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Veselik AK, Arteyeva NV, Varlamova NG, Loginova TP, Garnov IO, Bojko ER, Azarov JE. Cardiac repolarisation indices are associated with oxygen consumption during maximal exercise test in highly-trained cross-country skiers. J Sports Sci 2024; 42:1072-1080. [PMID: 39056492 DOI: 10.1080/02640414.2024.2383009] [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: 10/04/2023] [Accepted: 06/30/2024] [Indexed: 07/28/2024]
Abstract
The objective of this study was to test the vectorelectrocardiographic T-wave characteristics for their associations with oxygen consumption (VO2) and physical performance during a maximal cardiopulmonary exercise test (CPET) in highly trained cross-country skiers. Male highly trained cross-country skiers (n = 30) performed the maximal CPET on the bicycle ergospirometric "Oxycon Pro" system with simultaneous oxygen consumption (VO2) and electrocardiogram recording. The measurements were done at rest; the stage preceding anaerobic threshold (preAnT); peak load; and recovery. The anaerobic threshold was estimated by respiratory exchange ratio. Physical performance was estimated by maximal oxygen consumption (VO2max/kg). VECG characteristics were calculated using Kors transformation procedure. During the test, the magnitudes of T-vector, Tx and Ty components decreased until preAnT, then stayed relatively stable until peak load, and reversed during recovery. In univariate linear regression analysis, T-vector amplitude and Tx, Ty and Tz magnitudes were associated with VO2/kg during the test (p < 0.010). The baseline T-vector characteristics were not associated with physical performance. At the preAnT stage, Tx and T-vector amplitude were associated with VO2max/kg (RC 12.70, 95% CI 0.68-24.73, p = 0.039 and RC 10.64, 95% CI 1.62-19.67, p = 0.023, respectively).
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Affiliation(s)
- Alla K Veselik
- Department of Ecological and Medical Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
| | - Natalia V Arteyeva
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
| | - Nina G Varlamova
- Department of Ecological and Medical Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
| | - Tatyana P Loginova
- Department of Ecological and Medical Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
| | - Igor O Garnov
- Department of Ecological and Medical Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
| | - Evgeny R Bojko
- Department of Ecological and Medical Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
| | - Jan E Azarov
- Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, Syktyvkar, Russia
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Tian WB, Zhang WS, Jiang CQ, Jin YL, Lam TH, Cheng KK, Xu L. Association of insulin resistance and glycemic measures with major abnormal electrocardiogram in older Chinese: Cross-sectional analysis based on the Guangzhou Biobank Cohort study. Diabetes Res Clin Pract 2024; 207:111046. [PMID: 38070543 DOI: 10.1016/j.diabres.2023.111046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/16/2023] [Accepted: 12/05/2023] [Indexed: 12/21/2023]
Abstract
AIMS To examine whether insulin resistance (IR) and glycemic measures were associated with major abnormal electrocardiogram (MA-ECG) and its specific abnormalities in the general population. METHODS Twelve-lead ECG measurements were performed on 21,720 participants without cardiovascular disease (5,918 men) from the Guangzhou Biobank Cohort Study. The participants were aged 50 years or above (mean age 61.6, standard deviation 7.1 years). Logistic regression was used to assess the associations of IR and glycemic measures with MA-ECG and specific abnormalities. RESULTS Ln-fasting insulin was significantly associated with MA-ECG and ST-T abnormalities (adjusted odds ratio = 1.52, 95 % confidence interval = 1.15-2.02 and 1.83, 1.37-2.45, respectively, for per standard deviation), which were stronger than those of TyG index with MA-ECG (1.08, 1.04-1.13) and ST-T abnormalities (1.16, 1.11-1.22). Ln-fasting insulin had association with Q wave abnormalities (3.19, 1.52-6.67). The association of TyG index with prolonged QTc varied by sex and obesity (P for interaction ≤ 0.01). Participants with diabetes had stronger associations of ln-fasting plasma glucose with ECG abnormalities than those without. CONCLUSIONS IR and glycemic measures were associated with MA-ECG, ischemia and prolonged QTc in older Chinese, especially in women, those with obesity, and those with diabetes. These findings underscore the importance of regular evaluations for these groups.
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Affiliation(s)
- Wen Bo Tian
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
| | - Wei Sen Zhang
- Guangzhou Twelfth People's Hospital, Guangzhou 510620, China.
| | | | - Ya Li Jin
- Guangzhou Twelfth People's Hospital, Guangzhou 510620, China
| | - Tai Hing Lam
- Guangzhou Twelfth People's Hospital, Guangzhou 510620, China; School of Public Health, the University of Hong Kong, Hong Kong
| | - Kar Keung Cheng
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Lin Xu
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China; School of Public Health, the University of Hong Kong, Hong Kong.
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Sun DK, Zhang N, Liu Y, Qiu JC, Tse G, Li GP, Roever L, Liu T. Dysglycemia and arrhythmias. World J Diabetes 2023; 14:1163-1177. [PMID: 37664481 PMCID: PMC10473954 DOI: 10.4239/wjd.v14.i8.1163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/19/2023] [Accepted: 07/05/2023] [Indexed: 08/11/2023] Open
Abstract
Disorders in glucose metabolism can be divided into three separate but interrelated domains, namely hyperglycemia, hypoglycemia, and glycemic variability. Intensive glycemic control in patients with diabetes might increase the risk of hypoglycemic incidents and glucose fluctuations. These three dysglycemic states occur not only amongst patients with diabetes, but are frequently present in other clinical settings, such as during critically ill. A growing body of evidence has focused on the relationships between these dysglycemic domains with cardiac arrhythmias, including supraventricular arrhythmias (primarily atrial fibrillation), ventricular arrhythmias (malignant ventricular arrhythmias and QT interval prolongation), and bradyarrhythmias (bradycardia and heart block). Different mechanisms by which these dysglycemic states might provoke cardiac arr-hythmias have been identified in experimental studies. A customized glycemic control strategy to minimize the risk of hyperglycemia, hypoglycemia and glucose variability is of the utmost importance in order to mitigate the risk of cardiac arrhythmias.
