-perfused rabbit hearts were compared with those of lignocaine. 2. OPC-88117 above 10(-5) M caused a significant prolongation of atrio-His bundle conduction time (A-H interval) as well as His bundle-ventricular conduction time (H-V interval). Lignocaine above 10(-5) M caused a similar prolongation of H-V interval with a minimum change of A-H interval. The conduction time from His bundle stimulus to the left ventricle (St-LV) at a low frequency (1 Hz) was also prolonged by these drugs around 10(-4) M. 3. OPC-88117 above 3 x 10(-6) M prolonged the effective and functional refractory periods of His bundle (ERPHB, FRPHB) as well as the effective refractory period of left ventricular muscle (ERPVM) in a dose-dependent manner. ERPHB, FRPHB and ERPVM were shortened by low concentrations of lignocaine (3 x 10(-6)-10(-5) M), but were prolonged by high concentrations (3 x 10(-5)-10(-4) M). 4. Lignocaine (3 x 10(-6)-10(-4) M) induced an upward displacement of the His bundle refractory curve, indicating a greater intraventricular conduction delay for premature excitation. In experiments with OPC-88117, such an upward displacement was observed only at 10(-4) M. 5. These results suggest that the primary electrophysiological effect of OPC-88117 is a lengthening of ventricular refractoriness, and that at high concentrations it may also exert lignocaine-like inhibition of ventricular conduction.

Influence of pHo on calcium channel block by amlodipine, a charged dihydropyridine compound. Implications for location of the dihydropyridine receptor

We have investigated the modulation of L-type calcium channel currents in isolated ventricular cells by the dihydropyridine derivative amlodipine, a weak base with a pKa of 8.6. Under conditions that favor neutral drug molecules, amlodipine block resembles other, previously described, neutral dihydropyridine derivatives: block is more pronounced at depolarized voltages, repetitive pulsing is not needed to promote block, and recovery is complete at hyperpolarized voltages. When the drug is ionized, depolarized voltages still enhance block, however, the time course is slow and speeded by repetitive pulses that open channels. Recovery from block by ionized drug molecules is very slow and incomplete, but can be rapidly modified by changes in external hydrogen ion concentration. We conclude from these observations that the degree of ionization of the drug molecule can affect access to the dihydropyridine receptor and that external protons can interact with the drug-receptor complex even if channels are blocked and closed. These observations place limitations on the location of this receptor in the ventricular cell membrane.

Use dependence of amiodarone during the sinus tachycardia of exercise in coronary artery disease

The QRS duration at rest and during exercise was studied in 19 patients with coronary artery disease before and after oral amiodarone therapy to determine if this drug produces detectable rate-dependent conduction slowing during physiologic increases in heart rate. QRS duration did not change significantly during exercise in the absence of the drug. However, after amiodarone, QRS duration at rest increased from 99 to 114 ms (p less than 0.001), and increased further from 114 to 127 ms (p less than 0.001) during the 45 beats/min mean increase in heart rate produced by exercise. The magnitude of this effect was related to the resting QRS duration. After amiodarone therapy, the QRS increased during exercise by only 6% in 8 patients with QRS less than 110 ms, while in 12 patients with QRS greater than or equal to 110 ms, the QRS increased by 15% (p less than 0.05). Rate-dependent conduction slowing occurs during the sinus tachycardia of exercise in patients treated with amiodarone, presumbably due to use-dependent sodium channel blockade. This result is most pronounced in patients with abnormal ventricular conduction at rest.

