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Hughes G, Young WJ, Bern H, Crook A, Lambiase PD, Goodall RL, Nunn AJ, Meredith SK. T-wave morphology abnormalities in the STREAM stage 1 trial. Expert Opin Drug Saf 2024; 23:469-476. [PMID: 38462751 DOI: 10.1080/14740338.2024.2322116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 12/15/2023] [Indexed: 03/12/2024]
Abstract
BACKGROUND Shorter regimens for drug-resistant tuberculosis (DR-TB) have non-inferior efficacy compared with longer regimens, but QT prolongation is a concern. T-wave morphology abnormalities may be a predictor of QT prolongation. RESEARCH DESIGN AND METHODS STREAM Stage 1 was a randomized controlled trial in rifampicin-resistant TB, comparing short and long regimens. All participants had regular ECGs. QT/QTcF prolongation (≥500 ms or increase in ≥60 ms from baseline) was more common on the short regimen which contained high-dose moxifloxacin and clofazimine. Blinded ECGs were selected from the baseline, early (weeks 1-4), and late (weeks 12-36) time points. T-wave morphology was categorized as normal or abnormal (notched, asymmetric, flat-wave, flat peak, or broad). Differences between groups were assessed using Chi-Square tests (paired/unpaired, as appropriate). RESULTS Two-hundred participants with available ECGs at relevant times were analyzed (QT prolongation group n = 82; non-prolongation group n = 118). At baseline, 23% (45/200) of participants displayed abnormal T-waves, increasing to 45% (90/200, p < 0.001) at the late time point. Abnormalities were more common in participants allocated the Short regimen (75/117, 64%) than the Long (14/38, 36.8%, p = 0.003); these occurred prior to QT/QTcF ≥500 ms in 53% of the participants (Long 2/5; Short 14/25). CONCLUSIONS T-wave abnormalities may help identify patients at risk of QT prolongation on DR-TB treatment. TRIAL REGISTRATION The trial is registered at ClinicalTrials.gov (CT.gov identifier: NCT02409290). Current Controlled Trial number, ISRCTN78372190.
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Affiliation(s)
- Gareth Hughes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - William J Young
- Centre for Clinical Pharmacology and Precision Medicine, William Harvey Research Institute, Queen Mary University of London, London, UK
- Barts Heart Centre, St Bartholomews Hospital, Barts Health NHS Trust, London, UK
| | - Henry Bern
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Angela Crook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College London, London, UK
- NIHR Barts Biomedical Research Centre, London, UK
| | - Ruth L Goodall
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Andrew J Nunn
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Sarah K Meredith
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
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Kanade PP, Oyunbaatar NE, Kim J, Lee BK, Kim ES, Lee DW. Cardiotoxicity Assessment through a Polymer-Based Cantilever Platform: An Integrated Electro-Mechanical Screening Approach. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024:e2311274. [PMID: 38511575 DOI: 10.1002/smll.202311274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/08/2024] [Indexed: 03/22/2024]
Abstract
Preclinical drug screening for cardiac toxicity has traditionally relied on observing changes in cardiomyocytes' electrical activity, primarily through invasive patch clamp techniques or non-invasive microelectrode arrays (MEA). However, relying solely on field potential duration (FPD) measurements for electrophysiological assessment can miss the full spectrum of drug-induced toxicity, as different drugs affect cardiomyocytes through various mechanisms. A more comprehensive approach, combining field potential and contractility measurements, is essential for accurate toxicity profiling, particularly for drugs targeting contractile proteins without affecting electrophysiology. However, previously proposed platform has significant limitations in terms of simultaneous measurement. The novel platform addresses these issues, offering enhanced, non-invasive evaluation of drug-induced cardiotoxicity. It features eight cantilevers with patterned strain sensors and MEA, enabling real-time monitoring of both cardiomyocyte contraction force and field potential. This system can detect minimum cardiac contraction force of ≈2 µN and field potential signals with 50 µm MEA diameter, using the same cardiomyocytes in measurements of two parameters. Testing with six drugs of varied mechanisms of action, the platform successfully identifies these mechanisms and accurately assesses toxicity profiles, including drugs not inhibiting potassium channels. This innovative approach presents a comprehensive, non-invasive method for cardiac function assessment, poised to revolutionize preclinical cardiotoxicity screening.
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Affiliation(s)
- Pooja P Kanade
- School of Mechanical Engineering, Chonnam National University, Gwangju, 61186, South Korea
- Advanced Medical Device Research Center for Cardiovascular Disease, Chonnam National University, Gwangju, 61186, Republic of Korea
| | - Nomin-Erdene Oyunbaatar
- School of Mechanical Engineering, Chonnam National University, Gwangju, 61186, South Korea
- Advanced Medical Device Research Center for Cardiovascular Disease, Chonnam National University, Gwangju, 61186, Republic of Korea
| | - Jongyun Kim
- School of Mechanical Engineering, Chonnam National University, Gwangju, 61186, South Korea
- Advanced Medical Device Research Center for Cardiovascular Disease, Chonnam National University, Gwangju, 61186, Republic of Korea
| | - Bong-Kee Lee
- School of Mechanical Engineering, Chonnam National University, Gwangju, 61186, South Korea
| | - Eung-Sam Kim
- Department of Biological Sciences, Chonnam National University, Gwangju, 61186, Republic of Korea
| | - Dong-Weon Lee
- School of Mechanical Engineering, Chonnam National University, Gwangju, 61186, South Korea
- Advanced Medical Device Research Center for Cardiovascular Disease, Chonnam National University, Gwangju, 61186, Republic of Korea
- Center for Next-Generation Sensor Research and Development, Chonnam National University, Gwangju, 61186, Republic of Korea
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Arteyeva NV, Komarov IA, Azarov JE. Action potential morphology affects T-wave symmetry (simulation study). J Electrocardiol 2023; 81:237-243. [PMID: 37844373 DOI: 10.1016/j.jelectrocard.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Assessing T-wave symmetry in addition to QT subintervals measurements can provide novel independent data about ventricular repolarization abnormalities linked with arrhythmogenesis. However, the causes of the changes of T-wave symmetry are not completely understood. In silico studies showed that the more symmetrical T-waves were associated with shorter action potential duration (APD) and larger dispersion of ventricular repolarization (DOR). The aim of present simulation was to study the association between T-wave symmetry and action potential (AP) shape. METHODS ECGs were simulated using a cellular automata model shaped as a ventricular wall segment, and two biophysically-detailed models of ventricular AP - the rabbit and the human. The symmetry ratio (SR) was calculated as a T-wave onset-peak to peak-end area ratio. The individual and combined effects of APD, DOR and AP shape on SR were simulated. To study the effect of AP shape, different APs from triangulated to rectangular were simulated. RESULTS The simulations showed that AP shape along with APD and DOR contributes much to T-wave symmetry. APs with a flat phase 3 (triangulated) produced asymmetrical T-waves (SR ≥ 1.5) in all simulations, except the shortest APD range. APs with a rapid phase 3 (rectangular) were associated with more symmetrical T-waves (SR ≤ =1) both at the short and the long APDs. CONCLUSION SR marker in combination with the standard ECG parameters (QT interval, Tpeak-Tend interval) may be useful to identify the proarrhythmic triangulated AP shape.
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Affiliation(s)
- Natalia V Arteyeva
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, 50, Pervomayskaya st, Syktyvkar 167982, Russia.
| | - Ilia A Komarov
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, 50, Pervomayskaya st, Syktyvkar 167982, Russia
| | - Jan E Azarov
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, 50, Pervomayskaya st, Syktyvkar 167982, Russia; Department of Physiology, Medical Institute of Pitirim Sorokin, Syktyvkar State University, 11, Babushkin st, Syktyvkar 167000, Russia
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Cruces PD, Toscano A, Rodríguez FJA, Romo-Vázquez R, Arini PD. Drug-induced symmetry effects on ventricular repolarization dynamics. Biomed Signal Process Control 2023. [DOI: 10.1016/j.bspc.2022.104493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Chiu K, Racz R, Burkhart K, Florian J, Ford K, Iveth Garcia M, Geiger RM, Howard KE, Hyland PL, Ismaiel OA, Kruhlak NL, Li Z, Matta MK, Prentice KW, Shah A, Stavitskaya L, Volpe DA, Weaver JL, Wu WW, Rouse R, Strauss DG. New science, drug regulation, and emergent public health issues: The work of FDA's division of applied regulatory science. Front Med (Lausanne) 2023; 9:1109541. [PMID: 36743666 PMCID: PMC9893027 DOI: 10.3389/fmed.2022.1109541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 12/13/2022] [Indexed: 01/20/2023] Open
Abstract
The U.S. Food and Drug Administration (FDA) Division of Applied Regulatory Science (DARS) moves new science into the drug review process and addresses emergent regulatory and public health questions for the Agency. By forming interdisciplinary teams, DARS conducts mission-critical research to provide answers to scientific questions and solutions to regulatory challenges. Staffed by experts across the translational research spectrum, DARS forms synergies by pulling together scientists and experts from diverse backgrounds to collaborate in tackling some of the most complex challenges facing FDA. This includes (but is not limited to) assessing the systemic absorption of sunscreens, evaluating whether certain drugs can convert to carcinogens in people, studying drug interactions with opioids, optimizing opioid antagonist dosing in community settings, removing barriers to biosimilar and generic drug development, and advancing therapeutic development for rare diseases. FDA tasks DARS with wide ranging issues that encompass regulatory science; DARS, in turn, helps the Agency solve these challenges. The impact of DARS research is felt by patients, the pharmaceutical industry, and fellow regulators. This article reviews applied research projects and initiatives led by DARS and conducts a deeper dive into select examples illustrating the impactful work of the Division.
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Affiliation(s)
- Kimberly Chiu
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Rebecca Racz
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Keith Burkhart
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Jeffry Florian
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Kevin Ford
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - M. Iveth Garcia
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Robert M. Geiger
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Kristina E. Howard
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Paula L. Hyland
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Omnia A. Ismaiel
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Naomi L. Kruhlak
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Zhihua Li
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Murali K. Matta
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Kristin W. Prentice
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States,Booz Allen Hamilton, McLean, VA, United States
| | - Aanchal Shah
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States,Booz Allen Hamilton, McLean, VA, United States
| | - Lidiya Stavitskaya
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Donna A. Volpe
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - James L. Weaver
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Wendy W. Wu
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Rodney Rouse
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - David G. Strauss
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States,*Correspondence: David G. Strauss,
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Marill KA, Lopez S, Hark D, Spahr J, Shesh-Muthal K, Xue J, Rowlandson GI, Liu SW. Electrocardiographic measures of repolarization heterogeneity are not predictive for Torsades de Pointes among undifferentiated patients with prolonged QTc: A case control study. J Cardiovasc Electrophysiol 2023; 34:166-176. [PMID: 36335640 DOI: 10.1111/jce.15735] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 09/27/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Torsades de Pointes (TdP) is a potentially lethal polymorphic ventricular tachydysrhythmia associated with and caused by prolonged myocardial repolarization. However, prediction of TdP is challenging. We sought to determine if electrocardiographic myocardial repolarization heterogeneity is necessary and predictive of TdP. METHODS We performed a case control study of TdP at a large urban hospital. We identified cases based on a hospital center electrocardiogram (ECG) database search for tracings from 1/2005 to 6/2019 with heart rate corrected QT (QTc) > 500, QRS < 120, and heart rate (HR) < 60, and a subsequent natural language search of electronic health records for the terms: TdP, polymorphic ventricular tachycardia, sudden cardiac death, and relevant variants. Controls were drawn in a 2:1 ratio to cases from a similar pool of ECGs, and matching for QTc, heart rate, sex, and age. We abstracted historical, laboratory, and ECG data using detailed written instructions and an electronic database. We included a second blinded data abstractor to test data abstraction and manual ECG measurement reliability. We used General Electric (GE) QT Guard software for automated repolarization measurements. We compared groups using unpaired statistics. RESULTS We included 75 cases and 150 controls. The number of current QTc prolonging medications and serum electrolytes were substantially the same between the two groups. We found no significant difference in measures of QT or T wave repolarization heterogeneity. CONCLUSION Electrocardiographic repolarization heterogeneity is not greater in otherwise unselected patients with QTc prolongation who suffer TdP and does not appear predictive of TdP. However, previous observations suggest specific repolarization characteristics may be useful for defined patient subgroups at risk for TdP.
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Affiliation(s)
- Keith A Marill
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samantha Lopez
- University of Texas at Southwestern Medical Center, Dallas, Texas, USA
| | - David Hark
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Ketaki Shesh-Muthal
- Department of Biomedical Engineering, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joel Xue
- General Electric Healthcare, Milwaukee, Wisconsin, USA
| | | | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Tardo DT, Peck M, Subbiah R, Vandenberg JI, Hill AP. The diagnostic role of T wave morphology biomarkers in congenital and acquired long QT syndrome: A systematic review. Ann Noninvasive Electrocardiol 2022; 28:e13015. [PMID: 36345173 PMCID: PMC9833360 DOI: 10.1111/anec.13015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION QTc prolongation is key in diagnosing long QT syndrome (LQTS), however 25%-50% with congenital LQTS (cLQTS) demonstrate a normal resting QTc. T wave morphology (TWM) can distinguish cLQTS subtypes but its role in acquired LQTS (aLQTS) is unclear. METHODS Electronic databases were searched using the terms "LQTS," "long QT syndrome," "QTc prolongation," "prolonged QT," and "T wave," "T wave morphology," "T wave pattern," "T wave biomarkers." Whole text articles assessing TWM, independent of QTc, were included. RESULTS Seventeen studies met criteria. TWM measurements included T-wave amplitude, duration, magnitude, Tpeak-Tend, QTpeak, left and right slope, center of gravity (COG), sigmoidal and polynomial classifiers, repolarizing integral, morphology combination score (MCS) and principal component analysis (PCA); and vectorcardiographic biomarkers. cLQTS were distinguished from controls by sigmoidal and polynomial classifiers, MCS, QTpeak, Tpeak-Tend, left slope; and COG x axis. MCS detected aLQTS more significantly than QTc. Flatness, asymmetry and notching, J-Tpeak; and Tpeak-Tend correlated with QTc in aLQTS. Multichannel block in aLQTS was identified by early repolarization (ERD30% ) and late repolarization (LRD30% ), with ERD reflecting hERG-specific blockade. Cardiac events were predicted in cLQTS by T wave flatness, notching, and inversion in leads II and V5 , left slope in lead V6 ; and COG last 25% in lead I. T wave right slope in lead I and T-roundness achieved this in aLQTS. CONCLUSION Numerous TWM biomarkers which supplement QTc assessment were identified. Their diagnostic capabilities include differentiation of genotypes, identification of concealed LQTS, differentiating aLQTS from cLQTS; and determining multichannel versus hERG channel blockade.