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Affiliation(s)
- Dong-Kun Sun
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Nan Zhang
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Ying Liu
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Jiu-Chun Qiu
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Gary Tse
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
- Kent and Medway Medical School, Kent CT2 7NT, Canterbury, United Kingdom
- School of Nursing and Health Studies, Metropolitan University, Hong Kong 999077, China
| | - Guang-Ping Li
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Leonardo Roever
- Department of Clinical Research, Federal University of Uberlândia, Uberlândia, 38400384, MG, Brazil
| | - Tong Liu
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
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Li G, Zhong S, Wang X, Zhuge F. Association of hypoglycaemia with the risks of arrhythmia and mortality in individuals with diabetes - a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1222409. [PMID: 37645418 PMCID: PMC10461564 DOI: 10.3389/fendo.2023.1222409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
Background Hypoglycaemia has been linked to an increased risk of cardiac arrhythmias by causing autonomic and metabolic alterations, which may be associated with detrimental outcomes in individuals with diabetes(IWD), such as cardiovascular diseases (CVDs) and mortality, especially in multimorbid or frail people. However, such relationships in this population have not been thoroughly investigated. For this reason, we conducted a systematic review and meta-analysis. Methods Relevant papers published on PubMed, Embase, Cochrane, Web of Knowledge, Scopus, and CINHAL complete from inception to December 22, 2022 were routinely searched without regard for language. All of the selected articles included odds ratio, hazard ratio, or relative risk statistics, as well as data for estimating the connection of hypoglycaemia with cardiac arrhythmia, CVD-induced death, or total death in IWD. Regardless of the heterogeneity assessed by the I2 statistic, pooled relative risks (RRs) and 95% confidence intervals (CI) were obtained using random-effects models. Results After deleting duplicates and closely evaluating all screened citations, we chose 60 studies with totally 5,960,224 participants for this analysis. Fourteen studies were included in the arrhythmia risk analysis, and 50 in the analysis of all-cause mortality. Hypoglycaemic patients had significantly higher risks of arrhythmia occurrence (RR 1.42, 95%CI 1.21-1.68), CVD-induced death (RR 1.59, 95% CI 1.24-2.04), and all-cause mortality (RR 1.68, 95% CI 1.49-1.90) compared to euglycaemic patients with significant heterogeneity. Conclusion Hypoglycaemic individuals are more susceptible to develop cardiac arrhythmias and die, but evidence of potential causal linkages beyond statistical associations must await proof by additional specifically well planned research that controls for all potential remaining confounding factors.
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Affiliation(s)
- Gangfeng Li
- Clinical Laboratory Center, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Shuping Zhong
- Department of Hospital Management, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Xingmu Wang
- Clinical Laboratory Center, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Fuyuan Zhuge
- Department of Endocrine and Metabolism, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
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Andreasen CR, Andersen A, Hagelqvist PG, Maytham K, Lauritsen JV, Engberg S, Faber J, Pedersen-Bjergaard U, Knop FK, Vilsbøll T. Sustained heart rate-corrected QT prolongation during recovery from hypoglycaemia in people with type 1 diabetes, independently of recovery to hyperglycaemia or euglycaemia. Diabetes Obes Metab 2023; 25:1566-1575. [PMID: 36752677 DOI: 10.1111/dom.15005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/27/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
AIM To investigate changes in cardiac repolarization abnormalities (heart rate-corrected QT [QTc ] [primary endpoint], T-wave abnormalities) and heart-rate variability measures in people with type 1 diabetes during insulin-induced hypoglycaemia followed by recovery hyperglycaemia versus euglycaemia. METHODS In a randomized crossover study, 24 individuals with type 1 diabetes underwent two experimental clamps with three steady-state phases during electrocardiographic monitoring: (1) a 45-minute euglycaemic phase (5-8 mmol/L), (2) a 60-minute insulin-induced hypoglycaemic phase (2.5 mmol/L), and (3) 60-minute recovery in either hyperglycaemia (20 mmol/L) or euglycaemia (5-8 mmol/L). RESULTS All measured markers of arrhythmic risk indicated increased risk during hypoglycaemia. These findings were accompanied by a decrease in vagal tone during both hyperglycaemia and euglycaemia clamps. Compared with baseline, the QTc interval increased during hypoglycaemia, and 63% of the participants exhibited a peak QTc of more than 500 ms. The prolonged QTc interval was sustained during both recovery phases with no difference between recovery hyperglycaemia versus euglycaemia. During recovery, no change from baseline was observed in heart-rate variability measures. CONCLUSIONS In people with type 1 diabetes, insulin-induced hypoglycaemia prolongs cardiac repolarization, which is sustained during a 60-minute recovery period independently of recovery to hyperglycaemia or euglycaemia. Thus, vulnerability to serious cardiac arrhythmias and sudden cardiac death may extend beyond a hypoglycaemic event, regardless of hyperglycaemic or euglycaemic recovery.