Quinidine blocks cardiac sodium channels during opening and slow inactivation in guinea-pig papillary muscle

1. In order to quantify the time- and voltage-dependent block of sodium channels by quinidine, we voltage clamped guinea-pig papillary muscles and measured the maximum upstroke velocity (Vmax) of the cardiac action potential. 2. Quinidine reduces Vmax presumably by blocking cardiac sodium channels. In therapeutic concentrations, quinidine causes a small amount of tonic block. Upon depolarization of the cardiac cell membrane, a use-dependent block develops. 3. A slow component of use-dependent block has time- and voltage-dependence similar to that of slow inactivation, develops for the duration of the depolarization or until a steady state is reached. 4. In addition, closely associated with the action potential upstroke, a fraction of the channels blocks very quickly. This represents block of activated or open channels. 5. Near the normal resting potential, channels recover from block with a time constant of 3 to 8 s. At more negative membrane potentials recovery from block occurs slightly faster, while at more positive potentials recovery from block proceeds somewhat more slowly. 6. In terms of the modulated receptor hypothesis, quinidine has a low affinity for the rested state, avidly blocks open sodium channels, but does not bind significantly to inactivated channels. In addition, quinidine blocks channels as they exhibit slow inactivation.

Lidocaine blocks open and inactivated cardiac sodium channels

Guinea-pig papillary muscles were voltage-clamped using the single sucrose gap technique. The maximum upstroke velocity of the action potential (Vmax) was used as an indicator of the sodium conductance. Lidocaine (5 mumol/l to 40 mumol/l) reduced Vmax in a use-dependent fashion. Block of sodium channels developed during channel opening and while the channels were inactivated. Block of inactivated channels was not voltage-dependent over the -40 mV to +40 mV range. Recovery from block occurs upon repolarization, and for a given diastolic interval the recovery is more complete as the membrane potential is hyperpolarized over the -80 mV to -150 mV range. These results can be accounted for in terms of the modulated receptor hypothesis, where lidocaine has a low affinity for rested sodium channels, but a high affinity for open and inactivated channels.

Comparison of the inhibitory effects of mexiletine and lidocaine on the calcium current of single ventricular cells

Effects of mexiletine and lidocaine on inward calcium current (ICa) of single ventricular myocytes from guinea pigs were studied using tight seal whole cell clamp method. Mexiletine at the concentrations of 10, 30 and 100 microM decreased ICa by 23.0, 28.9 and 55.4%, respectively, while lidocaine decreased it by 8.9, 16.8 and 25.2%. At all concentrations tested, a potency for ICa inhibition in mexiletine was significantly greater than that in lidocaine (p less than 0.05). The results suggest that mexiletine has, at therapeutic concentrations, a considerable blocking action on the Ca channels other than well-known action on the Na channels.

Cardiac cell action potential duration is dependent upon induced changes in free Ca2+ activity during pH changes in vitro

We examined how changes in solution pH alter myocardial cell action potentials (AP) with and without changes in free [Ca2+] caused by pH induced effects on calcium binding. Guinea pig ventricular tissue was isolated, superfused either with Krebs-Ringer (K-R) bicarbonate, phosphate buffered solution, or with Hepes buffered solution, and electrically paced during control (5% CO2 in O2), acidic (12% CO2), and alkalotic (0% CO2) conditions. Action potentials were recorded with intracellular microelectrodes. Extracellular free [Ca2+] was measured with a calcium ion selective electrode and total soluble calcium was measured by ultrafiltration and spectrophotometry. With a total [CaCl2] of 2.5 mM in the K-R solution, we found a free [Ca2+] of 2.14 mM at pH 7.44 (control), 2.48 mM at pH 6.97 and 1.60 mM at pH 8.19; total soluble calcium concentration was 2.00 mM at pH 8.19. In the Hepes solution, free [Ca2+] was only slightly altered (2.42 to 2.55 mM) within this pH range. Equivalent acidosis of either K-R or Hepes suffusate significantly, and similarly, prolonged the AP and its refractory period. Alkalosis of the Hepes suffusate shortened the AP; but equivalent alkalosis of the K-R suffusate prolonged the AP as did a reduction of [CaCl2] in Hepes suffusate from 3.0 to 1.5 mM at pH 7.43. Our study demonstrates that a paradoxical increase in APD occurs because free Ca2+ ion activity falls in K-R solution and overrides the effect of alkalosis alone to decrease APD.(ABSTRACT TRUNCATED AT 250 WORDS)