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Affiliation(s)
- Daniel T. Tardo
- Cardiac Electrophysiology LaboratoryVictor Chang Cardiac Research InstituteDarlinghurstNew South WalesAustralia,Department of CardiologySt. Vincent's HospitalDarlinghurstNew South WalesAustralia,School of MedicineUniversity of Notre Dame AustraliaDarlinghurstNew South WalesAustralia
| | - Matthew Peck
- Cardiac Electrophysiology LaboratoryVictor Chang Cardiac Research InstituteDarlinghurstNew South WalesAustralia
| | - Rajesh N. Subbiah
- Cardiac Electrophysiology LaboratoryVictor Chang Cardiac Research InstituteDarlinghurstNew South WalesAustralia,Department of CardiologySt. Vincent's HospitalDarlinghurstNew South WalesAustralia,St. Vincent's Clinical School, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | - Jamie I. Vandenberg
- Cardiac Electrophysiology LaboratoryVictor Chang Cardiac Research InstituteDarlinghurstNew South WalesAustralia,St. Vincent's Clinical School, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | - Adam. P. Hill
- Cardiac Electrophysiology LaboratoryVictor Chang Cardiac Research InstituteDarlinghurstNew South WalesAustralia,St. Vincent's Clinical School, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
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Pharmacological characterisation of electrocardiogram J-T peak interval in conscious Guinea pigs. Eur J Pharmacol 2022; 927:175065. [PMID: 35640715 DOI: 10.1016/j.ejphar.2022.175065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022]
Abstract
Drug-induced human ether-à-go-go-related gene (hERG) channel block and QT interval prolongation increase torsade de pointes (TdP) risk. However, some drugs block hERG channels and prolong QT interval with low TdP risk, likely because they block additional inward currents. We investigated the utility of J-Tpeak interval, a novel biomarker of inward current block and TdP risk, in conscious telemetered guinea pigs. Electrocardiogram parameters were analysed in Hartley guinea pigs orally administered one of eight test compounds (dofetilide, flecainide, nifedipine, quinidine, quinine, ranolazine, sotalol, verapamil) or vehicle alone as controls. Heart rate-corrected QT (QTcX) and J-Tpeak (J-TpeakcX) were calculated to evaluate the relations of QT-RR and J-Tpeak-RR. Dofetilide and sotalol significantly increased ΔQTcX and ΔJ-TpeakcX intervals to similar degrees. Quinidine, quinine and flecainide also increased ΔQTcX and ΔJ-TpeakcX intervals, but the degrees of ΔJ-TpeakcX interval prolongation were shorter than those of ΔQTcX interval prolongation. Ranolazine showed slight increasing trends in ΔQTcX and ΔJ-TpeakcX intervals, but the differences were not significant. Verapamil and nifedipine did not increase the ΔQTcX or ΔJ-TpeakcX intervals. Based on the relations of ΔΔJ-TpeakcX and ΔΔQTcX intervals, dofetilide, sotalol and quinidine were classified as high risk for TdP, quinine, flecainide and ranolazine were classified as intermediate risk and verapamil and nifedipine were classified as low risk. These results supported the usefulness of J-Tpeak interval assessment in conscious guinea pigs for predicting drug-induced balanced block of inward currents and TdP risk in early-stage preclinical studies.
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Electrocardiogram-based index for the assessment of drug-induced hERG potassium channel block. J Electrocardiol 2021; 69S:55-60. [PMID: 34736759 DOI: 10.1016/j.jelectrocard.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/15/2021] [Accepted: 10/16/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Drug-induced block of the hERG potassium channel could predispose to torsade de pointes, depending on occurrence of concomitant blocks of the calcium and/or sodium channels. Since the hERG potassium channel block affects cardiac repolarization, the aim of this study was to propose a new reliable index for non-invasive assessment of drug-induced hERG potassium channel block based on electrocardiographic T-wave features. METHODS ERD30% (early repolarization duration) and TS/A (down-going T-wave slope to T-wave amplitude ratio) features were measured in 22 healthy subjects who received, in different days, doses of dofetilide, ranolazine, verapamil and quinidine (all being hERG potassium channel blockers and the latter three being also blockers of calcium and/or sodium channels) while undergoing continuous electrocardiographic acquisition from which ERD30% and TS/A were evaluated in fifteen time points during the 24 h following drug administration ("ECG Effects of Ranolazine, Dofetilide, Verapamil, and Quinidine in Healthy Subjects" database by Physionet). A total of 1320 pairs of ERD30% and TS/A measurements, divided in training (50%) and testing (50%) datasets, were obtained. Drug-induced hERG potassium channel block was modelled by the regression equation BECG(%) = a·ERD30% + b·TS/A+ c·ERD30%·TS/A + d; BECG(%) values were compared to plasma-based measurements, BREF(%). RESULTS Regression coefficients values, obtained on the training dataset, were: a = -561.0 s-1, b = -9.7 s, c = 77.2 and d = 138.9. In the testing dataset, correlation coefficient between BECG(%) and BREF(%) was 0.67 (p < 10-81); estimation error was -11.5 ± 16.7%. CONCLUSION BECG(%) is a reliable non-invasive index for the assessment of drug-induced hERG potassium channel block, independently from concomitant blocks of other ions.
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Lyle JV, Nandi M, Aston PJ. Symmetric Projection Attractor Reconstruction: Sex Differences in the ECG. Front Cardiovasc Med 2021; 8:709457. [PMID: 34631814 PMCID: PMC8495026 DOI: 10.3389/fcvm.2021.709457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The electrocardiogram (ECG) is a key tool in patient management. Automated ECG analysis supports clinical decision-making, but traditional fiducial point identification discards much of the time-series data that captures the morphology of the whole waveform. Our Symmetric Projection Attractor Reconstruction (SPAR) method uses all the available data to provide a new visualization and quantification of the morphology and variability of any approximately periodic signal. We therefore applied SPAR to ECG signals to ascertain whether this more detailed investigation of ECG morphology adds clinical value. Methods: Our aim was to demonstrate the accuracy of the SPAR method in discriminating between two biologically distinct groups. As sex has been shown to influence the waveform appearance, we investigated sex differences in normal sinus rhythm ECGs. We applied the SPAR method to 9,007 10 second 12-lead ECG recordings from Physionet, which comprised; Dataset 1: 104 subjects (40% female), Dataset 2: 8,903 subjects (54% female). Results: SPAR showed clear visual differences between female and male ECGs (Dataset 1). A stacked machine learning model achieved a cross-validation sex classification accuracy of 86.3% (Dataset 2) and an unseen test accuracy of 91.3% (Dataset 1). The mid-precordial leads performed best in classification individually, but the highest overall accuracy was achieved with all 12 leads. Classification accuracy was highest for young adults and declined with older age. Conclusions: SPAR allows quantification of the morphology of the ECG without the need to identify conventional fiducial points, whilst utilizing of all the data reduces inadvertent bias. By intuitively re-visualizing signal morphology as two-dimensional images, SPAR accurately discriminated ECG sex differences in a small dataset. We extended the approach to a machine learning classification of sex for a larger dataset, and showed that the SPAR method provided a means of visualizing the similarities of subjects given the same classification. This proof-of-concept study therefore provided an implementation of SPAR using existing data and showed that subtle differences in the ECG can be amplified by the attractor. SPAR's supplementary analysis of ECG morphology may enhance conventional automated analysis in clinically important datasets, and improve patient stratification and risk management.
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Affiliation(s)
- Jane V. Lyle
- Department of Mathematics, University of Surrey, Guildford, United Kingdom
| | - Manasi Nandi
- School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Philip J. Aston
- Department of Mathematics, University of Surrey, Guildford, United Kingdom
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Zhu Y, Wang L, Cui C, Qin H, Chen H, Chen S, Lin Y, Cheng H, Jiang X, Chen M. Pathogenesis and drug response of iPSC-derived cardiomyocytes from two Brugada syndrome patients with different Na v1.5-subunit mutations. J Biomed Res 2021; 35:395-407. [PMID: 34628405 PMCID: PMC8502687 DOI: 10.7555/jbr.35.20210045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Brugada syndrome (BrS) is a complex genetic cardiac ion channel disease that causes a high predisposition to sudden cardiac death. Considering that its heterogeneity in clinical manifestations may result from genetic background, the application of patient-specific induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) may help to reveal cell phenotype characteristics underlying different genetic variations. Here, to verify and compare the pathogenicity of mutations (SCN5A c.4213G>A andSCN1B c.590C>T) identified from two BrS patients, we generated two novel BrS iPS cell lines that carried missense mutations inSCN5A or SCN1B, compared their structures and electrophysiology, and evaluated the safety of quinidine in patient-specific iPSC-derived CMs. Compared to the control group, BrS-CMs showed a significant reduction in sodium current, prolonged action potential duration, and varying degrees of decreased Vmax, but no structural difference. After applying different concentrations of quinidine, drug-induced cardiotoxicity was not observed within 3-fold unbound effective therapeutic plasma concentration (ETPC). The data presented proved that iPSC-CMs with variants in SCN5A c.4213G>A orSCN1B c.590C>T are able to recapitulate single-cell phenotype features of BrS and respond appropriately to quinidine without increasing incidence of arrhythmic events.
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Affiliation(s)
- Yue Zhu
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Linlin Wang
- Department of Cardiology, the Affiliated Brain Hospital of Nanjing Medical University, Nanjing Chest Hospital, Nanjing, Jiangsu 210029, China
| | - Chang Cui
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Huiyuan Qin
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Hongwu Chen
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Shaojie Chen
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Yongping Lin
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Hongyi Cheng
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xiaohong Jiang
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Minglong Chen
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
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12
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Predicting drug-mediated pro-arrhythmic effects using pre-drug electrocardiograms. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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13
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Skinner M, Hale E, Ceuppens P, Pollard C. Differentiating multichannel block on the guinea pig ECG: Use of T peak-T end and J-T peak. J Pharmacol Toxicol Methods 2021; 111:107085. [PMID: 34182121 DOI: 10.1016/j.vascn.2021.107085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/14/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The anaesthetised guinea pig is a well characterised assay for early assessment of drug effects on ventricular repolarisation and risk of Torsade de Pointes (TdP). We assessed whether a selective hERG blocker with known TdP risk could be differentiated from lower risk, balanced ion channel blockers in the guinea pig, using corrected QT (QTc) interval alongside novel electrocardiogram (ECG) biomarkers J-Tpeakc and Tpeak-Tend. Effects were compared with previous clinical investigations at similar plasma concentrations and with another index of TdP risk, the electromechanical window (EMW). METHODS Twenty-two Dunkin Hartley guinea pigs anaesthetised with sodium pentobarbitone were instrumented for haemodynamic measurement and ECG recording. Three ascending doses of vehicle (n = 6), dofetilide (2, 6 or 20 μg/kg; n = 7), ranolazine (2, 6 or 20 mg/kg; n = 5) or verapamil (0.1, 0.3 or 1.0 mg/kg; n = 4) were administered intravenously. RESULTS As reported in previous clinical studies, dofetilide induced dose-dependent increases in QTc interval, with increases in both J-TpeakC or Tpeak-Tend, while verapamil caused no significant increase in QTc interval, J-TpeakC or Tpeak-Tend. Ranolazine caused dose-dependent increases in QTc interval and corrected J-Tpeakc, but had no effect on Tpeak-Tend, which is in contrast to the effects reported in humans at similar concentrations. Only dofetilide caused a clear, dose-related decrease in the EMW. DISCUSSION These findings suggest that measurements of J-Tpeakc and Tpeak-Tend in addition to QT interval, may help differentiate pure hERG channel blockers with high risk of TdP from lower risk, multichannel blockers.
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Affiliation(s)
- Matt Skinner
- Vivonics Preclinical Ltd, BioCity Nottingham, Pennyfoot Street, Nottingham NG1 1GF, UK.
| | - Ed Hale
- Vivonics Preclinical Ltd, BioCity Nottingham, Pennyfoot Street, Nottingham NG1 1GF, UK.
| | - Peter Ceuppens
- Inferstats Consulting Ltd, Biohub at Alderley Park, Cheshire SK10 4TG, UK.
| | - Chris Pollard
- Vivonics Preclinical Ltd, BioCity Nottingham, Pennyfoot Street, Nottingham NG1 1GF, UK.
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14
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A predictive in vitro risk assessment platform for pro-arrhythmic toxicity using human 3D cardiac microtissues. Sci Rep 2021; 11:10228. [PMID: 33986332 PMCID: PMC8119415 DOI: 10.1038/s41598-021-89478-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
Cardiotoxicity of pharmaceutical drugs, industrial chemicals, and environmental toxicants can be severe, even life threatening, which necessitates a thorough evaluation of the human response to chemical compounds. Predicting risks for arrhythmia and sudden cardiac death accurately is critical for defining safety profiles. Currently available approaches have limitations including a focus on single select ion channels, the use of non-human species in vitro and in vivo, and limited direct physiological translation. We have advanced the robustness and reproducibility of in vitro platforms for assessing pro-arrhythmic cardiotoxicity using human induced pluripotent stem cell-derived cardiomyocytes and human cardiac fibroblasts in 3-dimensional microtissues. Using automated algorithms and statistical analyses of eight comprehensive evaluation metrics of cardiac action potentials, we demonstrate that tissue-engineered human cardiac microtissues respond appropriately to physiological stimuli and effectively differentiate between high-risk and low-risk compounds exhibiting blockade of the hERG channel (E4031 and ranolazine, respectively). Further, we show that the environmental endocrine disrupting chemical bisphenol-A (BPA) causes acute and sensitive disruption of human action potentials in the nanomolar range. Thus, this novel human 3D in vitro pro-arrhythmic risk assessment platform addresses critical needs in cardiotoxicity testing for both environmental and pharmaceutical compounds and can be leveraged to establish safe human exposure levels.