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Affiliation(s)
- Christine R Andreasen
- Clinical Research, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Andreas Andersen
- Clinical Research, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Per G Hagelqvist
- Clinical Research, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Kaisar Maytham
- Clinical Research, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Julius V Lauritsen
- Clinical Research, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Susanne Engberg
- Clinical Research, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Jens Faber
- Department of Medicine, Herlev Hospital, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology and Nephrology, Nordsjaellands Hospital Hillerød, University of Copenhagen, Hillerød, Denmark
| | - Filip K Knop
- Clinical Research, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Medicine, Herlev Hospital, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Clinical Research, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Association of N-Acetyl Asparagine with QTc in Diabetes: A Metabolomics Study. Biomedicines 2022; 10:biomedicines10081955. [PMID: 36009502 PMCID: PMC9405979 DOI: 10.3390/biomedicines10081955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
Changes in the cardio-metabolomics profile and hormonal status have been associated with long QT syndrome, sudden cardiac death and increased mortality. The mechanisms underlying QTc duration are not fully understood. Therefore, an identification of novel markers that complement the diagnosis in these patients is needed. In the present study, we performed untargeted metabolomics on the sera of diabetic patients at a high risk of cardiovascular disease, followed up for 2.55 [2.34–2.88] years (NCT02431234), with the aim of identifying the metabolomic changes associated with QTc. We used independent weighted gene correlation network analysis (WGCNA) to explore the association between metabolites clusters and QTc at T1 (baseline) and T2 (follow up). The overlap of the highly correlated modules at T1 and T2 identified N-Acetyl asparagine as the only metabolite in common, which was involved with the urea cycle and metabolism of arginine, proline, glutamate, aspartate and asparagine. This analysis was confirmed by applying mixed models, further highlighting its association with QTc. In the current study, we were able to identify a metabolite associated with QTc in diabetic patients at two chronological time points, suggesting a previously unrecognized potential role of N-Acetyl asparagine in diabetic patients suffering from long QTc.
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Kaze AD, Yuyun MF, Erqou S, Fonarow GC, Echouffo-Tcheugui JB. Severe Hypoglycemia and Incidence of QT Interval Prolongation Among Adults With Type 2 Diabetes. J Clin Endocrinol Metab 2022; 107:e2743-e2750. [PMID: 35396596 PMCID: PMC9202715 DOI: 10.1210/clinem/dgac195] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT There is a paucity of large-scale epidemiological studies on the link between severe hypoglycemia (SH) and corrected QT (QTc) interval prolongation in type 2 diabetes (T2DM). OBJECTIVE To evaluate the association of SH with QTc prolongation in adults with T2DM. METHODS Prospective cohort analysis of participants enrolled in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) study without QTc prolongation at baseline. SH was assessed over a 24-month period. Incident QTc prolongation was ascertained using follow-up electrocardiograms. Modified Poisson regression was used to generate the risk ratio (RR) and 95% CI for QTc prolongation. RESULTS Among 8277 participants (mean age 62.6 years [SD 6.5], 38.7% women, 62.8% White), 324 had ≥1 SH episode (3.9%). Over a median of 5 years, 517 individuals developed QTc prolongation (6.3%). Participants with SH had a 66% higher risk of QTc prolongation (RR 1.66, 95% CI 1.16-2.38). The incidence of QTc prolongation was 10.3% (27/261) and 14.3% (9/63) for participants with 1 and ≥2 SH, respectively. Compared with no SH, RRs for patients with 1 and ≥2 SH episodes were 1.57 (95% CI 1.04-2.39) and 2.01 (95% CI 1.07-3.78), respectively. Age modified the association of SH with QTc prolongation (PInteraction = .008). The association remained significant among younger participants (<61.9 years [median age]: RR 2.63, 95% CI 1.49-4.64), but was nonsignificant among older participants (≥61.9 years: RR 1.37, 95% CI 0.87-2.17). CONCLUSION In a large population with T2DM, SH was associated with an increased risk of QTc prolongation independently of other risk factors such as cardiac autonomic neuropathy. The association was strongest among younger participants.
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Affiliation(s)
- Arnaud D Kaze
- Department of Medicine, LifePoint Health, Danville, VA 24541, USA
| | - Matthew F Yuyun
- Department of Medicine, Harvard Medical School & Veteran Affairs Boston Healthcare System, Boston, MA 02132, USA
| | - Sebhat Erqou
- Department of Medicine, Division of Cardiology, Providence VA Medical Center and Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA 90095, USA
| | - Justin B Echouffo-Tcheugui
- Correspondence: Justin B. Echouffo-Tcheugui, MD, PhD, Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Baltimore, MD 21224, USA.
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Effect of hyperglycaemia in combination with moxifloxacin on cardiac repolarization in male and female patients with type I diabetes. Clin Res Cardiol 2022; 111:1147-1160. [PMID: 35596784 PMCID: PMC9525410 DOI: 10.1007/s00392-022-02037-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/05/2022] [Indexed: 11/20/2022]
Abstract
Background Patients with Type 1 diabetes mellitus have been shown to be at a two to ten-fold higher risk of sudden cardiac death (SCD) (Svane et al., Curr Cardiol 2020; 22:112) than the general population, but the underlying mechanism is unclear. Hyperglycaemia is a recognised cause of QTc prolongation; a state patients with type 1 diabetes are more prone to, potentially increasing their risk of ventricular arrhythmia. Understanding the QTc prolongation effect of both hyperglycaemia and the concomitant additive risk of commonly prescribed QTc-prolonging drugs such as Moxifloxacin may help to elucidate the mechanism of sudden cardiac death in this cohort. This single-blinded, placebo-controlled study investigated the extent to which hyperglycaemia prolongs the QTc in controlled conditions, and the potential additive risk of QTc-prolonging medications. Methods 21 patients with type 1 diabetes mellitus were enrolled to a placebo-controlled crossover study at a single clinical trials unit. Patients underwent thorough QTc assessment throughout the study. A ‘hyperglycaemic clamp’ of oral and intravenous glucose was administered with a target blood glucose of > 25 mM and maintained for 2 h on day 1 and day 3, alongside placebo on day 1 and moxifloxacin on day 3. Day 2 served as a control day between the two active treatment days. Thorough QTc assessment was conducted at matched time points over 3 days, and regular blood sampling was undertaken at matched time intervals for glucose levels and moxifloxacin exposure. Results Concentration-effect modelling showed that acute hyperglycaemia prolonged the QTc interval in female and male volunteers with type 1 diabetes by a peak mean increase of 13 ms at 2 h. Peak mean QTc intervals after the administration of intravenous Moxifloxacin during the hyperglycaemic state were increased by a further 9 ms at 2 h, to 22 ms across the entire study population. Regression analysis suggested this additional increase was additive, not exponential. Hyperglycaemia was associated with a significantly greater mean QTc-prolonging effect in females, but the mean peak increase with the addition of moxifloxacin was the same for males and females. This apparent sex difference was likely due to the exclusive use of basal insulin in the male patients, which provided a low level of exogenous insulin during the study assessments thereby mitigating the effects of hyperglycaemia on QTc. This effect was partially overcome by Moxifloxacin administration, suggesting both hyperglycaemia and moxifloxacin prolong QTc by different mechanisms, based on subinterval analysis. Conclusions Hyperglycaemia was found to be a significant cause of QTc prolongation and the additional effect of a QTc-prolonging positive control (moxifloxacin) was found to be additive. Given the high risk of sudden cardiac death in type 1 diabetes mellitus, extra caution should be exercised when prescribing any medication in this cohort for QTc effects, and further research needs to be undertaken to elucidate the exact mechanism underlying this finding and explore the potential prescribing risk in diabetes. Trial Registration NCT number: NCT01984827. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-022-02037-8.