Electrophysiological interactions between quinidine-lidocaine and quinidine-phenytoin in guinea-pig papillary muscle

The interactions between quinidine and lidocaine or phenytoin at the sodium channel level have been studied in the present work. The maximum upstroke velocity (Vmax) of the guinea-pig papillary muscle action potential has been used as a measure of the sodium current. Lidocaine interfered with the use-dependent blocking effects on Vmax of quinidine, by decreasing the fraction of sodium channels blocked by quinidine during the conditioning action potential, in an apparently competitive way. These results strongly suggest that quinidine and lidocaine bind to a common receptor site. Alternatively, it has been suggested that lidocaine and quinidine bind to different but related receptor sites, since lidocaine may induce allosteric changes in quinidine's receptor. Phenytoin increased the use-dependent blocking effects on Vmax of quinidine by slowing the time course of the slow component of reactivation of Vmax induced by quinidine. Phenytoin did not change the fraction of sodium channels blocked by quinidine during the conditioning action potential. These results suggest that phenytoin binds to a different receptor site than quinidine.

The cellular mechanisms of cardiac antiarrhythmic drug action

In the preceding pages we have considered a number of mechanisms whereby drugs may modify arrhythmias and we also have demonstrated that certain types of action are specific to individual drugs. In addition, through the description of the use-dependence of drug effects, we have shown that the specificity of a drug's action often is attributable to its interactions with specific channels. As we learn more about the specificity of individual drug effects we should be better able not only to understand the actions of presently available drugs, but also to discover compounds that promise to be of use in the future.

Influence of pH on the inhibitory effects of local anesthetics on histamine release induced from rat mast cells by concanavalin A and compound 48/80

The study concerned the effects of lidocaine and mepivacaine on rat mast cell histamine release. At low concentrations these drugs inhibited the histamine release induced by concanavalin A and compound 48/80 although, at high concentrations, they caused cell lysis. The mechanism of their inhibition of histamine release was studied by examining the pH dependence of the inhibitory action. In the absence of drugs, the release of histamine was not affected by the pH of the medium, but the inhibitory effects of the drugs increased with increase in pH. The percent inhibition of histamine release by these drugs at each pH was plotted against the calculated concentration of the nonionized form of the drug, according to the Henderson-Hasselbalch equation. The inhibitory action was correlated with the concentration of nonionized molecules, which readily penetrate the cell membrane. From the interaction of lidocaine with the phospholipid bilayer, it was concluded that this drug penetrates the lipid bilayer and that this effect increases with increasing pH of the medium. Thus, it seems that it is the nonionized form of local anesthetics that inhibits histamine release and that it is nonionized molecules that penetrate the mast cell membrane.

Use-dependent block of cardiac sodium channels by quaternary derivatives of lidocaine

Modulation of the reduction of fast inward sodium current by local anesthetics due to changes in electrical activity has been termed use-dependent block ( Courtney 1975). To determine the mechanisms responsible for use-dependent block of cardiac sodium channels and to compare use-dependent block in cardiac and nerve preparations, we investigated use-dependent block of cardiac sodium channels by the quaternary lidocaine analogues QX -314 and QX -222 (two agents previously studied in nerve). We used canine cardiac Purkinje fibers, and assessed changes in the fast inward sodium current using changes in the maximum rate of rise of the action potential upstroke (Vmax). Two microelectrode voltage clamp and current clamp techniques were used to control membrane potential prior to stimulated upstrokes . Use-dependent block was not affected by shortening the action potential duration during rapid stimulation. Partial recovery from use-dependent block was observed during rapid stimulation with brief depolarizing prepulses terminating immediately prior to the upstroke. Similar prepulses also prevented the development of use-dependent block following an abrupt increase in the stimulation rate. Hyperpolarizing prepulses during rapid stimulation caused recovery from use-dependent block; recovery was greater and more rapid with increasingly negative prepulses . Hyperpolarization during periods of electrical quiescence also caused greater recovery. These results, interpreted using the modulated receptor hypothesis ( Hille 1977; Hondeghem and Katzung 1977), suggest that use-dependent block of cardiac sodium channels by quaternary local anesthetics is due to drug association with the inactivated sodium channel receptor which occurs only after these drugs gain access to the receptor site through open sodium channels.