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15
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Alahmadi A, Davies A, Royle J, Goodwin L, Cresswell K, Arain Z, Vigo M, Jay C. An explainable algorithm for detecting drug-induced QT-prolongation at risk of torsades de pointes (TdP) regardless of heart rate and T-wave morphology. Comput Biol Med 2021; 131:104281. [PMID: 33636421 DOI: 10.1016/j.compbiomed.2021.104281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 12/23/2022]
Abstract
Torsade de points (TdP), a life-threatening arrhythmia that can increase the risk of sudden cardiac death, is associated with drug-induced QT-interval prolongation on the electrocardiogram (ECG). While many modern ECG machines provide automated measurements of the QT-interval, these automated QT values are usually correct only for a noise-free normal sinus rhythm, in which the T-wave morphology is well defined. As QT-prolonging drugs often affect the morphology of the T-wave, automated QT measurements taken under these circumstances are easily invalidated. An additional challenge is that the QT-value at risk of TdP varies with heart rate, with the slower the heart rate, the greater the risk of TdP. This paper presents an explainable algorithm that uses an understanding of human visual perception and expert ECG interpretation to automate the detection of QT-prolongation at risk of TdP regardless of heart rate and T-wave morphology. It was tested on a large number of ECGs (n=5050) with variable QT-intervals at varying heart rates, acquired from a clinical trial that assessed the effect of four known QT-prolonging drugs versus placebo on healthy subjects. The algorithm yielded a balanced accuracy of 0.97, sensitivity of 0.94, specificity of 0.99, F1-score of 0.88, ROC (AUC) of 0.98, precision-recall (AUC) of 0.88, and Matthews correlation coefficient (MCC) of 0.88. The results indicate that a prolonged ventricular repolarisation area can be a significant risk predictor of TdP, and detection of this is potentially easier and more reliable to automate than measuring the QT-interval distance directly. The proposed algorithm can be visualised using pseudo-colour on the ECG trace, thus intuitively 'explaining' how its decision was made, which results of a focus group show may help people to self-monitor QT-prolongation, as well as ensuring clinicians can validate its results.
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Affiliation(s)
- Alaa Alahmadi
- Department of Computer Science, The University of Manchester, Manchester, UK.
| | - Alan Davies
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, The University of Manchester, Manchester, UK.
| | - Jennifer Royle
- Digital Experimental Cancer Medicine Team, CRUK Manchester Institute, And the Christie NHS Foundation, Manchester, UK.
| | - Leanna Goodwin
- Digital Experimental Cancer Medicine Team, CRUK Manchester Institute, And the Christie NHS Foundation, Manchester, UK.
| | - Katharine Cresswell
- Cancer Precision Medicine and Cancer Prevention and Early Detection, NIHR Manchester Biomedical Research Centre (BRC), Manchester University NHS Foundation Trust, Manchester, UK.
| | - Zahra Arain
- Cancer Precision Medicine and Cancer Prevention and Early Detection, NIHR Manchester Biomedical Research Centre (BRC), Manchester University NHS Foundation Trust, Manchester, UK.
| | - Markel Vigo
- Department of Computer Science, The University of Manchester, Manchester, UK.
| | - Caroline Jay
- Department of Computer Science, The University of Manchester, Manchester, UK.
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16
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de Vries TAC, Seelig J, Pisters R, Hemels MEW. Drug-induced notched T waves. Neth Heart J 2021; 29:473-474. [PMID: 33564958 PMCID: PMC8397812 DOI: 10.1007/s12471-021-01544-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 10/30/2022] Open
Affiliation(s)
- T A C de Vries
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands. .,Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
| | - J Seelig
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - R Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - M E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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17
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Isaksen JL, Ghouse J, Graff C, Olesen MS, Holst AG, Pietersen A, Nielsen JB, Skov MW, Kanters JK. Electrocardiographic T-wave morphology and risk of mortality. Int J Cardiol 2020; 328:199-205. [PMID: 33321127 DOI: 10.1016/j.ijcard.2020.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/10/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Electrocardiographic T-wave morphology is used in drug safety studies as an adjunct to the QTc interval, but few measurements of T-wave morphology can be interpreted in clinical practice. Morphology combination score (MCS) is a combination of T-wave flatness/peakedness, asymmetry, and notching, enabling easy visual assessment of T-wave morphology. We aimed to test the association between T-wave morphology, quantified by MCS, and mortality. METHODS We included electrocardiograms recorded in 2001-2011 from 342,294 primary care patients. Using Cox regression, we evaluated the association between MCS, cardiovascular death, and all-cause mortality, adjusting for heart rate, QTc, QT-prolonging drugs, diabetes, ischemic heart disease, hypertension, and congestive heart failure. RESULTS 270,039 individuals (44% men, median age 55 [inter-quartile range: 42-67 years]) were included and followed for a median of 9.3 years, during which time 13,489 (5.0%) died from cardiovascular causes and 50,481 (18.7%) from any cause. High values of MCS (i.e. asymmetric, flattened, and/or notched T waves) were associated with an adjusted mortality Hazard Ratio of 1.75 (95% CI 1.62-1.89) and 1.61 (1.43-1.92) for women and men, respectively. Low values of MCS (i.e. peaked and symmetric T waves) were associated with a Hazard Ratio of 1.18 (1.08-1.28) and 1.71 (1.48-1.98) for women and men, respectively. CONCLUSIONS In a large primary care population, we found that T-wave asymmetry, flatness, and notching provided prognostic information on mortality independent of heart rate, QTc, and baseline comorbidities.
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Affiliation(s)
- Jonas L Isaksen
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas Ghouse
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Morten S Olesen
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Anders G Holst
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Adrian Pietersen
- Copenhagen General Practitioners' Laboratory, Copenhagen, Denmark
| | - Jonas B Nielsen
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark; Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Morten W Skov
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.
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18
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Bystricky W, Maier C, Gintant G, Bergau D, Carter D. Identification of Drug-Induced Multichannel Block and Proarrhythmic Risk in Humans Using Continuous T Vector Velocity Effect Profiles Derived From Surface Electrocardiograms. Front Physiol 2020; 11:567383. [PMID: 33071822 PMCID: PMC7530300 DOI: 10.3389/fphys.2020.567383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/27/2020] [Indexed: 01/07/2023] Open
Abstract
We present continuous T vector velocity (TVV) effect profiles as a new method for identifying drug effects on cardiac ventricular repolarization. TVV measures the temporal change in the myocardial action potential distribution during repolarization. The T vector dynamics were measured as the time required to reach p percent of the total T vector trajectory length, denoted as Tr(p), with p in {1, …, 100%}. The Tr(p) values were individually corrected for heart rate at each trajectory length percentage p. Drug effects were measured by evaluating the placebo corrected changes from baseline of Tr(p)c jointly for all p using functional mixed effects models. The p-dependent model parameters were implemented as cubic splines, providing continuous drug effect profiles along the entire ventricular repolarization process. The effect profile distributions were approximated by bootstrap simulations. We applied this TVV-based analysis approach to ECGs available from three published studies that were conducted in the CiPA context. These studies assessed the effect of 10 drugs and drug combinations with different ion channel blocking properties on myocardial repolarization in a total of 104 healthy volunteers. TVV analysis revealed that blockade of outward potassium currents alone presents an effect profile signature of continuous accumulation of delay throughout the entire repolarization interval. In contrast, block of inward sodium or calcium currents involves acceleration, which accumulates during early repolarization. The balance of blocking inward versus outward currents was reflected in the percentage pzero of the T vector trajectory length where accelerated repolarization transitioned to delayed repolarization. Binary classification using a threshold pzero = 43% separated predominant hERG channel blocking drugs with potentially higher proarrhythmic risk (moxifloxacin, dofetilide, quinidine, chloroquine) from multichannel blocking drugs with low proarrhythmic risk (ranolazine, verapamil, lopinavir/ritonavir) with sensitivity 0.99 and specificity 0.97. The TVV-based effect profile provides a detailed view of drug effects throughout the entire ventricular repolarization interval. It enables the evaluation of drug-induced blocks of multiple cardiac repolarization currents from clinical ECGs. The proposed pzero parameter enhances identification of the proarrhythmic risk of a drug beyond QT prolongation, and therefore constitutes an important tool for cardiac arrhythmia risk assessment.
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Affiliation(s)
- Werner Bystricky
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, United States
| | - Christoph Maier
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, United States.,Department of Medical Informatics, Heilbronn University, Heilbronn, Germany
| | - Gary Gintant
- Integrated Sciences and Technology, AbbVie, Inc., North Chicago, IL, United States
| | - Dennis Bergau
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, United States
| | - David Carter
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, United States
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19
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Alahmadi A, Davies A, Vigo M, Jay C. Pseudo-colouring an ECG enables lay people to detect QT-interval prolongation regardless of heart rate. PLoS One 2020; 15:e0237854. [PMID: 32853262 PMCID: PMC7451551 DOI: 10.1371/journal.pone.0237854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 08/04/2020] [Indexed: 01/08/2023] Open
Abstract
Drug-induced long QT syndrome (diLQTS), characterized by a prolongation of the QT-interval on the electrocardiogram (ECG), is a serious adverse drug reaction that can cause the life-threatening arrhythmia Torsade de Points (TdP). Self-monitoring for diLQTS could therefore save lives, but detecting it on the ECG is difficult, particularly at high and low heart rates. In this paper, we evaluate whether using a pseudo-colouring visualisation technique and changing the coordinate system (Cartesian vs. Polar) can support lay people in identifying QT-prolongation at varying heart rates. Four visualisation techniques were evaluated using a counterbalanced repeated measures design including Cartesian no-colouring, Cartesian pseudo-colouring, Polar no-colouring and Polar pseudo-colouring. We used a multi-reader, multi-case (MRMC) receiver operating characteristic (ROC) study design within a psychophysical paradigm, along with eye-tracking technology. Forty-three lay participants read forty ECGs (TdP risk n = 20, no risk n = 20), classifying each QT-interval as normal/abnormal, and rating their confidence on a 6-point scale. The results show that introducing pseudo-colouring to the ECG significantly increased accurate detection of QT-interval prolongation regardless of heart rate, T-wave morphology and coordinate system. Pseudo-colour also helped to reduce reaction times and increased satisfaction when reading the ECGs. Eye movement analysis indicated that pseudo-colour helped to focus visual attention on the areas of the ECG crucial to detecting QT-prolongation. The study indicates that pseudo-colouring enables lay people to visually identify drug-induced QT-prolongation regardless of heart rate, with implications for the more rapid identification and management of diLQTS.
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Affiliation(s)
- Alaa Alahmadi
- Department of Computer Science, The University of Manchester, Manchester, United Kingdom
| | - Alan Davies
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Markel Vigo
- Department of Computer Science, The University of Manchester, Manchester, United Kingdom
| | - Caroline Jay
- Department of Computer Science, The University of Manchester, Manchester, United Kingdom
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20
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Meo M, Bonizzi P, Bear LR, Cluitmans M, Abell E, Haïssaguerre M, Bernus O, Dubois R. Body Surface Mapping of Ventricular Repolarization Heterogeneity: An Ex-vivo Multiparameter Study. Front Physiol 2020; 11:933. [PMID: 32903614 PMCID: PMC7438571 DOI: 10.3389/fphys.2020.00933] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/10/2020] [Indexed: 12/15/2022] Open
Abstract
Background Increased heterogeneity of ventricular repolarization is associated with life-threatening arrhythmia and sudden cardiac death (SCD). T-wave analysis through body surface potential mapping (BSPM) is a promising tool for risk stratification, but the clinical effectiveness of current electrocardiographic indices is still unclear, with limited experimental validation. This study aims to investigate performance of non-invasive state-of-the-art and novel T-wave markers for repolarization dispersion in an ex vivo model. Methods Langendorff-perfused pig hearts (N = 7) were suspended in a human-shaped 256-electrode torso tank. Tank potentials were recorded during sinus rhythm before and after introducing repolarization inhomogeneities through local perfusion with dofetilide and/or pinacidil. Drug-induced repolarization gradients were investigated from BSPMs at different experiment phases. Dispersion of electrical recovery was quantified by duration parameters, i.e., the time interval between the peak and the offset of T-wave (TPEAK-TEND) and QT interval, and variability over time and electrodes was also assessed. The degree of T-wave symmetry to the peak was quantified by the ratio between the terminal and initial portions of T-wave area (Asy). Morphological variability between left and right BSPM electrodes was measured by dynamic time warping (DTW). Finally, T-wave organization was assessed by the complexity of repolarization index (CR), i.e., the amount of energy non-preserved by the dominant eigenvector computed by principal component analysis (PCA), and the error between each multilead T-wave and its 3D PCA approximation (NMSE). Body surface indices were compared with global measures of epicardial dispersion of repolarization, and with local gradients between adjacent ventricular sites. Results After drug intervention, both regional and global repolarization heterogeneity were significantly enhanced. On the body surface, TPEAK-TEND was significantly prolonged and less stable in time in all experiments, while QT interval showed higher variability across the interventions in terms of duration and spatial dispersion. The rising slope of the repolarization profile was steeper, and T-waves were more asymmetric than at baseline. Interventricular shape dissimilarity was enhanced by repolarization gradients according to DTW. Organized T-wave patterns were associated with abnormal repolarization, and they were properly described by the first principal components. Conclusion Repolarization heterogeneity significantly affects T-wave properties, and can be non-invasively captured by BSPM-based metrics.