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Valentin JP, Hoffmann P, Ortemann-Renon C, Koerner J, Pierson J, Gintant G, Willard J, Garnett C, Skinner M, Vargas HM, Wisialowski T, Pugsley MK. The Challenges of Predicting Drug-Induced QTc Prolongation in Humans. Toxicol Sci 2022; 187:3-24. [PMID: 35148401 PMCID: PMC9041548 DOI: 10.1093/toxsci/kfac013] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The content of this article derives from a Health and Environmental Sciences Institute (HESI) consortium with a focus to improve cardiac safety during drug development. A detailed literature review was conducted to evaluate the concordance between nonclinical repolarization assays and the clinical thorough QT (TQT) study. Food and Drug Administration and HESI developed a joint database of nonclinical and clinical data, and a retrospective analysis of 150 anonymized drug candidates was reviewed to compare the performance of 3 standard nonclinical assays with clinical TQT study findings as well as investigate mechanism(s) potentially responsible for apparent discrepancies identified. The nonclinical assays were functional (IKr) current block (Human ether-a-go-go related gene), action potential duration, and corrected QT interval in animals (in vivo corrected QT). Although these nonclinical assays demonstrated good specificity for predicting negative clinical QT prolongation, they had relatively poor sensitivity for predicting positive clinical QT prolongation. After review, 28 discordant TQT-positive drugs were identified. This article provides an overview of direct and indirect mechanisms responsible for QT prolongation and theoretical reasons for lack of concordance between clinical TQT studies and nonclinical assays. We examine 6 specific and discordant TQT-positive drugs as case examples. These were derived from the unique HESI/Food and Drug Administration database. We would like to emphasize some reasons for discordant data including, insufficient or inadequate nonclinical data, effects of the drug on other cardiac ion channels, and indirect and/or nonelectrophysiological effects of drugs, including altered heart rate. We also outline best practices that were developed based upon our evaluation.
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Affiliation(s)
- Jean-Pierre Valentin
- Department of Investigative Toxicology, UCB Biopharma SRL, Braine-l’Alleud B-1420, Belgium
| | | | | | - John Koerner
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland 20993, USA
| | - Jennifer Pierson
- Health and Environmental Sciences Institute, Washington, District of Columbia 20005, USA
| | | | - James Willard
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland 20993, USA
| | - Christine Garnett
- Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland 20993, USA
| | | | - Hugo M Vargas
- Department of Safety Pharmacology & Animal Research Center, Amgen, Thousand Oaks, California 91320, USA
| | - Todd Wisialowski
- Department of Safety Pharmacology, Pfizer, Groton, Connecticut 06340, USA
| | - Michael K Pugsley
- Department of Toxicology, Cytokinetics, South San Francisco, California 94080, USA
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Lubberding AF, Juhl CR, Skovhøj EZ, Kanters JK, Mandrup‐Poulsen T, Torekov SS. Celebrities in the heart, strangers in the pancreatic beta cell: Voltage-gated potassium channels K v 7.1 and K v 11.1 bridge long QT syndrome with hyperinsulinaemia as well as type 2 diabetes. Acta Physiol (Oxf) 2022; 234:e13781. [PMID: 34990074 PMCID: PMC9286829 DOI: 10.1111/apha.13781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/20/2021] [Accepted: 01/02/2022] [Indexed: 12/13/2022]
Abstract
Voltage‐gated potassium (Kv) channels play an important role in the repolarization of a variety of excitable tissues, including in the cardiomyocyte and the pancreatic beta cell. Recently, individuals carrying loss‐of‐function (LoF) mutations in KCNQ1, encoding Kv7.1, and KCNH2 (hERG), encoding Kv11.1, were found to exhibit post‐prandial hyperinsulinaemia and episodes of hypoglycaemia. These LoF mutations also cause the cardiac disorder long QT syndrome (LQTS), which can be aggravated by hypoglycaemia. Interestingly, patients with LQTS also have a higher burden of diabetes compared to the background population, an apparent paradox in relation to the hyperinsulinaemic phenotype, and KCNQ1 has been identified as a type 2 diabetes risk gene. This review article summarizes the involvement of delayed rectifier K+ channels in pancreatic beta cell function, with emphasis on Kv7.1 and Kv11.1, using the cardiomyocyte for context. The functional and clinical consequences of LoF mutations and polymorphisms in these channels on blood glucose homeostasis are explored using evidence from pre‐clinical, clinical and genome‐wide association studies, thereby evaluating the link between LQTS, hyperinsulinaemia and type 2 diabetes.