Electropharmacology of antiarrhythmic drugs

Cardiac arrhythmias may be caused by abnormalities of impulse initiation, impulse propagation, or a combination of the two. The specific mechanisms that may induce arrhythmias are reviewed, as are the means whereby antiarrhythmic drugs might be expected to modify arrhythmias. The cellular electrophysiologic effects of the following antiarrhythmic drugs are discussed: quinidine, procainamide, disopyramide, lidocaine, tocainide, mexiletine, phenytoin, beta-blocking and slow-channel-blocking drugs, aprindine, bretylium, ethmozin, and amiodarone. A knowledge of the similarities and differences of their actions on the determinants of conduction, on repolarization and refractoriness, on automatic mechanisms, and on afterdepolarizations, when considered in the context of the mechanism of clinically occurring tachyarrhythmias, may provide the correct framework for the choice of an appropriate agent for the control of an individual disorder of rhythm. However, it is emphasized that neither the precise mechanism of various dysrhythmias nor the fundamental basis for the salutary action of antiarrhythmic compounds is completely understood.

Lidocaine block of cardiac sodium channels

Lidocaine block of cardiac sodium channels was studied in voltage-clamped rabbit purkinje fibers at drug concentrations ranging from 1 mM down to effective antiarrhythmic doses (5-20 muM). Dose-response curves indicated that lidocaine blocks the channel by binding one-to-one, with a voltage-dependent K(d). The half-blocking concentration varied from more than 300 muM, at a negative holding potential where inactivation was completely removed, to approximately 10 muM, at a depolarized holding potential where inactivation was nearly complete. Lidocaine block showed prominent use dependence with trains of depolarizing pulses from a negative holding potential. During the interval between pulses, repriming of I (Na) displayed two exponential components, a normally recovering component (tauless than 0.2 s), and a lidocaine-induced, slowly recovering fraction (tau approximately 1-2 s at pH 7.0). Raising the lidocaine concentration magnified the slowly recovering fraction without changing its time course; after a long depolarization, this fraction was one-half at approximately 10 muM lidocaine, just as expected if it corresponded to drug-bound, inactivated channels. At less than or equal to 20 muM lidocaine, the slowly recovering fraction grew exponentially to a steady level as the preceding depolarization was prolonged; the time course was the same for strong or weak depolarizations, that is, with or without significant activation of I(Na). This argues that use dependence at therapeutic levels reflects block of inactivated channels, rather than block of open channels. Overall, these results provide direct evidence for the "modulated-receptor hypothesis" of Hille (1977) and Hondeghem and Katzung (1977). Unlike tetrodotoxin, lidocaine shows similar interactions with Na channels of heart, nerve, and skeletal muscle.

Spatial distribution of [14C]-lidocaine and blood flow in transmural and lateral border zones of ischemic canine myocardium

