Cardiac electrophysiological remodeling associated with enhanced arrhythmia susceptibility in a canine model of elite exercise

HCN4 in the atrioventricular node

Hyperpolarization-activated cyclic nucleotide-gated channel 4 (HCN4) drives the funny current in cardiac pacemaker regions. Its involvement in sinoatrial node pacemaker generation is well known, but its function in the atrioventricular (AV) node (AVN) has not intensively been studied. HCN4 is expressed in the AVN, and its expression within the AVN seems similar across mammalian species with HCN4 presence in the inferior nodal extensions, compact node, and AV bundle. The main direct regulators of HCN4 are cAMP and protein kinase A. In addition, indirect regulators may affect HCN4 via trafficking and localization. However, these effects are underexplored in the AVN. AVN-specific effects in knockout and knockin mice include reduced funny current density and increased AV block. HCN4 expression in the AVN could be affected by aging, exercise, heart failure, and diabetes. This could underlie changes in PR interval, atria-His interval, Wenckebach cycle length, and AVN effective refractory period. Clinical reports link the HCN4 variant G1097W to AV block. Other clinical data come from studies assessing ivabradine, an HCN4 inhibitor. In animals, ivabradine resulted in prolonged PR and atrial-his intervals. To date, uncertainty regarding the role of HCN4 in the AVN remains. However, AVN-focused studies suggest HCN4's importance for AVN function. This review summarizes recent findings and highlights the involvement of HCN4 in normal and pathological AVN function.

The mechanisms of exercise improving cardiovascular function by stimulating Piezo1 and TRP ion channels: a systemic review

Mechanosensitive ion channels are widely distributed in the heart, lung, bladder and other tissues, and plays an important role in exercise-induced cardiovascular function promotion. By reviewing the PubMed databases, the results were summarized using the terms "Exercise/Sport", "Piezo1", "Transient receptor potential (TRP)" and "Cardiovascular" as the keywords, 124-related papers screened were sorted and reviewed. The results showed that: (1) Piezo1 and TRP channels play an important role in regulating blood pressure and the development of cardiovascular diseases such as atherosclerosis, myocardial infarction, and cardiac fibrosis; (2) Exercise promotes cardiac health, inhibits the development of pathological heart to heart failure, regulating the changes in the characterization of Piezo1 and TRP channels; (3) Piezo1 activates downstream signaling pathways with very broad pathways, such as AKT/eNOS, NF-κB, p38MAPK and HIPPO-YAP signaling pathways. Piezo1 and Irisin regulate nuclear localization of YAP and are hypothesized to act synergistically to regulate tissue mechanical properties of the cardiovascular system and (4) The cardioprotective effects of exercise through the TRP family are mostly accomplished through Ca2+ and involve many signaling pathways. TRP channels exert their important cardioprotective effects by reducing the TRPC3-Nox2 complex and mediating Irisin-induced Ca2+ influx through TRPV4. It is proposed that exercise stimulates the mechanosensitive cation channel Piezo1 and TRP channels, which exerts cardioprotective effects. The activation of Piezo1 and TRP channels and their downstream targets to exert cardioprotective function by exercise may provide a theoretical basis for the prevention of cardiovascular diseases and the rehabilitation of clinical patients.

Electrocardiograms from different types of exercise in Eventing horses with and without cardiac signs

BACKGROUND

Exercising arrhythmias can be clinically irrelevant or associated with poor performance, collapse and sudden cardiac death.

OBJECTIVES

To test if readable exercising ECGs can be recorded by grooms or riders and to describe arrhythmias in ECGs from different types of exercise in Eventing horses and investigate associations with type of workout, the presence of previous cardiac signs and intensity of exercise.

STUDY DESIGN

Cohort study.

METHODS

Single lead exercising ECGs were obtained by riders or grooms during training and competition from a convenience sample of horses in training for Eventing competitions. Arrhythmias were described, and associations between different arrhythmia categories and variables that described the horse and the workouts were sought.

RESULTS

There were 1002 ECGs from 62 horses (median [range] 7 [2-97] ECGs/horse) evaluated and 737 workouts (73.6%) were >95% readable and included in the analysis. There were arrhythmias in 250 (33.9%) of the workouts, complex arrhythmias in 13 (1.8%) and the number of premature complexes was median (range) 0 (0-118). Peak heart rate and duration of exercise were associated with the number of premature complexes, the presence of arrhythmias and complex arrhythmias and were colinear with the type of exercise. Having previous signs of cardiac disease and the type of workout were associated with higher odds of having arrhythmias.

CONCLUSIONS

Monitoring the rhythm of equine athletes with ECGs obtained by riders and transmitted to an online cloud was feasible. Arrhythmias were frequent, and complex arrhythmias were rare. The presence of cardiac signs, type of exercise and peak heart rate were associated with the presence of arrhythmias. None of the horses developed poor performance or collapse attributed to cardiac disease. The arrhythmias that should be concerning for equine veterinarians need further definition.

Ventricular arrhythmias in association with athletic cardiac remodelling

Athletes are predisposed to atrial arrhythmias but the association between intense endurance exercise training, ventricular arrhythmias (VAs), and sudden cardiac death is less well established. Thus, it is unclear whether the 'athlete's heart' promotes specific arrhythmias or whether it represents a more general pro-arrhythmogenic phenotype. Whilst direct causality has not been established, it appears possible that repeated exposure to high-intensity endurance exercise in some athletes contributes to formation of pro-arrhythmic cardiac phenotypes that underlie VAs. Theories regarding potential mechanisms for exercise-induced VAs include repeated bouts of myocardial inflammation and stretch-induced cellular remodelling. Small animal models provide some insights, but larger animal and human data are sparse. The current clinical approach to VAs in athletes is to differentiate those with and without structural or electrical heart disease. However, if the athlete's heart involves a degree of pro-arrhythmogenic remodelling, then this may not be such a simple dichotomy. Questions are posed by athletes with VAs in combination with extreme remodelling. Some markers, such as scar on magnetic resonance imaging, may point towards a less benign phenotype but are also quite common in ostensibly healthy athletes. Other clinical and invasive electrophysiology features may be helpful in identifying the at-risk athlete. This review seeks to discuss the association between athletic training and VAs. We will discuss the potential mechanisms, clinical significance, and approach to the management of athletes with VAs.

Sympathetic Modulation in Cardiac Arrhythmias: Where We Stand and Where We Go

The nuance of autonomic cardiac control has been studied for more than 400 years, yet little is understood. This review aimed to provide a comprehensive overview of the current understanding, clinical implications, and ongoing studies of cardiac sympathetic modulation and its anti-ventricular arrhythmias' therapeutic potential. Molecular-level studies and clinical studies were reviewed to elucidate the gaps in knowledge and the possible future directions for these strategies to be translated into the clinical setting. Imbalanced sympathoexcitation and parasympathetic withdrawal destabilize cardiac electrophysiology and confer the development of ventricular arrhythmias. Therefore, the current strategy for rebalancing the autonomic system includes attenuating sympathoexcitation and increasing vagal tone. Multilevel targets of the cardiac neuraxis exist, and some have emerged as promising antiarrhythmic strategies. These interventions include pharmacological blockade, permanent cardiac sympathetic denervation, temporal cardiac sympathetic denervation, etc. The gold standard approach, however, has not been known. Although neuromodulatory strategies have been shown to be highly effective in several acute animal studies with very promising results, the individual and interspecies variation between human autonomic systems limits the progress in this young field. There is, however, still much room to refine the current neuromodulation therapy to meet the unmet need for life-threatening ventricular arrhythmias.