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Affiliation(s)
- Anniek F. Lubberding
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Christian R. Juhl
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Emil Z. Skovhøj
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Jørgen K. Kanters
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Thomas Mandrup‐Poulsen
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Signe S. Torekov
- Department of Biomedical Sciences Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
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11
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Bernjak A, Iqbal A, Heller SR, Clayton RH. Hypoglycaemia combined with mild hypokalaemia reduces the heart rate and causes abnormal pacemaker activity in a computational model of a human sinoatrial cell. J R Soc Interface 2021; 18:20210612. [PMID: 34814734 PMCID: PMC8611338 DOI: 10.1098/rsif.2021.0612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Low blood glucose, hypoglycaemia, has been implicated as a possible contributing factor to sudden cardiac death (SCD) in people with diabetes but it is challenging to investigate in clinical studies. We hypothesized the effects of hypoglycaemia on the sinoatrial node (SAN) in the heart to be a candidate mechanism and adapted a computational model of the human SAN action potential developed by Fabbri et al., to investigate the effects of hypoglycaemia on the pacemaker rate. Using Latin hypercube sampling, we combined the effects of low glucose (LG) on the human ether-a-go-go-related gene channel with reduced blood potassium, hypokalaemia, and added sympathetic and parasympathetic stimulus. We showed that hypoglycaemia on its own causes a small decrease in heart rate but there was also a marked decrease in heart rate when combined with hypokalaemia. The effect of the sympathetic stimulus was diminished, causing a smaller increase in heart rate, with LG and hypokalaemia compared to normoglycaemia. By contrast, the effect of the parasympathetic stimulus was enhanced, causing a greater decrease in heart rate. We therefore demonstrate a potential mechanistic explanation for hypoglycaemia-induced bradycardia and show that sinus arrest is a plausible mechanism for SCD in people with diabetes.
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Affiliation(s)
- Alan Bernjak
- Department of Oncology and Metabolism, University of Sheffield, Medical School, Beech Hill Road, Sheffield S10 2RX, UK.,INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - Ahmed Iqbal
- Department of Oncology and Metabolism, University of Sheffield, Medical School, Beech Hill Road, Sheffield S10 2RX, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon R Heller
- Department of Oncology and Metabolism, University of Sheffield, Medical School, Beech Hill Road, Sheffield S10 2RX, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Richard H Clayton
- INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, UK.,Department of Computer Science, University of Sheffield, Sheffield, UK
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12
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de Souza AMA, Ecelbarger CM, Sandberg K. Caloric Restriction and Cardiovascular Health: the Good, the Bad, and the Renin-Angiotensin System. Physiology (Bethesda) 2021; 36:220-234. [PMID: 34159807 DOI: 10.1152/physiol.00002.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Much excitement exists over the cardioprotective and life-extending effects of caloric restriction (CR). This review integrates population studies with experimental animal research to address the positive and negative impact of mild and severe CR on cardiovascular physiology and pathophysiology, with a particular focus on the renin-angiotensin system (RAS). We also highlight the gaps in knowledge and areas ripe for future physiological research.
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Affiliation(s)
- Aline M A de Souza
- Division of Nephrology and Hypertension, Department of Medicine, Georgetown University, Washington, District of Columbia
| | - Carolyn M Ecelbarger
- Division of Nephrology and Hypertension, Department of Medicine, Georgetown University, Washington, District of Columbia
| | - Kathryn Sandberg
- Division of Nephrology and Hypertension, Department of Medicine, Georgetown University, Washington, District of Columbia
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13
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Ardhianto D, Suharjono, Soedarsono, Fatmawati U. Analysis of the side effect of QTc interval prolongation in the bedaquiline regimen in drug resistant tuberculosis patients. J Basic Clin Physiol Pharmacol 2021; 32:421-427. [PMID: 34214323 DOI: 10.1515/jbcpp-2020-0415] [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: 11/27/2020] [Accepted: 02/23/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Indonesia is one of the top 20 countries with the highest prevalence of drug resistant tuberculosis (DR-TB) worldwide with a percentage of new cases of 2.4% and retreatment of 13%. Bedaquiline (BDQ) is one of the drugs that used in the individual long regimen treating DR-TB. BDQ is also combined with levofloxacin (LFX) and/or clofazimine (CFZ) that can cause QTc interval prolongation. The aim was to study the differences in the use of BDQ regimens to the lengthening of the QTc interval and to study risk factors (diabetes, hypokalemia, sex, BMI, and age) in BDQ regimen. METHODS This study was an observational retrospective study with a total sampling method, which was conducted at Dr. Soetomo General Hospital Surabaya. Samples from this study were patients diagnosed with DR-TB at Dr. Soetomo General Hospital Surabaya in the period of January 2015-December 2019 who used BDQ regimen and met the inclusion criteria. The ECG data were analyzed from the mean of each group (BDQ regimen and risk factors), also analyzed using statistical analysis. RESULTS Data obtained from total sample in this study were 73 patients. The most widely used different regimens in this study were the combination of BDQ + LFX by 36 patients (49.3%), BDQ + LFX + CFZ by 16 patients (21.9%), BDQ by 11 patients (15.1%) and BDQ + CFZ 10 patients (13.7%). Out of 73 patients, 52 patients (71.2%) experienced lengthening of the QT interval and grade 1 of QTc interval prolongation occurred in most patients and also the onset was mostly one month after using BDQ regimen. The side effects of QTc interval prolongation from groups of combination and risk factors were no difference in each month (p>0.05). CONCLUSIONS This study can be concluded that there were no differences in the QTc prolongation between the groups of BDQ regimen (BDQ, BDQ + LFX, BDQ + CFZ and BDQ + LFX + CFZ) and the groups of risk factors.