The purpose of this study was to determine the spatial distribution of lidocaine relative to blood flow in ischemic, normal and border zone canine myocardium. Ischemic zone tissue was distinguished from normal zone tissue by a special microsphere technique in adjacent sections 4 to 5 mm wide from the center to the lateral border of the ischemic region in 14 open chest dogs. Gamma-labeled microspheres were separated by a special technique from carbon-14 ([14C])-lidocaine in the same tissue sample. Blood flow (mean value +/- 1 standard deviation) was reduced to 46 +/- 25 percent of normal in the ischemic subepicardium and 17 +/- 18 percent of normal in the subendocardium. [14C]-lidocaine was 0.56 +/- 0.12 microgram/g in normal myocardium 10 minutes after bolus injection of [14C]-lidocaine; it was reduced to 91 +/- 15 percent of normal in ischemic subepicardium and 58 +/- 12 percent of normal in the subendocardium. Blood flow and lidocaine concentration were uniformly lowest in gross samples from the central and intermediate ischemic zones, and highest in the gross samples from the border normal zone (p less than 0.05). The values for flow and lidocaine in samples from the border ischemic zone were intermediate, that is, higher than values from central ischemic (p less than 0.05) and lower than values from border normal zone samples (p less than 0.05). However, the labeling technique for normal zone tissue revealed that the values of blood flow and lidocaine in the gross samples from the lateral border of the ischemic zone were intermediate between those of adjacent ischemic and normal samples because of the mixture of overlapping normal and ischemic tissues components--not because of a unique mildly ischemic region. Both blood flow and lidocaine concentration were lower in the subendocardial third than in the subepicardial third of the ischemic zone (p less than 0.05) even after the contribution of normal zone tissue was subtracted, suggesting a gradient of ischemia across the transmural border zone. In conclusion, lidocaine is distributed uniformly in ischemic components from the center to the lateral border of the ischemic zone, but there is an endocardial to epicardial gradient. Both lateral and transmural border zone distributions must be considered to understand the mechanisms of drug effects in myocardial ischemia.

Does the organic calcium channel blocker D600 act from inside or outside on the cardiac cell membrane?

The effects of extra- and intracellularly applied D600 (methoxyverapamil) and D890 (a quarternary derivative) on the action potentials of isolated guinea pig myocytes were compared. We also studied the extracellular myocytes were compared. We also studied the extracellular effects of these drugs on the calcium current (hybride sucrose gap) and contractile force of right ventricular trabeculae of the cat heart. The following results were obtained: 1. In ventricular trabeculae D600 suppressed the calcium current, tension and the plateau of the action potential. In contrast, D890 even in a 50 times higher concentration did not display any effect on these parameters. 2. In single isolated cells external application of D890 did not alter the configuration of the action potential. In contrast, external application of D600 suppressed the plateau and shortened the action potential in a dose-dependent way. 3. Intracellular injection of D600 or D890 strongly lowered the height of the plateau and abbreviated the action potential. The onset of the effects of both drugs was more rapid on intracellular application than that of external D600. Whereas the effect of an intracellular injection of D600 was reversible, that of D890 was not. These results support the hypothesis that the organic calcium channel blocker D600 enters the cell in the uncharged lipid soluble form and reaches its receptor associated with the calcium channel from inside. Because of its inability to pass the hydrophobic cell membrane, D890 is ineffective from outside but displays blocking effects on intracellular application.

Lignocaine prophylaxis in acute myocardial infarction: an evaluation of randomised trials

Although lignocaine has been used in coronary care units for almost two decades, its role in preventing ventricular fibrillation (VF) during acute myocardial infarction (MI) is still debated. Of fifteen randomised trials of lignocaine prophylaxis, most showed no apparent benefit. When the data from all fifteen trials were pooled and a summary relative risk estimate calculated, there was a significant benefit of lignocaine treatment in preventing VF. However, the trials had widely differing treatment schedules, modes of drug administration, and doses of lignocaine; to decrease the clinical heterogenity, minimum criteria for adequacy of treatment were established and the data from six trials which fulfilled these requirements were pooled. The summary relative risk estimate calculated from the pooled data of these six trials also demonstrated a significant prophylactic effect of lignocaine that was even greater when the two trials which treated patients with left ventricular failure and shock were excluded. From these analyses, it is concluded that lignocaine treatment provides prophylaxis against VF in acute MI. The failure of most trials to demonstrate such a prophylactic effect is due to small sample sizes and inadequate treatment protocols.