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Affiliation(s)
- Marianna Meo
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France
| | - Pietro Bonizzi
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, Netherlands
| | - Laura R Bear
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France
| | - Matthijs Cluitmans
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Emma Abell
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France
| | - Michel Haïssaguerre
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France.,Bordeaux University Hospital (CHU), Electrophysiology and Ablation Unit, Pessac, France
| | - Olivier Bernus
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France
| | - Rémi Dubois
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France
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21
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Krisai P, Vlachos K, Ramirez FD, Nakatani Y, Nakashima T, Takagi T, Kamakura T, Surget E, André C, Cheniti G, Welte N, Chauvel R, Tixier R, Duchateau J, Pambrun T, Derval N, Hocini M, Jaïs P, Haïssaguerre M, Sacher F. Evaluation of the QT interval in patients with drug-induced QT prolongation and torsades de pointes. J Cardiovasc Electrophysiol 2020; 31:2696-2701. [PMID: 32700358 DOI: 10.1111/jce.14687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/15/2020] [Accepted: 07/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Data on the optimal location of the electrocardiogram (ECG) leads for the diagnosis of drug-induced long QT syndrome (diLQTS) with torsades de pointes (TdP) are lacking. METHODS We systematically reviewed the literature for the ECGs of patients with diLQTS and subsequent TdP. We assessed T wave morphology in each lead and measured the longest QT interval in the limb and chest leads in a standardized fashion. RESULTS Of 84 patients, 61.9% were female and the mean age was 58.8 years. QTc was significantly longer in chest versus limb leads (mean (SD) 671 (102) vs. 655 (97) ms, p = .02). Using only limb leads for QT interpretation, 18 (21.4%) ECGs were noninterpretable: 10 (11.9%) due to too flat T waves, 7 (8.3%) due to frequent, early PVCs and 1 (1.2%) due to too low ECG recording quality. In the chest leads, ECGs were noninterpretable in nine (10.7%) patients: six (7.1%) due to frequent, early PVCs, one (1.2%) due to insufficient ECG quality, two (2.4%) due to missing chest leads but none due to too flat T waves. The most common T wave morphologies in the limb leads were flat (51.0%), broad (14.3%), and late peaking (12.6%) T waves. Corresponding chest lead morphologies were inverted (35.5%), flat (19.6%), and biphasic (15.2%) T waves. CONCLUSIONS Our results indicate that QT evaluation by limb leads only underestimates the incidence of diLQTS experiencing TdP and favors the screening using both limb and chest lead ECG.
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Affiliation(s)
- Philipp Krisai
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Konstantinos Vlachos
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - F Daniel Ramirez
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Yosuke Nakatani
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Takashi Nakashima
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Takamitsu Takagi
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Tsukasa Kamakura
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Elodie Surget
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Clémentine André
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Ghassen Cheniti
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Nicolas Welte
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Rémi Chauvel
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Romain Tixier
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Josselin Duchateau
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Thomas Pambrun
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Nicolas Derval
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Mélèze Hocini
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Pierre Jaïs
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Michel Haïssaguerre
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Frédéric Sacher
- Department of Cardiology, Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Centre de recherche Cardio-Thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
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22
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Vormfelde SV, Pezous N, Lefèvre G, Kolly C, Neumann U, Jordaan P, Ufer M, Legangneux E. A Pooled Analysis of Three Randomized Phase I/IIa Clinical Trials Confirms Absence of a Clinically Relevant Effect on the QTc Interval by Umibecestat. Clin Transl Sci 2020; 13:1316-1326. [PMID: 32583957 PMCID: PMC7719381 DOI: 10.1111/cts.12832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/01/2020] [Indexed: 01/17/2023] Open
Abstract
Umibecestat, an orally active β‐secretase inhibitor, reduces the production of amyloid beta‐peptide that accumulates in the brain of patients with Alzheimer’s disease. The echocardiogram effects of umibecestat, on QTcF (Fridericia‐corrected QT), on PR and QRS and heart rate (HR), were estimated by concentration‐effect modeling. Three phase I/II studies with durations up to 3 months, with 372 healthy subjects over a wide age range, including both sexes and 2 ethnicities, were pooled, providing a large data set with good statistical power. No clinically relevant effect on QTcF, PR interval, QRS duration, or HR were observed up to supratherapeutic doses. The upper bound of 90% confidence intervals of the ∆QTcF was below the 10 ms threshold of regulatory concern for all concentrations measured. Prespecified sensitivity analysis confirmed the results in both sexes, in those over and below 60 years, and in Japanese subjects. All conclusions were endorsed by the US Food and Drug Administration (FDA).
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Affiliation(s)
- Stefan Viktor Vormfelde
- Department of Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Nicole Pezous
- Department of Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Gilbert Lefèvre
- Department of Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Carine Kolly
- Department of Preclinical Safety, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Ulf Neumann
- Department of Neuroscience, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Pierre Jordaan
- Cardiovascular Safety Expert - CMO and Patient Safety - Oncology, Novartis Pharma, Basel, Switzerland
| | - Mike Ufer
- Department of Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Eric Legangneux
- Department of Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
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23
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Hwang M, Lim CH, Leem CH, Shim EB. In silico models for evaluating proarrhythmic risk of drugs. APL Bioeng 2020; 4:021502. [PMID: 32548538 PMCID: PMC7274812 DOI: 10.1063/1.5132618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/27/2020] [Indexed: 02/07/2023] Open
Abstract
Safety evaluation of drugs requires examination of the risk of generating Torsade de Pointes (TdP) because it can lead to sudden cardiac death. Until recently, the QT interval in the electrocardiogram (ECG) has been used in the evaluation of TdP risk because the QT interval is known to be associated with the development of TdP. Although TdP risk evaluation based on QT interval has been successful in removing drugs with TdP risk from the market, some safe drugs may have also been affected due to the low specificity of QT interval-based evaluation. For more accurate evaluation of drug safety, the comprehensive in vitro proarrhythmia assay (CiPA) has been proposed by regulatory agencies, industry, and academia. Although the CiPA initiative includes in silico evaluation of cellular action potential as a component, attempts to utilize in silico simulation in drug safety evaluation are expanding, even to simulating human ECG using biophysical three-dimensional models of the heart and torso under the effects of drugs. Here, we review recent developments in the use of in silico models for the evaluation of the proarrhythmic risk of drugs. We review the single cell, one-dimensional, two-dimensional, and three-dimensional models and their applications reported in the literature and discuss the possibility of utilizing ECG simulation in drug safety evaluation.
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Affiliation(s)
- Minki Hwang
- SiliconSapiens Inc., Seoul 06097, South Korea
| | - Chul-Hyun Lim
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon 24341, South Korea
| | - Chae Hun Leem
- Department of Physiology, College of Medicine, University of Ulsan, Asan Medical Center, Seoul 05505, South Korea
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24
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Corino VDA, Rivolta MW, Mainardi LT, Sassi R. Assessment of spatial heterogeneity of ventricular repolarization after multi-channel blocker drugs in healthy subjects. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 189:105291. [PMID: 31935579 DOI: 10.1016/j.cmpb.2019.105291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVES In contrast to potassium channel blockers, drugs affecting multiple channels seem to reduce torsadogenic risks. However, their effect on spatial heterogeneity of ventricular repolarization (SHVR) is still matter of investigation. Aim of this work is to assess the effect of four drugs blocking the human ether-à-go-go-related gene (hERG) potassium channel, alone or in combination with other ionic channel blocks, on SHVR, as estimated by the V-index on short triplicate 10 s ECG. METHODS The V-index is an estimate of the standard deviation of the repolarization times of the myocytes across the entire myocardium, obtained from multi-lead surface electrocardiograms. Twenty-two healthy subjects received a pure hERG potassium channel blocker (dofetilide) and 3 other drugs with additional varying degrees of sodium and calcium (L-type) channel block (quinidine, ranolazine, and verapamil), as well as placebo. A one-way repeated-measures Friedman test was performed to compare the V-index over time. RESULTS Computer simulations and Bland-Altman analysis supported the reliability of the estimates of V-index on triplicate 10 s ECG. Ranolazine, verapamil and placebo did not affect the V-index. On the contrary, after quinidine and dofetilide administration, an increase of V-index from predose to its peak value was observed (ΔΔV-index values were 19 ms and 27 ms, respectively, p < 0.05). CONCLUSIONS High torsadogenic drugs (dofetilide and quinidine) affected significantly the SHVR, as quantified by the V-index. The metric has therefore a potential in assessing drug arrhythmogenicity.
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Affiliation(s)
- Valentina D A Corino
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, via Golgi 39, 20133 Milan, Italy.
| | - Massimo W Rivolta
- Dipartimento di Informatica, Università degli Studi di Milano, Via Celoria 18, 20133 Milan, Italy
| | - Luca T Mainardi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, via Golgi 39, 20133 Milan, Italy
| | - Roberto Sassi
- Dipartimento di Informatica, Università degli Studi di Milano, Via Celoria 18, 20133 Milan, Italy
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25
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Authier S, Abernathy MM, Correll K, Chui RW, Dalton J, Foley CM, Friedrichs GS, Koerner JE, Kallman MJ, Pannirselvam M, Redfern WS, Urmaliya V, Valentin JP, Wisialowski T, Zabka TS, Pugsley MK. An Industry Survey With Focus on Cardiovascular Safety Pharmacology Study Design and Data Interpretation. Int J Toxicol 2020; 39:274-293. [DOI: 10.1177/1091581820921338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: The Safety Pharmacology Society (SPS) conducted a membership survey to examine industry practices related mainly to cardiovascular (CV) safety pharmacology (SP). Methods: Questions addressed nonclinical study design, data analysis methods, drug-induced effects, and conventional and novel CV assays. Results: The most frequent therapeutic area targeted by drugs developed by the companies/institutions that employ survey responders was oncology. The most frequently observed drug-mediated effects included an increased heart rate, increased arterial blood pressure, hERG (IKr) block, decreased arterial blood pressure, decreased heart rate, QTc prolongation, and changes in body temperature. Broadly implemented study practices included Latin square crossover study design with n = 4 for nonrodent CV studies, statistical analysis of data (eg, analysis of variance), use of arrhythmia detection software, and the inclusion of data from all study animals when integrating SP studies into toxicology studies. Most responders frequently used individual animal housing conditions. Responders commonly evaluated drug effects on multiple ion channels, but in silico modeling methods were used much less frequently. Most responders rarely measured the J-Tpeak interval in CV studies. Uncertainties relative to Standard for Exchange of Nonclinical Data applications for data derived from CV SP studies were common. Although available, the use of human induced pluripotent stem cell cardiomyocytes remains rare. The respiratory SP study was rarely involved with identifying drug-induced functional issues. Responders indicated that the study-derived no observed effect level was more frequently determined than the no observed adverse effect level in CV SP studies; however, a large proportion of survey responders used neither.
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Affiliation(s)
| | | | | | - Ray W. Chui
- Amgen Research, Safety Pharmacology & Animal Research Center, Amgen, Inc, Thousand Oaks, CA, USA
| | | | - C. Michael Foley
- Department of Safety Pharmacology, Integrated Sciences and Technology, AbbVie, North Chicago, IL, USA
| | | | - John E. Koerner
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | - Vijay Urmaliya
- Global Safety Pharmacology, Janssen Research & Development, Beerse, Belgium
| | | | | | - Tanja S. Zabka
- Development Sciences Safety Assessment, Genentech, South San Francisco, CA, USA
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26
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Yang PC, DeMarco KR, Aghasafari P, Jeng MT, Dawson JRD, Bekker S, Noskov SY, Yarov-Yarovoy V, Vorobyov I, Clancy CE. A Computational Pipeline to Predict Cardiotoxicity: From the Atom to the Rhythm. Circ Res 2020; 126:947-964. [PMID: 32091972 DOI: 10.1161/circresaha.119.316404] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
RATIONALE Drug-induced proarrhythmia is so tightly associated with prolongation of the QT interval that QT prolongation is an accepted surrogate marker for arrhythmia. But QT interval is too sensitive a marker and not selective, resulting in many useful drugs eliminated in drug discovery. OBJECTIVE To predict the impact of a drug from the drug chemistry on the cardiac rhythm. METHODS AND RESULTS In a new linkage, we connected atomistic scale information to protein, cell, and tissue scales by predicting drug-binding affinities and rates from simulation of ion channel and drug structure interactions and then used these values to model drug effects on the hERG channel. Model components were integrated into predictive models at the cell and tissue scales to expose fundamental arrhythmia vulnerability mechanisms and complex interactions underlying emergent behaviors. Human clinical data were used for model framework validation and showed excellent agreement, demonstrating feasibility of a new approach for cardiotoxicity prediction. CONCLUSIONS We present a multiscale model framework to predict electrotoxicity in the heart from the atom to the rhythm. Novel mechanistic insights emerged at all scales of the system, from the specific nature of proarrhythmic drug interaction with the hERG channel, to the fundamental cellular and tissue-level arrhythmia mechanisms. Applications of machine learning indicate necessary and sufficient parameters that predict arrhythmia vulnerability. We expect that the model framework may be expanded to make an impact in drug discovery, drug safety screening for a variety of compounds and targets, and in a variety of regulatory processes.