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Affiliation(s)
- Denny Ardhianto
- Department of Clinical Pharmacy, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia
| | - Suharjono
- Department of Clinical Pharmacy, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia
| | - Soedarsono
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Umi Fatmawati
- Department of Pharmacy, Dr. Soetomo General Hospital, Surabaya, Indonesia
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14
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Lubberding AF, Zhang J, Lundh M, Nielsen TS, Søndergaard MS, Villadsen M, Skovhøj EZ, Boer GA, Hansen JB, Thomsen MB, Treebak JT, Holst JJ, Kanters JK, Mandrup-Poulsen T, Jespersen T, Emanuelli B, Torekov SS. Age-dependent transition from islet insulin hypersecretion to hyposecretion in mice with the long QT-syndrome loss-of-function mutation Kcnq1-A340V. Sci Rep 2021; 11:12253. [PMID: 34112814 PMCID: PMC8192901 DOI: 10.1038/s41598-021-90452-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/05/2021] [Indexed: 11/24/2022] Open
Abstract
Loss-of-function (LoF) mutations in KCNQ1, encoding the voltage-gated K+ channel Kv7.1, lead to long QT syndrome 1 (LQT1). LQT1 patients also present with post-prandial hyperinsulinemia and hypoglycaemia. In contrast, KCNQ1 polymorphisms are associated with diabetes, and LQTS patients have a higher prevalence of diabetes. We developed a mouse model with a LoF Kcnq1 mutation using CRISPR-Cas9 and hypothesized that this mouse model would display QT prolongation, increased glucose-stimulated insulin secretion and allow for interrogation of Kv7.1 function in islets. Mice were characterized by electrocardiography and oral glucose tolerance tests. Ex vivo, islet glucose-induced insulin release was measured, and beta-cell area quantified by immunohistochemistry. Homozygous mice had QT prolongation. Ex vivo, glucose-stimulated insulin release was increased in islets from homozygous mice at 12–14 weeks, while beta-cell area was reduced. Non-fasting blood glucose levels were decreased at this age. In follow-up studies 8–10 weeks later, beta-cell area was similar in all groups, while glucose-stimulated insulin secretion was now reduced in islets from hetero- and homozygous mice. Non-fasting blood glucose levels had normalized. These data suggest that Kv7.1 dysfunction is involved in a transition from hyper- to hyposecretion of insulin, potentially explaining the association with both hypoglycemia and hyperglycemia in LQT1 patients.
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Affiliation(s)
- Anniek F Lubberding
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Jinyi Zhang
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten Lundh
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Svava Nielsen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mathilde S Søndergaard
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Maria Villadsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Emil Z Skovhøj
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Geke A Boer
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jakob B Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten B Thomsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Jonas T Treebak
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen K Kanters
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Thomas Mandrup-Poulsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Thomas Jespersen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Brice Emanuelli
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Signe S Torekov
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark. .,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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15
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Ali Abdelhamid Y, Bernjak A, Phillips LK, Summers MJ, Weinel LM, Lange K, Chow E, Kar P, Horowitz M, Heller S, Deane AM. Nocturnal Hypoglycemia in Patients With Diabetes Discharged From ICUs: A Prospective Two-Center Cohort Study. Crit Care Med 2021; 49:636-649. [PMID: 33591015 DOI: 10.1097/ccm.0000000000004810] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES There is very limited information about glycemic control after discharge from the ICU. The aims of this study were to evaluate the prevalence of hypoglycemia in ICU survivors with type-2 diabetes and determine whether hypoglycemia is associated with cardiac arrhythmias. DESIGN Prospective, observational, two-center study. Participants underwent up to 5 days of simultaneous blinded continuous interstitial glucose monitoring and ambulatory 12-lead electrocardiogram monitoring immediately after ICU discharge during ward-based care. Frequency of arrhythmias, heart rate variability, and cardiac repolarization markers were compared between hypoglycemia (interstitial glucose ≤ 3.5 mmol/L) and euglycemia (5-10 mmol/L) matched for time of day. SETTING Mixed medical-surgical ICUs in two geographically distinct university-affiliated hospitals. PATIENTS Patients with type-2 diabetes who were discharged from ICU after greater than or equal to 24 hours with greater than or equal to one organ failure and were prescribed subcutaneous insulin were eligible. MEASUREMENTS AND MAIN RESULTS Thirty-one participants (mean ± sd, age 65 ± 13 yr, glycated hemoglobin 64 ± 22 mmol/mol) were monitored for 101 ± 32 hours post-ICU (total 3,117 hr). Hypoglycemia occurred in 12 participants (39%; 95% CI, 22-56%) and was predominantly nocturnal (40/51 hr) and asymptomatic (25/29 episodes). Participants experiencing hypoglycemia had 2.4 ± 0.7 discrete episodes lasting 45 minutes (interquartile range, 25-140 min). Glucose nadir was less than or equal to 2.2 mmol/L in 34% of episodes. The longest episode of nocturnal hypoglycemia was 585 minutes with glucose nadir less than 2.2 mmol/L. Simultaneous electrocardiogram and continuous interstitial glucose monitoring recordings were obtained during 44 hours of hypoglycemia and 991 hours of euglycemia. Hypoglycemia was associated with greater risk of bradycardia but did not affect atrial or ventricular ectopics, heart rate variability, or cardiac repolarization. CONCLUSIONS In ICU survivors with insulin-treated type-2 diabetes, hypoglycemia occurs frequently and is predominantly nocturnal, asymptomatic, and prolonged.
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Affiliation(s)
- Yasmine Ali Abdelhamid
- Discipline of Acute Care Medicine, Department of Surgical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Division of Critical Care and Investigative Services, Royal Melbourne Hospital, Parkville, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Alan Bernjak
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
- INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Liza K Phillips
- Discipline of Medicine, Department of Medical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- National Health and Medical Research Council Centre of Research Excellence in Translating Nutritional Science to Good Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- Endocrine and Metabolic Service, Medical Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Matthew J Summers
- Discipline of Acute Care Medicine, Department of Surgical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Luke M Weinel
- Intensive Care Unit, Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kylie Lange
- Discipline of Medicine, Department of Medical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- National Health and Medical Research Council Centre of Research Excellence in Translating Nutritional Science to Good Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Elaine Chow
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Palash Kar
- Discipline of Acute Care Medicine, Department of Surgical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Michael Horowitz
- Discipline of Medicine, Department of Medical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- National Health and Medical Research Council Centre of Research Excellence in Translating Nutritional Science to Good Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- Endocrine and Metabolic Service, Medical Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Simon Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Adam M Deane
- Discipline of Acute Care Medicine, Department of Surgical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Division of Critical Care and Investigative Services, Royal Melbourne Hospital, Parkville, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia
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16
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Cagiltay E, Pouwels S, Erbas O, Taskiran D, Kalkanli Tas S, Aslan I. The Prophylactic Effects of Metoprolol, Diltiazem, and Pilocarpine on Hypoglycemia-Induced Prolongation of QT Interval. Cureus 2021; 13:e14058. [PMID: 33898141 PMCID: PMC8061426 DOI: 10.7759/cureus.14058] [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] [Accepted: 03/23/2021] [Indexed: 01/08/2023] Open
Abstract
Background Insulin-induced hypoglycemia has been demonstrated to prolong the corrected QT (QTc) interval. Prolongation of the QTc interval, especially in diabetic patients using insulin, can cause fatal ventricular arrhythmias. The aim of this study was to evaluate the effects of metoprolol, diltiazem, and pilocarpine on hypoglycemia-induced QTc prolongation. Methods Thirty male rats were randomly distributed into the following five groups: Group 1 (1 mL/kg saline, n=6), Group 2 (40 U/kg crystalline insulin + saline, n=6), Group 3 (40 U/kg crystalline insulin + 1 mg/kg metoprolol, n=6), Group 4 (40 U/kg crystalline insulin + 0.8 mg/kg pilocarpine, n=6), and Group 5 (40 U/kg crystalline insulin + 2 mg/kg diltiazem, n=6). Three hours after insulin injection, the blood glucose level was measured in all groups. Blood glucose <40 mg/dl was defined as hypoglycemia. Electrocardiograms (ECG) were taken in lead I (DI), and QTc was calculated by using Bazett's formula. Results Group 2 (insulin + saline) showed that it had a significantly prolonged QTc interval as compared to the control group (p<0.0001). However, treatments of the rats with metoprolol, pilocarpine, and diltiazem significantly prevented prolongation of the QTc interval as compared to the insulin + saline group (p<0.005, p<0.005, and p<0.01, respectively). Conclusion The findings of the present study demonstrated the efficacy of metoprolol, pilocarpine, and diltiazem in the prevention of hypoglycemia-induced QTc prolongation in male rats.
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Affiliation(s)
- Eylem Cagiltay
- Department of Physiology, Istanbul Bilim University School of Medicine, Istanbul, TUR
| | - Sjaak Pouwels
- Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, NLD
| | - Oytun Erbas
- Department of Physiology, Istanbul Bilim University School of Medicine, Istanbul, TUR
| | - Dilek Taskiran
- Department of Physiology, Ege University School of Medicine, Izmir, TUR
| | - Sevgi Kalkanli Tas
- Department of Immunology, University of Health Sciences, Faculty of Medicine, Istanbul, TUR
| | - Ismael Aslan
- Department of Pharmacy, University of Health Sciences, Institute of Health Sciences, Istanbul, TUR
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17
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Choi SY, Ko SH. Severe hypoglycemia as a preventable risk factor for cardiovascular disease in patients with type 2 diabetes mellitus. Korean J Intern Med 2021; 36:263-270. [PMID: 32872725 PMCID: PMC7969056 DOI: 10.3904/kjim.2020.327] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/05/2020] [Indexed: 12/11/2022] Open
Abstract
Glucose-lowering medication and lifestyle modification are essential for optimal glycemic control in patients with type 2 diabetes mellitus (T2DM). However, glucose-lowering agents, particularly insulin and insulin secretagogues, may cause hypoglycemia, which has multiple negative effects on the cardiovascular (CV) system and may cause death. Previous studies using institutional data from the Korean Nationwide Health Insurance database have consistently found a causal relationship between severe hypoglycemia and CV outcomes and mortality. Screening for high-risk patients, appropriate management, and intensive individualized education are the most effective measures and essential for the prevention of harmful hypoglycemic events. Based on identified risk factors that predict severe hypoglycemia, we developed an 1-year risk prediction model for severe hypoglycemia that can be used in clinical settings. In this review, we describe the current understanding of severe hypoglycemia and the clinical implications in patients with T2DM. Furthermore, we highlight the importance of intensive individualized education for high-risk patients and the risk prediction model to reduce severe hypoglycemia.
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Affiliation(s)
- Soo-Yeon Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Seung-Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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18
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Ozturk N, Uslu S, Ozdemir S. Diabetes-induced changes in cardiac voltage-gated ion channels. World J Diabetes 2021; 12:1-18. [PMID: 33520105 PMCID: PMC7807254 DOI: 10.4239/wjd.v12.i1.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 11/05/2020] [Accepted: 11/13/2020] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus affects the heart through various mechanisms such as microvascular defects, metabolic abnormalities, autonomic dysfunction and incompatible immune response. Furthermore, it can also cause functional and structural changes in the myocardium by a disease known as diabetic cardiomyopathy (DCM) in the absence of coronary artery disease. As DCM progresses it causes electrical remodeling of the heart, left ventricular dysfunction and heart failure. Electrophysiological changes in the diabetic heart contribute significantly to the incidence of arrhythmias and sudden cardiac death in diabetes mellitus patients. In recent studies, significant changes in repolarizing K+ currents, Na+ currents and L-type Ca2+ currents along with impaired Ca2+ homeostasis and defective contractile function have been identified in the diabetic heart. In addition, insulin levels and other trophic factors change significantly to maintain the ionic channel expression in diabetic patients. There are many diagnostic tools and management options for DCM, but it is difficult to detect its development and to effectively prevent its progress. In this review, diabetes-associated alterations in voltage-sensitive cardiac ion channels are comprehensively assessed to understand their potential role in the pathophysiology and pathogenesis of DCM.