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Affiliation(s)
- Pei-Chi Yang
- From the Department of Physiology and Membrane Biology (P.-C.Y., K.R.D., P.A., M.-T.J., J.R.D.D., V.Y.-Y., I.V., C.E.C.), University of California Davis
| | - Kevin R DeMarco
- From the Department of Physiology and Membrane Biology (P.-C.Y., K.R.D., P.A., M.-T.J., J.R.D.D., V.Y.-Y., I.V., C.E.C.), University of California Davis
| | - Parya Aghasafari
- From the Department of Physiology and Membrane Biology (P.-C.Y., K.R.D., P.A., M.-T.J., J.R.D.D., V.Y.-Y., I.V., C.E.C.), University of California Davis
| | - Mao-Tsuen Jeng
- From the Department of Physiology and Membrane Biology (P.-C.Y., K.R.D., P.A., M.-T.J., J.R.D.D., V.Y.-Y., I.V., C.E.C.), University of California Davis
| | - John R D Dawson
- From the Department of Physiology and Membrane Biology (P.-C.Y., K.R.D., P.A., M.-T.J., J.R.D.D., V.Y.-Y., I.V., C.E.C.), University of California Davis.,Biophysics Graduate Group (J.R.D.D.), University of California Davis
| | - Slava Bekker
- Department of Science and Engineering, American River College, Sacramento, CA (S.B.)
| | - Sergei Y Noskov
- Faculty of Science, Centre for Molecular Simulations and Department of Biological Sciences, University of Calgary, Alberta, Canada (S.Y.N.)
| | - Vladimir Yarov-Yarovoy
- From the Department of Physiology and Membrane Biology (P.-C.Y., K.R.D., P.A., M.-T.J., J.R.D.D., V.Y.-Y., I.V., C.E.C.), University of California Davis
| | - Igor Vorobyov
- From the Department of Physiology and Membrane Biology (P.-C.Y., K.R.D., P.A., M.-T.J., J.R.D.D., V.Y.-Y., I.V., C.E.C.), University of California Davis.,Department of Pharmacology (I.V., C.E.C.), University of California Davis
| | - Colleen E Clancy
- From the Department of Physiology and Membrane Biology (P.-C.Y., K.R.D., P.A., M.-T.J., J.R.D.D., V.Y.-Y., I.V., C.E.C.), University of California Davis.,Department of Pharmacology (I.V., C.E.C.), University of California Davis
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27
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Snyder S, Murundi S, Crawford L, Putnam D. Enabling P-glycoprotein inhibition in multidrug resistant cancer through the reverse targeting of a quinidine-PEG conjugate. J Control Release 2020; 317:291-299. [DOI: 10.1016/j.jconrel.2019.11.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/15/2019] [Accepted: 11/22/2019] [Indexed: 11/15/2022]
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28
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Morettini M, Peroni C, Sbrollini A, Marcantoni I, Burattini L. Classification of drug-induced hERG potassium-channel block from electrocardiographic T-wave features using artificial neural networks. Ann Noninvasive Electrocardiol 2019; 24:e12679. [PMID: 31347753 DOI: 10.1111/anec.12679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/09/2019] [Accepted: 06/03/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Human ether-à-go-go-related gene (hERG) potassium-channel block represents a harmful side effect of drug therapy that may cause torsade de pointes (TdP). Analysis of ventricular repolarization through electrocardiographic T-wave features represents a noninvasive way to accurately evaluate the TdP risk in drug-safety studies. This study proposes an artificial neural network (ANN) for noninvasive electrocardiography-based classification of the hERG potassium-channel block. METHODS The data were taken from the "ECG Effects of Ranolazine, Dofetilide, Verapamil, and Quinidine in Healthy Subjects" Physionet database; they consisted of median vector magnitude (VM) beats of 22 healthy subjects receiving a single 500 μg dose of dofetilide. Fourteen VM beats were considered for each subject, relative to time-points ranging from 0.5 hr before to 14.0 hr after dofetilide administration. For each VM, changes in two indexes accounting for the early and the late phases of repolarization, ΔERD30% and ΔTS /A , respectively, were computed as difference between values at each postdose time-point and the predose time-point. Thus, the dataset contained 286 ΔERD30% -ΔTS /A pairs, partitioned into training, validation, and test sets (114, 29, and 143 pairs, respectively) and used as inputs of a two-layer feedforward ANN with two target classes: high block (HB) and low block (LB). Optimal ANN (OANN) was identified using the training and validation sets and tested on the test set. RESULTS Test set area under the receiver operating characteristic was 0.91; sensitivity, specificity, accuracy, and precision were 0.93, 0.83, 0.92, and 0.96, respectively. CONCLUSION OANN represents a reliable tool for noninvasive assessment of the hERG potassium-channel block.
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Affiliation(s)
- Micaela Morettini
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Chiara Peroni
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Agnese Sbrollini
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Ilaria Marcantoni
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Laura Burattini
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
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29
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Fleseriu M, Pivonello R, Elenkova A, Salvatori R, Auchus RJ, Feelders RA, Geer EB, Greenman Y, Witek P, Cohen F, Biller BMK. Efficacy and safety of levoketoconazole in the treatment of endogenous Cushing's syndrome (SONICS): a phase 3, multicentre, open-label, single-arm trial. Lancet Diabetes Endocrinol 2019; 7:855-865. [PMID: 31542384 DOI: 10.1016/s2213-8587(19)30313-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Levoketoconazole is a ketoconazole stereoisomer in development for treatment of Cushing's syndrome and has not been assessed previously in a clinical trial in patients with Cushing's syndrome. We aimed to investigate the efficacy and safety of levoketoconazole in patients with endogenous Cushing's syndrome. METHODS SONICS is a phase 3, multicentre, open-label, non-randomised, single-arm study in which we recruited adults (≥18 years) with confirmed Cushing's syndrome and a mean 24-h urinary free cortisol (mUFC) of at least 1·5 times the upper limit of normal from 60 hospital and community sites in 19 countries (15 countries in Europe, and Canada, Israel, Turkey, and the USA). Patients were treated with oral levoketoconazole in a 2-21 week incremental dose-titration phase starting at 150 mg twice daily (150 mg increments until mUFC normalisation, maximum 600 mg twice daily) and a 6-month maintenance phase. The primary outcome was the proportion of patients with mUFC normalisation at end of maintenance, without dose increase during the maintenance phase (in the intention-to-treat population). Prespecified adverse events of special interest were potential liver toxicity, corrected QT prolongation, and adrenal insufficiency. This trial is registered with ClinicalTrials.gov, NCT01838551. FINDINGS Between July 30, 2014, and June 30, 2017, 201 individuals were screened and 94 patients were enrolled and received at least one dose of study medication. Of the 94 patients, 80 (85%) had pituitary Cushing's syndrome. Mean mUFC at baseline was 671·4 nmol/24 h (243·3 μg/24 h), which is 4·9 times the upper limit of normal. Of the 77 patients who advanced to the maintenance phase, 62 (81%) had mUFC normalisation by end-of-dose titration. At the end of the 6-month maintenance phase, 29 (31%) of 94 patients were responders; the least-squares mean estimate of the proportion of responders was 0·30 (95% CI 0·21-0·40; p=0·0154 vs null hypothesis of ≤0·20). The most common adverse events in the 94 patients were nausea (30 [32%]) and headache (26 [28%]). Adverse events led to study discontinuation in 12 (13%) of 94 patients. Two patients had a QT interval (Fridericia corrected) of more than 500 ms, and three patients had suspected adrenal insufficiency. Alanine aminotransferase reversibly increased to more than three times the upper limit of normal in ten (11%) patients. Four patients had serious adverse events that were considered probably or definitely related to the study drug: abnormal liver function test results (n=1), prolonged QT interval (n=2), and adrenal insufficiency (n=1). One person died from colon carcinoma unrelated to study medication. INTERPRETATION Twice-daily oral levoketoconazole treatment led to sustained improvements in urinary free cortisol, with an acceptable safety and tolerability profile. Levoketoconazole might represent a useful therapeutic option for the medical treatment of Cushing's syndrome. FUNDING Strongbridge Biopharma.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine and Neurological Surgery, Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli Federico II, Naples, Italy
| | - Atanaska Elenkova
- Department of Endocrinology, Medical University Sofia, Sofia, Bulgaria
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes and Metabolism and Pituitary Center, Johns Hopkins University, Baltimore, MD, USA
| | - Richard J Auchus
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Eliza B Geer
- Pituitary & Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yona Greenman
- Institute of Endocrinology and Metabolism, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Przemyslaw Witek
- Department of Gastroenterology, Endocrinology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | | | - Beverly M K Biller
- Neuroendocrine Clinical Center, Massachusetts General Hospital, Boston, MA, USA
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Stabenau HF, Shen C, Tereshchenko LG, Waks JW. Changes in global electrical heterogeneity associated with dofetilide, quinidine, ranolazine, and verapamil. Heart Rhythm 2019; 17:460-467. [PMID: 31539628 DOI: 10.1016/j.hrthm.2019.09.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Electrocardiographic (ECG) markers of antiarrhythmic drug (AAD) activity could be used to optimize efficacy and minimize toxicity. Vectorcardiographic global electrical heterogeneity (GEH) is associated with ventricular arrhythmias and sudden death, but it is unclear how GEH measurements change in response to AADs. OBJECTIVE The purpose of this study was to characterize acute effects of AADs on GEH measurements. METHODS We analyzed double-blind placebo-controlled trial data from healthy volunteers given 1 dose of placebo, dofetilide, quinidine, ranolazine, or verapamil on subsequent visits. Serial ECGs and plasma drug concentrations were collected. Vectorcardiographic GEH parameters (spatial ventricular gradient [SVG], spatial QRST angle, sum absolute QRST integral, and SVG-QRS peak angle) were measured. Placebo-corrected change from baseline was regressed on drug concentration stratified by sex using linear mixed effects models. RESULTS Among 22 persons (11 (50%) male median age 27 ± 5 years), 5232 ECGs were analyzed. Dofetilide and quinidine were associated with significant changes in more GEH parameters (5) compared with verapamil (2) and ranolazine (1). The most notable change occurred in SVG azimuth, with largest changes (degrees per unit normalized drug concentration) in dofetilide (6.1; 95% confidence interval [CI] 4.2-8.0) and quinidine (9.4; 95% CI 6.7-12.0), and smaller effects in verapamil (4.4; 95% CI 2.9-5.9) and ranolazine (5.4; 95% CI 3.5-7.3). AAD-induced GEH changes significantly differed in men and women. CONCLUSION AADs change GEH measurements. These changes, which differ by sex, are likely driven by alterations in ion channel function and dispersion of depolarization or repolarization. GEH measurement may allow early assessment of favorable or adverse AAD effects.
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Affiliation(s)
- Hans Friedrich Stabenau
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Changyu Shen
- Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Harvard Medical School, Boston, Massachusetts
| | - Larisa G Tereshchenko
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Jonathan W Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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31
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Hwang M, Han S, Park MC, Leem CH, Shim EB, Yim DS. Three-Dimensional Heart Model-Based Screening of Proarrhythmic Potential by in silico Simulation of Action Potential and Electrocardiograms. Front Physiol 2019; 10:1139. [PMID: 31551815 PMCID: PMC6738014 DOI: 10.3389/fphys.2019.01139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/20/2019] [Indexed: 12/19/2022] Open
Abstract
The proarrhythmic risk is a major concern in drug development. The Comprehensive in vitro Proarrhythmia Assay (CiPA) initiative has proposed the JTpeak interval on electrocardiograms (ECGs) and qNet, an in silico metric, as new biomarkers that may overcome the limitations of the hERG assay and QT interval. In this study, we simulated body-surface ECGs from patch-clamp data using realistic models of the ventricles and torso to explore their suitability as new in silico biomarkers for cardiac safety. We tested seven drugs in this study: dofetilide (high proarrhythmic risk), ranolazine, verapamil (QT increasing, but safe), bepridil, cisapride, mexiletine, and diltiazem. Human ventricular geometry was reconstructed from computed tomography (CT) images, and a Purkinje fiber network was mapped onto the endocardial surface. The electrical wave propagation in the ventricles was obtained by solving a reaction-diffusion equation using finite-element methods. The body-surface ECG data were calculated using a torso model that included the ventricles. The effects of the drugs were incorporated in the model by partly blocking the appropriate ion channels. The effects of the drugs on single-cell action potential (AP) were examined first, and three-dimensional (3D) body-surface ECG simulations were performed at free Cmax values of 1×, 5×, and 10×. In the single-cell and ECG simulations at 5× Cmax, dofetilide, but not verapamil or ranolazine, caused arrhythmia. However, the non-increasing JTpeak caused by verapamil and ranolazine that has been observed in humans was not reproduced in our simulation. Our results demonstrate the potential of 3D body-surface ECG simulation as a biomarker for evaluation of the proarrhythmic risk of candidate drugs.
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Affiliation(s)
| | - Seunghoon Han
- Department of Clinical Pharmacology and Therapeutics, Seoul St. Mary's Hospital, Seoul, South Korea.,Pharmacometrics Institute for Practical Education and Training (PIPET), College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Min Cheol Park
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon, South Korea
| | - Chae Hun Leem
- Department of Physiology, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Eun Bo Shim
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon, South Korea
| | - Dong-Seok Yim
- Department of Clinical Pharmacology and Therapeutics, Seoul St. Mary's Hospital, Seoul, South Korea.,Pharmacometrics Institute for Practical Education and Training (PIPET), College of Medicine, The Catholic University of Korea, Seoul, South Korea
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32
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Darpo B, Benson C, Brown R, Dota C, Ferber G, Ferry J, Jarugula V, Keirns J, Ortemann‐Renon C, Pham T, Riley S, Sarapa N, Ticktin M, Zareba W, Couderc J. Evaluation of the Effect of 5 QT‐Positive Drugs on the JTpeak Interval — An Analysis of ECGs From the IQ‐CSRC Study. J Clin Pharmacol 2019; 60:125-139. [DOI: 10.1002/jcph.1502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/16/2019] [Indexed: 12/30/2022]
Affiliation(s)
| | | | | | | | | | - Jim Ferry
- Clinical PharmacologyEisai Woodcliff Lake New Jersey USA
| | | | - James Keirns
- Retired; at the time of the IQ‐CSRC study at Astellas Northbrook Illinois USA
| | | | | | | | - Nenad Sarapa
- Sarah Cannon Research Institute Nashville Tennessee USA
| | | | - Wojciech Zareba
- Cardiovascular Clinical Research CenterUniversity of Rochester New York USA
| | - Jean‐Philippe Couderc
- ERT Rochester New York USA
- Cardiovascular Clinical Research CenterUniversity of Rochester New York USA
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33
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Bystricky W, Maier C, Gintant G, Bergau D, Kamradt K, Welsh P, Carter D. T vector velocity: A new ECG biomarker for identifying drug effects on cardiac ventricular repolarization. PLoS One 2019; 14:e0204712. [PMID: 31283756 PMCID: PMC6613676 DOI: 10.1371/journal.pone.0204712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 06/04/2019] [Indexed: 11/23/2022] Open
Abstract
Background We present a new family of ECG biomarkers for assessing drug effects on ventricular repolarization. We show that drugs blocking inward (depolarizing) ion currents cause a relative increase of the T vector velocity (TVV) and accelerate repolarization, while drugs blocking outward ion currents cause a relative decrease of the TVV and delay repolarization. The results suggest a link between the TVV and the instantaneous change of the cellular action potentials that may contribute to bridge the gap between the surface ECG and myocardial cellular processes. Methods We measure TVV as the time required to reach X% of the total Trajectory length of the T vector loop, denoted as TrX. Applied to data from two FDA funded studies (22+22 subjects, 5232+4208 ECGs) which target ECG effects of various ion-channel blocking drugs, the TrX effect profiles indicate increasingly delayed electrical activity over the entire repolarization process for drugs solely reducing outward potassium current (dofetilide, moxifloxacin). For drugs eliciting block of the inward sodium or calcium currents (mexiletine, lidocaine), the TrX effect profiles were consistent with accelerated electrical activity in the initial repolarization phase. For multichannel blocking drugs (ranolazine) or drug combinations blocking multiple ion currents (dofetilide + mexiletine, dofetilide + lidocaine), the overall TrX effect profiles indicate a superposition of the individual TrX effect profiles. Results The parameter Tr40c differentiates pure potassium channel blocking drugs from multichannel blocking drugs with an area under the ROC curve (AUC) of 0.90, CI = [0.88 to 0.92]. This is significantly better than the performance of J-Tpeakc (0.81, CI = [0.78 to 0.84]) identified as the best parameter in the second FDA study. Combining the ten parameters Tr10c to Tr100c in a logistic regression model further improved the AUC to 0.94, CI = [0.92 to 0.96]. Conclusions TVV analysis substantially improves assessment of drug effects on cardiac repolarization, providing a plausible and improved mechanistic link between drug effects on ionic currents and overall ventricular repolarization reflected in the body surface ECG. TVV contributes to an enhanced appraisal of the proarrhythmic risk of drugs beyond QTc prolongation and J-Tpeakc.
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Affiliation(s)
- Werner Bystricky
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America
| | - Christoph Maier
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America.,Department of Medical Informatics, Heilbronn University, Heilbronn, Germany
| | - Gary Gintant
- Integrated Sciences and Technology, AbbVie Inc., North Chicago, Illinois, United States of America
| | - Dennis Bergau
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America
| | - Kent Kamradt
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America
| | - Patrick Welsh
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America
| | - David Carter
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America
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34
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Abi-Gerges N, McMahon C, Vargas H, Sager P, Chui R, Stevens D, Davila J, Schaub JR, Wu JC, Del Rio C, Mathes C, Miller PE, Burns-Naas LA, Ghetti A. The West coast regional safety pharmacology society meeting update: Filling translational gaps in safety assessment. J Pharmacol Toxicol Methods 2019; 98:106582. [PMID: 31077805 DOI: 10.1016/j.vascn.2019.106582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 12/20/2022]
Abstract
The Safety Pharmacology Society (SPS) held a West Coast Regional Meeting in Foster City, CA on November 14, 2018 at the Gilead Sciences Inc. site. The meeting was attended by scientists from the pharmaceutical and biotechnology industry, contract research organizations (CROs) and academia. A variety of scientific topics were presented by speakers, covering a broad variety of topics in the fields of safety risk assessment; from pro-arrhythmia and contractility risk evaluation, to models of heart failure and seizure in-a-dish; and discovery sciences; from stem cells and precision medicine, to models of inherited cardiomyopathy and precision cut tissue slices. The present review summarizes the highlights of the presentations and provides an overview of the high level of innovation currently underlying many frontiers in safety pharmacology.
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Affiliation(s)
| | | | | | - Philip Sager
- Stanford University, School of Medicine, Stanford, CA 94305, USA
| | - Ray Chui
- Amgen Inc., Thousand Oaks, CA 92320, USA
| | - Dale Stevens
- Genentech Inc., South San Francisco, CA 94080, USA
| | | | | | - Joseph C Wu
- Stanford University School of Medicine, Stanford Cardiovascular Institute, Stanford, CA 94305, USA
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35
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Peng T, Trew ML, Malik A. Predictive modeling of drug effects on electrocardiograms. Comput Biol Med 2019; 108:332-344. [PMID: 31048132 DOI: 10.1016/j.compbiomed.2019.03.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/27/2019] [Accepted: 03/28/2019] [Indexed: 11/25/2022]
Abstract
Whole electrocardiogram (ECG) waveform analysis is a technique for evaluating aggregate arrhythmic risks of drugs. In this paper, we propose methods for exploring changes to ECG morphology due to drug effects using Gaussian model parameters, and predict patient specific post-drug ECG based on pre-drug ECG. We evaluate the proposed methods using clinical ECG recordings from subjects under the effect of anti-arrhythmic drugs Dofetilide, Quinidine, Ranolazine, and Verapamil, from the ECGRVDQ database on PhysioNet. Paired-sample t-test p-values (>0.05) suggest the proposed method can achieve similar results when compared to expert annotated J to Tpeak and Tpeak to Tend intervals for all four drug states. We employed a leave-one-out cross validation strategy to train the prediction model and produce the results. Mean Pearson correlations between all predicted and recorded post-drug waveform morphologies for all drug states across both the vector magnitude lead and Lead II is 0.94±0.05, with p-values <0.01 for all predictions; indicating significant predictions. Parameters from ECG models with Gaussian basis can be used to calculate clinically useful information and to capture or predict changes in cardiac signals due to drug effects.
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Affiliation(s)
- T Peng
- Department of Electrical and Computer Engineering, University of Auckland, 1010, New Zealand.
| | - M L Trew
- Auckland Bioengineering Institute, University of Auckland, Auckland, 1010, New Zealand
| | - A Malik
- Department of Electrical and Computer Engineering, University of Auckland, 1010, New Zealand
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36
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Vicente J, Strauss DG, Upreti VV, Fossler MJ, Sager PT, Noveck R. The Potential Role of the J‐T
peak
Interval in Proarrhythmic Cardiac Safety: Current State of the Science From the American College of Clinical Pharmacology and the Cardiac Safety Research Consortium. J Clin Pharmacol 2019; 59:909-914. [DOI: 10.1002/jcph.1411] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Jose Vicente
- Division of Cardiovascular and Renal Products, Office of Drug Evaluation I, Office of New Drugs, Center for Drug Evaluation and ResearchUS Food and Drug Administration Silver Spring MD USA
| | - David G. Strauss
- Division of Applied Regulatory ScienceUS Food and Drug Administration Silver Spring MD USA
| | - Vijay V. Upreti
- Clinical Pharmacology Oncology Therapeutic Area HeadClinical Pharmacology Modeling and SimulationAmgen South San Francisco CA USA
| | - Michael J. Fossler
- Clinical Operations & Quantitative SciencesTrevena, Inc. Chesterbrook PA USA
| | | | - Robert Noveck
- Duke Early Phase 1 Clinical Research Unit Durham NC USA
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37
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Zhao Y, Rafatian N, Feric NT, Cox BJ, Aschar-Sobbi R, Wang EY, Aggarwal P, Zhang B, Conant G, Ronaldson-Bouchard K, Pahnke A, Protze S, Lee JH, Davenport Huyer L, Jekic D, Wickeler A, Naguib HE, Keller GM, Vunjak-Novakovic G, Broeckel U, Backx PH, Radisic M. A Platform for Generation of Chamber-Specific Cardiac Tissues and Disease Modeling. Cell 2019; 176:913-927.e18. [PMID: 30686581 PMCID: PMC6456036 DOI: 10.1016/j.cell.2018.11.042] [Citation(s) in RCA: 340] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/19/2018] [Accepted: 11/28/2018] [Indexed: 12/12/2022]
Abstract
Tissue engineering using cardiomyocytes derived from human pluripotent stem cells holds a promise to revolutionize drug discovery, but only if limitations related to cardiac chamber specification and platform versatility can be overcome. We describe here a scalable tissue-cultivation platform that is cell source agnostic and enables drug testing under electrical pacing. The plastic platform enabled on-line noninvasive recording of passive tension, active force, contractile dynamics, and Ca2+ transients, as well as endpoint assessments of action potentials and conduction velocity. By combining directed cell differentiation with electrical field conditioning, we engineered electrophysiologically distinct atrial and ventricular tissues with chamber-specific drug responses and gene expression. We report, for the first time, engineering of heteropolar cardiac tissues containing distinct atrial and ventricular ends, and we demonstrate their spatially confined responses to serotonin and ranolazine. Uniquely, electrical conditioning for up to 8 months enabled modeling of polygenic left ventricular hypertrophy starting from patient cells.
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Affiliation(s)
- Yimu Zhao
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, ON M5S 3E5, Canada
| | - Naimeh Rafatian
- Division of Cardiology and Peter Munk Cardiac Center, University of Health Network; Toronto, ON M5G 2N2, Canada
| | - Nicole T Feric
- TARA Biosystems, Inc., New York, NY 10016, USA; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | - Brian J Cox
- Department of Physiology, Faculty of Medicine; University of Toronto; Toronto; Ontario, M5S 1A8, Canada; Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Roozbeh Aschar-Sobbi
- Division of Cardiology and Peter Munk Cardiac Center, University of Health Network; Toronto, ON M5G 2N2, Canada; TARA Biosystems, Inc., New York, NY 10016, USA
| | - Erika Yan Wang
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | - Praful Aggarwal
- Section of Genomic Pediatrics, Department of Pediatrics and Genomic Sciences and Precision Medicine Center, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Boyang Zhang
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, ON M5S 3E5, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | - Genevieve Conant
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, ON M5S 3E5, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | - Kacey Ronaldson-Bouchard
- TARA Biosystems, Inc., New York, NY 10016, USA; Department of Biomedical Engineering and Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Aric Pahnke
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, ON M5S 3E5, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | - Stephanie Protze
- Department of Molecular Genetics, University of Toronto, Toronto, ON M5G 1A8, Canada; McEwen Stem Cell Institute, University Health Network, Toronto, ON M5G 1L7, Canada
| | - Jee Hoon Lee
- McEwen Stem Cell Institute, University Health Network, Toronto, ON M5G 1L7, Canada; BlueRock Therapeutics, MaRS Discovery District, Toronto, ON M5G 1L7, Canada
| | - Locke Davenport Huyer
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, ON M5S 3E5, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | - Danica Jekic
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, ON M5S 3E5, Canada; Department of Anatomy and Cell Biology, Faculty of Science, McGill University, Montreal, QC H3A 2K6, Canada
| | - Anastasia Wickeler
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON M5S 3G8, Canada
| | - Hani E Naguib
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON M5S 3G8, Canada
| | - Gordon M Keller
- McEwen Stem Cell Institute, University Health Network, Toronto, ON M5G 1L7, Canada
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering and Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Ulrich Broeckel
- Section of Genomic Pediatrics, Department of Pediatrics and Genomic Sciences and Precision Medicine Center, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Peter H Backx
- Division of Cardiology and Peter Munk Cardiac Center, University of Health Network; Toronto, ON M5G 2N2, Canada; Department of Physiology, Faculty of Medicine; University of Toronto; Toronto; Ontario, M5S 1A8, Canada; Department of Biology; York University, Toronto, ON M3J 1P3, Canada; Toronto General Hospital Research Institute, Toronto, ON M5G 2C4, Canada.
| | - Milica Radisic
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, ON M5S 3E5, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada; Toronto General Hospital Research Institute, Toronto, ON M5G 2C4, Canada.
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Antiarrhythmic Effects of Combining Dofetilide and Ranolazine in a Model of Acutely Induced Atrial Fibrillation in Horses. J Cardiovasc Pharmacol 2019; 71:26-35. [PMID: 29068807 PMCID: PMC5768216 DOI: 10.1097/fjc.0000000000000541] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: Antiarrhythmic compounds against atrial fibrillation (AF) often have reduced efficacy and may display cardiac and/or noncardiac toxicity. Efficacy can be improved by combining 2 compounds with distinct mechanisms, and it may be possible to use lower doses of each compound, thereby reducing the likelihood of adverse side effects. The purpose of this study was to investigate whether the effective doses of dofetilide and ranolazine can be reduced if the drugs are combined. Methods: Dofetilide, ranolazine, and a combination of these were administered in 4 incremental dosing regimens to horses with acutely pacing-induced AF. Time to cardioversion, atrial effective refractory period, and AF vulnerability and duration were assessed. Results: Of 8 horses, 6 cardioverted to sinus rhythm after infusion with a combination of 0.889 μg/kg dofetilide and 0.104 mg/kg ranolazine. Two horses cardioverted with 0.104 mg/kg ranolazine alone, and 3 cardioverted with 0.889 μg/kg dofetilide alone. The combination therapy decreased AF vulnerability (P < 0.05) and AF duration (P < 0.05). No change in atrial effective refractory period was detected with any of the drugs. Conclusions: The combination of dofetilide and ranolazine showed increased antiarrhythmic effects on acutely induced AF in horses, affecting time to cardioversion, AF vulnerability, and AF duration.
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Vicente J, Zusterzeel R, Johannesen L, Ochoa-Jimenez R, Mason JW, Sanabria C, Kemp S, Sager PT, Patel V, Matta MK, Liu J, Florian J, Garnett C, Stockbridge N, Strauss DG. Assessment of Multi-Ion Channel Block in a Phase I Randomized Study Design: Results of the CiPA Phase I ECG Biomarker Validation Study. Clin Pharmacol Ther 2019; 105:943-953. [PMID: 30447156 PMCID: PMC6654598 DOI: 10.1002/cpt.1303] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/20/2018] [Indexed: 11/24/2022]
Abstract
Balanced multi‐ion channel‐blocking drugs have low torsade risk because they block inward currents. The Comprehensive In Vitro Proarrhythmia Assay (CiPA) initiative proposes to use an in silico cardiomyocyte model to determine the presence of balanced block, and absence of heart rate corrected J‐Tpeak (J‐Tpeakc) prolongation would be expected for balanced blockers. This study included three balanced blockers in a 10‐subject‐per‐drug parallel design; lopinavir/ritonavir and verapamil met the primary end point of ΔΔJ‐Tpeakc upper bound < 10 ms, whereas ranolazine did not (upper bounds of 8.8, 6.1, and 12.0 ms, respectively). Chloroquine, a predominant blocker of the potassium channel encoded by the ether‐à‐go‐go related gene (hERG), prolonged ΔΔQTc and ΔΔJ‐Tpeakc by ≥ 10 ms. In a separate crossover design, diltiazem (calcium block) did not shorten dofetilide‐induced ΔQTc prolongation, but shortened ΔJ‐Tpeakc and prolonged ΔTpeak‐Tend. Absence of J‐Tpeakc prolongation seems consistent with balanced block; however, small sample size (10 subjects) may be insufficient to characterize concentration‐response in some cases.
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Affiliation(s)
- Jose Vicente
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robbert Zusterzeel
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lars Johannesen
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Roberto Ochoa-Jimenez
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jay W Mason
- Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City, Utah, USA.,Spaulding Clinical Research, West Bend, Wisconsin, USA
| | | | - Sarah Kemp
- Spaulding Clinical Research, West Bend, Wisconsin, USA
| | | | - Vikram Patel
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Murali K Matta
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jiang Liu
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jeffry Florian
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Garnett
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Norman Stockbridge
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - David G Strauss
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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Täubel J, Ferber G, Van Langenhoven L, Del Bianco T, Fernandes S, Djumanov D, Kanters JK, Graff C, Camm AJ. The Cardiovascular Effects of a Meal: J-T peak and T peak -T end Assessment and Further Insights Into the Physiological Effects. J Clin Pharmacol 2019; 59:799-810. [PMID: 30633366 PMCID: PMC6590239 DOI: 10.1002/jcph.1374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/14/2018] [Indexed: 12/13/2022]
Abstract
Meal intake leads to a significant and prolonged increase in cardiac output to supply the splanchnic vasculature. A meal is associated with sympathetic activation of the cardiovascular system, and food ingestion is correlated with an increase in heart rate, an increase in cardiac stroke volume, and QTc interval shortening for up to 7 hours. Given the complexity of the system, one or several of many mechanisms could explain this observation. The shortening of the QTc interval was correlated with a rise of C‐peptide following food ingestion, but the mechanisms by which C‐peptide may be involved in the modulation of cardiac repolarization are still unknown. This shortening of the myocardial action potential caused by the ingestion of food was further investigated in the present study by measuring the QRS, J‐Tpeak, and Tpeak‐Tend intervals in search of further clues to better understand the underlying mechanisms. A retrospective analysis was conducted based on data collected in a formal thorough QT/QTc study in which 32 subjects received a carbohydrate‐rich “continental” breakfast, moxifloxacin without food, and moxifloxacin with food. We assessed the effect of food on T‐wave morphology using validated algorithms for measurement of J‐Tpeak and Tpeak‐Tend intervals. Our findings demonstrate that a standardized meal significantly shortened J‐Tpeak for 4 hours after a meal and to a much lesser extent and shorter duration (up to 1 hour) prolonged the Tpeak‐Tend and QRS intervals. This suggests that the QTc shortening occurs mainly during phase 2 of the cardiac action potential. As there was no corresponding effect on Tpeak‐Tend beyond the first hour, we conclude that a meal does not interfere with the outward correcting potassium channels but possibly with Ca2+ currents. An effect on mainly Ca2+ aligns well with our understanding of physiology whereby an increase in stroke volume, as observed after a meal, is associated with changes in Ca2+ cycling in and out of the sarcoplasmic reticulum during cardiac myocyte contraction.
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Affiliation(s)
- Jörg Täubel
- Richmond Pharmacology Ltd., St George's University of London, Cranmer Terrace, London, UK.,Cardiovascular and Cell Sciences Research Institute, St George's University of London, London, UK
| | - Georg Ferber
- Statistik Georg Ferber GmbH, Cagliostrostrasse, Riehen, Switzerland
| | - Leen Van Langenhoven
- Richmond Pharmacology Ltd., St George's University of London, Cranmer Terrace, London, UK
| | - Teresa Del Bianco
- Richmond Pharmacology Ltd., St George's University of London, Cranmer Terrace, London, UK
| | - Sara Fernandes
- Richmond Pharmacology Ltd., St George's University of London, Cranmer Terrace, London, UK
| | - Dilshat Djumanov
- Richmond Pharmacology Ltd., St George's University of London, Cranmer Terrace, London, UK
| | - Jørgen K Kanters
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - A John Camm
- Cardiovascular and Cell Sciences Research Institute, St George's University of London, London, UK
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Boulay E, Abernathy MM, Chui R, Friedrichs GS, Gendron-Parra N, Greiter-Wilke A, Guillon JM, Koerner JE, Menard A, Steidl-Nichols J, Pierson J, Pugsley MK, Rossman EI, Strauss D, Troncy E, Valentin JP, Wisialowski T, Authier S. A Proof-of-Concept Evaluation of JTPc and Tp-Tec as Proarrhythmia Biomarkers in Preclinical Species: A Retrospective Analysis by an HESI-Sponsored Consortium. Int J Toxicol 2018; 38:23-32. [DOI: 10.1177/1091581818813601] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Based on the ICH S7B and E14 guidance documents, QT interval (QTc) is used as the primary in vivo biomarker to assess the risk of drug-induced torsades de pointes (TdP). Clinical and nonclinical data suggest that drugs that prolong the corrected QTc with balanced multiple ion channel inhibition (most importantly the l-type calcium, Cav1.2, and persistent or late inward sodium current, Nav1.5, in addition to human Ether-à-go-go-Related Gene [hERG] IKr or Kv11.1) may have limited proarrhythmic liability. The heart rate-corrected J to T-peak (JTpc) measurement in particular may be considered to discriminate selective hERG blockers from multi-ion channel blockers. Methods: Telemetry data from Beagle dogs given dofetilide (0.3 mg/kg), sotalol (32 mg/kg), and verapamil (30 mg/kg) orally and Cynomolgus monkeys given medetomidine (0.4 mg/kg) orally were retrospectively analyzed for effects on QTca, JTpca, and T-peak to T-end covariate adjusted (Tpeca) interval using individual rate correction and super intervals (calculated from 0-6, 6-12, 12-18, and 18-24 hours postdose). Results: Dofetilide and cisapride (IKr or Kv11.1 blockers) were associated with significant increases in QTca and JTpca, while sotalol was associated with significant increases in QTca, JTpca, and Tpeca. Verapamil (a Kv11.1 and Cav1.2 blocker) resulted in a reduction in QTca and JTpca, however, and increased Tpeca. Medetomidine was associated with a reduction in Tpeca and increase in JTpca. Discussion: Results from this limited retrospective electrocardiogram analysis suggest that JTpca and Tpeca may discriminate selective IKr blockers and multichannel blockers and could be considered in the context of an integrated comprehensive proarrhythmic risk assessment.
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Affiliation(s)
- Emmanuel Boulay
- GREPAQ (Groupe de recherche en pharmacologie animale du Québec), Université de Montréal, St-Hyacinthe, Quebec, Canada
- CiToxLAB North America, Laval, Quebec, Canada
| | | | | | | | - Nicolas Gendron-Parra
- GREPAQ (Groupe de recherche en pharmacologie animale du Québec), Université de Montréal, St-Hyacinthe, Quebec, Canada
| | | | | | - John E. Koerner
- Center for Drug Evaluation and Research, US Food & Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | | | - David Strauss
- Center for Drug Evaluation and Research, US Food & Drug Administration, Silver Spring, MD, USA
| | - Eric Troncy
- GREPAQ (Groupe de recherche en pharmacologie animale du Québec), Université de Montréal, St-Hyacinthe, Quebec, Canada
| | | | | | - Simon Authier
- GREPAQ (Groupe de recherche en pharmacologie animale du Québec), Université de Montréal, St-Hyacinthe, Quebec, Canada
- CiToxLAB North America, Laval, Quebec, Canada
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Attia ZI, Sugrue A, Asirvatham SJ, Ackerman MJ, Kapa S, Friedman PA, Noseworthy PA. Noninvasive assessment of dofetilide plasma concentration using a deep learning (neural network) analysis of the surface electrocardiogram: A proof of concept study. PLoS One 2018; 13:e0201059. [PMID: 30133452 PMCID: PMC6104915 DOI: 10.1371/journal.pone.0201059] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 07/06/2018] [Indexed: 01/16/2023] Open
Abstract
Background Dofetilide is an effective antiarrhythmic medication for rhythm control in atrial fibrillation, but carries a significant risk of pro-arrhythmia and requires meticulous dosing and monitoring. The cornerstone of this monitoring, measurement of the QT/QTc interval, is an imperfect surrogate for plasma concentration, efficacy, and risk of pro-arrhythmic potential. Objective The aim of our study was to test the application of a deep learning approach (using a convolutional neural network) to assess morphological changes on the surface ECG (beyond the QT interval) in relation to dofetilide plasma concentrations. Methods We obtained publically available serial ECGs and plasma drug concentrations from 42 healthy subjects who received dofetilide or placebo in a placebo‐controlled cross‐over randomized controlled clinical trial. Three replicate 10-s ECGs were extracted at predefined time-points with simultaneous measurement of dofetilide plasma concentration We developed a deep learning algorithm to predict dofetilide plasma concentration in 30 subjects and then tested the model in the remaining 12 subjects. We compared the deep leaning approach to a linear model based only on QTc. Results Fourty two healthy subjects (21 females, 21 males) were studied with a mean age of 26.9 ± 5.5 years. A linear model of the QTc correlated reasonably well with dofetilide drug levels (r = 0.64). The best correlation to dofetilide level was achieved with the deep learning model (r = 0.85). Conclusion This proof of concept study suggests that artificial intelligence (deep learning/neural network) applied to the surface ECG is superior to analysis of the QT interval alone in predicting plasma dofetilide concentration.
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Affiliation(s)
- Zachi I. Attia
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Alan Sugrue
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Samuel J. Asirvatham
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Michael J. Ackerman
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Suraj Kapa
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Paul A. Friedman
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Peter A. Noseworthy
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
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43
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Vicente J. Update on the ECG component of the CiPA initiative. J Electrocardiol 2018; 51:S98-S102. [PMID: 30121123 DOI: 10.1016/j.jelectrocard.2018.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/23/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
Abstract
The Comprehensive in vitro Proarrhythmia Assay (CiPA) initiative is validating a new paradigm for assessing proarrhythmic potential of drugs that goes beyond hERG block and QT prolongation. Based on in vitro data of the drug's effects on multiple cardiac ion channel currents, CiPA's in silico model of the human cardiomyocyte will classify drugs as low, intermediate or high risk for torsade de pointes. Under CiPA, early phase 1 ECG data will be used to determine if there are unexpected ion channel effects in humans compared to the in vitro ion channel data. CiPA's ECG biomarker working group identified the heart rate corrected J-Tpeak interval (J-Tpeakc, from the end of the QRS to the peak of the T-wave) as the best of 12 ECG biomarkers to detect late sodium current block in presence of hERG block. While predominant hERG blockers prolonged QTc and J-Tpeakc, "balanced" ion channel blocking drugs (hERG + late sodium and/or calcium block) prolonged QTc without prolonging J-Tpeakc. This manuscript reviews the ECG component of CiPA and provides a description of the ECG methods used in the CiPA ECG validation clinical study.
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Affiliation(s)
- Jose Vicente
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA.
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Okada JI, Yoshinaga T, Kurokawa J, Washio T, Furukawa T, Sawada K, Sugiura S, Hisada T. Arrhythmic hazard map for a 3D whole-ventricle model under multiple ion channel block. Br J Pharmacol 2018; 175:3435-3452. [PMID: 29745425 PMCID: PMC6086978 DOI: 10.1111/bph.14357] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 03/12/2018] [Accepted: 04/20/2018] [Indexed: 01/05/2023] Open
Abstract
Background and Purpose To date, proposed in silico models for preclinical cardiac safety testing are limited in their predictability and usability. We previously reported a multi‐scale heart simulation that accurately predicts arrhythmogenic risk for benchmark drugs. Experimental Approach We created a comprehensive hazard map of drug‐induced arrhythmia based on the electrocardiogram (ECG) waveforms simulated under wide range of drug effects using the multi‐scale heart simulator described here, implemented with cell models of human cardiac electrophysiology. Key Results A total of 9075 electrocardiograms constitute the five‐dimensional hazard map, with coordinates representing the extent of the block of each of the five ionic currents (rapid delayed rectifier potassium current (IKr), fast (INa) and late (INa,L) components of the sodium current, L‐type calcium current (ICa,L) and slow delayed rectifier current (IKs)), involved in arrhythmogenesis. Results of the evaluation of arrhythmogenic risk based on this hazard map agreed well with the risk assessments reported in the literature. ECG databases also suggested that the interval between the J‐point and the T‐wave peak is a superior index of arrhythmogenicity when compared to the QT interval due to its ability to characterize the multi‐channel effects compared with QT interval. Conclusion and Implications Because concentration‐dependent effects on electrocardiograms of any drug can be traced on this map based on in vitro current assay data, its arrhythmogenic risk can be evaluated without performing costly and potentially risky human electrophysiological assays. Hence, the map serves as a novel tool for use in pharmaceutical research and development.
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Affiliation(s)
- Jun-Ichi Okada
- Graduate School of Frontier Sciences, The University of Tokyo, Kashiwa, Japan.,UT-Heart Inc., Tokyo, Japan
| | | | - Junko Kurokawa
- School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Takumi Washio
- Graduate School of Frontier Sciences, The University of Tokyo, Kashiwa, Japan.,UT-Heart Inc., Tokyo, Japan
| | - Tetsushi Furukawa
- Department of Bio-informational Pharmacology, Medical Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohei Sawada
- Global CV Assessment, Eisai Co., Ltd., Ibaraki, Japan
| | - Seiryo Sugiura
- Graduate School of Frontier Sciences, The University of Tokyo, Kashiwa, Japan.,UT-Heart Inc., Tokyo, Japan
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Darpo B, Couderc JP. Challenges in implementing and obtaining acceptance for J-Tpeak assessment as the clinical component of CiPA. J Pharmacol Toxicol Methods 2018; 93:75-79. [PMID: 29879475 DOI: 10.1016/j.vascn.2018.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/13/2018] [Accepted: 05/30/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION This paper is based on a presentation held at the Annual Safety Pharmacology Society meeting in September 2017, at which challenges for the clinical component of CiPA were presented. FDA has published an automated algorithm for measurement of the J-Tpeak interval on a median beat from a vector magnitude lead derived from a 12-lead ECG. CiPA proposes that J-Tpeak prolongation < 10 ms can be used for drugs with a QTc effect < 20 ms to differentiate between safe and unsafe delayed repolarization and to reduce the level of ECG monitoring in late stage clinical trials. METHODS We applied FDA's algorithm, complemented with iCOMPAS, to moxifloxacin and dolasetron data from the IQ-CSRC study with 9 subjects on active and 6 on placebo. The effect on QTcF and corrected J-Tpeak (J-Tpeak_c) was analyzed using concentration-effect modeling. RESULTS There was a good correlation between QTcF and J-Tpeak_c prolongation after oral dosing of 400 mg moxifloxacin with placebo-adjusted, change-from-baseline (ΔΔ) J-Tpeak_c of ~12 ms at concentrations that caused ΔΔQTcF of ~20 ms. On dolasetron, J-Tpeak_c was highly variable, no prolongation was seen and an effect on ΔΔJ-Tpeak_c > 10 ms could be excluded across the observed plasma concentration range. DISCUSSION In this limited analysis performed on the IQ-CSRC study waveforms using FDA's automated algorithm, J-Tpeak prolongation was observed on moxifloxacin, but not on dolasetron, despite clinical observations of proarrhythmias with both drugs. Challenges for the implementation of the J-Tpeak interval as a replacement or complement to the QTc interval, include to demonstrate that the proposed clinical algorithm using a J-Tpeak threshold of 10 ms, can be used to categorize drugs with a QT effect up to ~20 ms as having low pro-arrhythmic risk.
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Affiliation(s)
- Borje Darpo
- iCardiac Technologies, Inc., Rochester, NY, USA.
| | - Jean-Philippe Couderc
- iCardiac Technologies, Inc., Rochester, NY, USA; Heart Research Follow-up Program, University of Rochester Medical Center, Rochester, NY, USA
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Turner JR, Rodriguez I, Mantovani E, Gintant G, Kowey PR, Klotzbaugh RJ, Prasad K, Sager PT, Stockbridge N, Strnadova C. Drug-induced Proarrhythmia and Torsade de Pointes: A Primer for Students and Practitioners of Medicine and Pharmacy. J Clin Pharmacol 2018; 58:997-1012. [PMID: 29672845 DOI: 10.1002/jcph.1129] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022]
Abstract
Multiple marketing withdrawals due to proarrhythmic concerns occurred in the United States, Canada, and the United Kingdom in the late 1980s to early 2000s. This primer reviews the clinical implications of a drug's identified proarrhythmic liability, the issues associated with these safety-related withdrawals, and the actions taken by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) and by regulatory agencies in terms of changing drug development practices and introducing new nonclinical and clinical tests to asses proarrhythmic liability. ICH Guidelines S7B and E14 were released in 2005. Since then, they have been adopted by many regional regulatory authorities and have guided nonclinical and clinical proarrhythmic cardiac safety assessments during drug development. While this regulatory paradigm has been successful in preventing drugs with unanticipated potential for inducing the rare but potentially fatal polymorphic ventricular arrhythmia torsade de pointes from entering the market, it has led to the termination of drug development programs for other potentially useful medicines because of isolated results from studies with limited predictive value. Research efforts are now exploring alternative approaches to better predict potential proarrhythmic liabilities. For example, in the domain of human electrocardiographic assessments, concentration-response modeling conducted during phase 1 clinical development has recently become an accepted alternate primary methodology to the ICH E14 "thorough QT/QTc" study for defining a drug's corrected QT interval prolongation liability under certain conditions. When a drug's therapeutic benefit is considered important at a public health level but there is also an identified proarrhythmic liability that may result from administration of the single drug in certain individuals and/or drug-drug interactions, marketing approval will be accompanied by appropriate directions in the drug's prescribing information. Health-care professionals in the fields of medicine and pharmacy need to consider the prescribing information in conjunction with individual patients' clinical characteristics and concomitant medications when prescribing and dispensing such drugs.
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Affiliation(s)
- J Rick Turner
- Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
| | - Ignacio Rodriguez
- Cardiac Safety Research Consortium, Roche TCRC, Inc., New York, NY, USA
| | - Emily Mantovani
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | | | - Peter R Kowey
- Lankenau Heart Institute and Jefferson Medical College, Philadelphia, PA, USA
| | - Ralph J Klotzbaugh
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Krishna Prasad
- Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Philip T Sager
- Sager Consulting and Stanford University, San Francisco, CA, USA
| | - Norman Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Colette Strnadova
- Therapeutic Products Directorate, Health Canada, Ottawa, Ontario, Canada
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Influence of type of sport on cardiac repolarization assessed by electrocardiographic T-wave morphology combination score. J Electrocardiol 2018; 51:296-302. [DOI: 10.1016/j.jelectrocard.2017.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Indexed: 11/21/2022]
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Rouse R, Kruhlak N, Weaver J, Burkhart K, Patel V, Strauss DG. Translating New Science Into the Drug Review Process: The US FDA's Division of Applied Regulatory Science. Ther Innov Regul Sci 2018; 52:244-255. [PMID: 29568713 PMCID: PMC5844453 DOI: 10.1177/2168479017720249] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 06/21/2017] [Indexed: 12/16/2022]
Abstract
In 2011, the US Food and drug Administration (FDA) developed a strategic plan for regulatory science that focuses on developing new tools, standards, and approaches to assess the safety, efficacy, quality, and performance of FDA-regulated products. In line with this, the Division of Applied Regulatory Science was created to move new science into the Center for Drug Evaluation and Research (CDER) review process and close the gap between scientific innovation and drug review. The Division, located in the Office of Clinical Pharmacology, is unique in that it performs mission-critical applied research and review across the translational research spectrum including in vitro and in vivo laboratory research, in silico computational modeling and informatics, and integrated clinical research covering clinical pharmacology, experimental medicine, and postmarket analyses. The Division collaborates with Offices throughout CDER, across the FDA, other government agencies, academia, and industry. The Division is able to rapidly form interdisciplinary teams of pharmacologists, biologists, chemists, computational scientists, and clinicians to respond to challenging regulatory questions for specific review issues and for longer-range projects requiring the development of predictive models, tools, and biomarkers to speed the development and regulatory evaluation of safe and effective drugs. This article reviews the Division's recent work and future directions, highlighting development and validation of biomarkers; novel humanized animal models; translational predictive safety combining in vitro, in silico, and in vivo clinical biomarkers; chemical and biomedical informatics tools for safety predictions; novel approaches to speed the development of complex generic drugs, biosimilars, and antibiotics; and precision medicine.
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Affiliation(s)
- Rodney Rouse
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Naomi Kruhlak
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - James Weaver
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Keith Burkhart
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Vikram Patel
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - David G. Strauss
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
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Tse G, Gong M, Wong CW, Chan C, Georgopoulos S, Chan YS, Yan BP, Li G, Whittaker P, Ciobanu A, Ali‐Hasan‐Al‐Saegh S, Wong SH, Wu WKK, Bazoukis G, Lampropoulos K, Wong WT, Tse LA, Baranchuk AM, Letsas KP, Liu T. Total cosine R-to-T for predicting ventricular arrhythmic and mortality outcomes: A systematic review and meta-analysis. Ann Noninvasive Electrocardiol 2018; 23:e12495. [PMID: 28901628 PMCID: PMC6931891 DOI: 10.1111/anec.12495] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/27/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The total cosine R-to-T (TCRT), a vectorcardiographic marker reflecting the spatial difference between the depolarization and repolarization wavefronts, has been used to predict ventricular tachycardia/fibrillation (VT/VF) and sudden cardiac death (SCD) in different clinical settings. However, its prognostic value has been controversial. OBJECTIVE This systematic review and meta-analysis evaluated the significance of TRCT in predicting arrhythmic and/or mortality endpoints. METHODS PubMed and Embase databases were searched through December 31, 2016. RESULTS Of the 890 studies identified initially, 13 observational studies were included in our meta-analysis. A total of 11,528 patients, mean age 47 years old, 72% male, were followed for 43 ± 6 months. Data from five studies demonstrated lower TCRT values in myocardial infarction patients with adverse events (syncope, ventricular arrhythmias, or sudden cardiac death) compared to those without these events (mean difference = -0.36 ± 0.05, p < .001; I2 = 48%). By contrast, only two studies analyzed outcomes in heart failure, and pooled meta-analysis did not demonstrate significant difference in TCRT between event-positive and event-negative patients (mean difference = -0.01 ± 0.10, p > .05; I2 = 80%). CONCLUSION TCRT is lower in MI patients at high risk of adverse events when compared to those free from such events. It can provide additional risk stratification beyond the use of clinical parameters and traditional electrocardiogram markers. Its value in other diseases such as heart failure requires further studies.
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Affiliation(s)
- Gary Tse
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong Kong SARChina
- Faculty of MedicineLi Ka Shing Institute of Health SciencesChinese University of Hong KongHong Kong SARChina
| | - Mengqi Gong
- Department of CardiologyTianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular diseaseTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Cheuk Wai Wong
- Li Ka Shing Faculty of MedicineUniversity of Hong KongHong Kong SARChina
| | - Cynthia Chan
- Li Ka Shing Faculty of MedicineUniversity of Hong KongHong Kong SARChina
| | - Stamatis Georgopoulos
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensAthensGreece
| | - Yat Sun Chan
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong Kong SARChina
| | - Bryan P. Yan
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong Kong SARChina
| | - Guangping Li
- Department of CardiologyTianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular diseaseTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Paula Whittaker
- Division of Population HealthHealth Services Research and Primary CareSchool of Health SciencesUniversity of ManchesterManchesterUnited Kingdom
| | - Ana Ciobanu
- Department of CardiologyTheodor Burghele Clinical HospitalCarol Davila University of Medicine and PharmacyBucharestRomania
| | | | - Sunny H. Wong
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong Kong SARChina
- Faculty of MedicineLi Ka Shing Institute of Health SciencesChinese University of Hong KongHong Kong SARChina
| | - William K. K. Wu
- Faculty of MedicineLi Ka Shing Institute of Health SciencesChinese University of Hong KongHong Kong SARChina
- Department of Anesthesia and Intensive CareState Key Laboratory of Digestive DiseaseThe Chinese University of Hong KongHong KongChina
| | - George Bazoukis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensAthensGreece
| | - Konstantinos Lampropoulos
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensAthensGreece
| | - Wing Tak Wong
- School of Life SciencesThe Chinese University of Hong KongHong KongChina
| | - Lap Ah Tse
- Division of Occupational and Environmental HealthJC School of Public Health and Primary CareThe Chinese University of Hong KongHong KongChina
| | - Adrian M. Baranchuk
- Department of MedicineKingston General HospitalQueen's UniversityKingstonONCanada
| | - Konstantinos P. Letsas
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensAthensGreece
| | - Tong Liu
- Department of CardiologyTianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular diseaseTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
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Sahli Costabal F, Yao J, Kuhl E. Predicting the cardiac toxicity of drugs using a novel multiscale exposure-response simulator. Comput Methods Biomech Biomed Engin 2018; 21:232-246. [PMID: 29493299 PMCID: PMC6361171 DOI: 10.1080/10255842.2018.1439479] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A common but serious side effect of many drugs is torsades de pointes, a rhythm disorder that can have fatal consequences. Torsadogenic risk has traditionally been associated with blockage of a specific potassium channel and an increased recovery period in the electrocardiogram. However, the mechanisms that trigger torsades de pointes remain incompletely understood. Here we establish a computational model to explore how drug-induced effects propagate from the single channel, via the single cell, to the whole heart level. Our mechanistic exposure-response simulator translates block-concentration characteristics for arbitrary drugs into three-dimensional excitation profiles and electrocardiogram recordings to rapidly assess torsadogenic risk. For the drug of dofetilide, we show that this risk is highly dose-dependent: at a concentration of 1x, QT prolongation is 55% but the heart maintains its regular sinus rhythm; at 5.7x, QT prolongation is 102% and the heart spontaneously transitions into torsades de points; at 30x, QT prolongation is 132% and the heart adapts a quasi-depolarized state with numerous rapidly flickering local excitations. Our simulations suggest that neither potassium channel blockage nor QT interval prolongation alone trigger torsades de pointes. The underlying mechanism predicted by our model is early afterdepolarization, which translates into pronounced U waves in the electrocardiogram, a signature that is correctly predicted by our model. Beyond the risk assessment of existing drugs, our exposure-response simulator can become a powerful tool to optimize the co-administration of drugs and, ultimately, guide the design of new drugs toward reducing life threatening drug-induced rhythm disorders in the heart.
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Affiliation(s)
- Francisco Sahli Costabal
- a Departments of Mechanical Engineering, Bioengineering, and Cardiothoracic Surgery , Stanford University , CA , USA
| | - Jiang Yao
- b Dassault Systèmes Simulia Corporation , Johnston , RI , USA
| | - Ellen Kuhl
- a Departments of Mechanical Engineering, Bioengineering, and Cardiothoracic Surgery , Stanford University , CA , USA
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