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Affiliation(s)
- Nihal Ozturk
- Department of Biophysics, Akdeniz University Faculty of Medicine, Antalya 07058, Turkey
| | - Serkan Uslu
- Department of Biophysics, Akdeniz University Faculty of Medicine, Antalya 07058, Turkey
| | - Semir Ozdemir
- Department of Biophysics, Akdeniz University Faculty of Medicine, Antalya 07058, Turkey
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19
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Mylona M, Liatis S, Anastasiadis G, Kapelios C, Kokkinos A. Severe iatrogenic hypoglycaemia requiring medical assistance is associated with concurrent prolongation of the QTc interval. Diabetes Res Clin Pract 2020; 161:108038. [PMID: 32006648 DOI: 10.1016/j.diabres.2020.108038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/03/2020] [Accepted: 01/27/2020] [Indexed: 11/28/2022]
Abstract
AIMS Hypoglycaemia has been shown to exert arrhythmogenic effects. Herein, we explore the association between severe hypoglycaemia requiring medical assistance and the length of the QT interval in patients with diabetes. METHODS Data from a prospective study, conducted in eight tertiary hospitals, which recorded cases of hypoglycaemia from patients with diabetes seeking treatment at emergency departments (ED) were analyzed. The patients' electrocardiograms (ECGs), were compared to those of non-hypoglycaemic diabetic individuals, matched for age, gender and duration of diabetes, obtained during their scheduled follow-up visits. The corrected QT intervals (QTc) were calculated blindly by two cardiologists. RESULTS ECGs from 154 patients presenting with hypoglycaemia were analyzed and compared to 95 matched controls. The mean QTc interval was significantly longer in patients with hypoglycaemia than in controls (441.9 ± 48.2 vs. 401.0 ± 29.6 ms, p < 0.001) A significantly higher proportion of hypoglycaemic patients had an abnormally prolonged QTc (≥440 ms) compared to controls (49.4% vs. 11.6%, p < 0.001). Among patients with hypoglycaemia, there was a statistically significant but rather weak negative correlation between QTc interval and plasma glucose at presentation (r: -0.183, p = 0.02). CONCLUSIONS In diabetic patients, hypoglycemia requiring medical assistance is associated with a significant prolongation of the QTc interval. The degree of this prolongation is associated with hypoglycaemia severity.
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Affiliation(s)
- Maria Mylona
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece.
| | - Stavros Liatis
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | | | | | - Alexander Kokkinos
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
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20
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Murad HY, Bortz EP, Yu H, Luo D, Halliburton GM, Sholl AB, Khismatullin DB. Phenotypic alterations in liver cancer cells induced by mechanochemical disruption. Sci Rep 2019; 9:19538. [PMID: 31862927 PMCID: PMC6925139 DOI: 10.1038/s41598-019-55920-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/04/2019] [Indexed: 12/11/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a highly fatal disease recognized as a growing global health crisis worldwide. Currently, no curative treatment is available for early-to-intermediate stage HCC, characterized by large and/or multifocal tumors. If left untreated, HCC rapidly progresses to a lethal stage due to favorable conditions for metastatic spread. Mechanochemical disruption of cellular structures can potentially induce phenotypic alterations in surviving tumor cells that prevent HCC progression. In this paper, HCC response to mechanical vibration via high-intensity focused ultrasound and a chemical disruptive agent (ethanol) was examined in vitro and in vivo. Our analysis revealed that mechanochemical disruption caused a significant overproduction of reactive oxygen species (ROS) in multiple HCC cell lines (HepG2, PLC/PRF/5, and Hep3B). This led to a decrease in cell viability and long-term proliferation due to increased expression and activity of death receptors TNFR1 and Fas. The cells that survived mechanochemical disruption had a reduced expression of cancer stem cell markers (CD133, CD90, CD49f) and a diminished colony-forming ability. Mechanochemical disruption also impeded HCC migration and their adhesion to vascular endothelium, two critical processes in hematogenous metastasis. The HCC transformation to a non-tumorigenic phenotype post mechanochemical disruption was confirmed by a lack of tumor spheroid formation in vitro and complete tumor regression in vivo. These results show that mechanochemical disruption inhibits uncontrolled proliferation and reduces tumorigenicity and aggressiveness of HCC cells through ROS overproduction and associated activation of TNF- and Fas-mediated cell death signaling. Our study identifies a novel curative therapeutic approach that can prevent the development of aggressive HCC phenotypes.
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Affiliation(s)
- Hakm Y Murad
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, USA
- Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, New Orleans, LA, USA
| | - Emma P Bortz
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, USA
- Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, New Orleans, LA, USA
| | - Heng Yu
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, USA
- Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, New Orleans, LA, USA
| | - Daishen Luo
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, USA
- Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, New Orleans, LA, USA
| | - Gray M Halliburton
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, USA
- Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, New Orleans, LA, USA
| | - Andrew B Sholl
- Department of Pathology and Laboratory Medicine, Tulane University, New Orleans, LA, USA
| | - Damir B Khismatullin
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, USA.
- Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, New Orleans, LA, USA.
- Tulane Cancer Center, Tulane University, New Orleans, LA, USA.
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Hauben M, Reynolds R, Caubel P. Deconstructing the Pharmacovigilance Hype Cycle. Clin Ther 2019; 40:1981-1990.e3. [PMID: 30545608 DOI: 10.1016/j.clinthera.2018.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/11/2018] [Accepted: 10/24/2018] [Indexed: 12/31/2022]
Abstract
Data science is making increasing contributions to pharmacovigilance. Although the technical innovation of these works are indisputable, efficient progress in real-world pharmacovigilance signal detection may be hampered by corresponding technology life cycle effects, with a resulting tendency to conclude that, with large enough datasets and intricate algorithms, "the numbers speak for themselves," discounting the importance of clinical and scientific judgment. A practical consequence is overzealous declarations regarding the safety or lack of safety of drugs. We describe these concerns through a critical discussion of key results and conclusions from case studies selected to illustrate these points.
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22
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Yan M, Feng L, Shi Y, Wang J, Liu Y, Li F, Li B. Mechanism of As2O3-Induced Action Potential Prolongation and Using hiPS-CMs to Evaluate the Rescue Efficacy of Drugs With Different Rescue Mechanism. Toxicol Sci 2018; 158:379-390. [PMID: 28521025 DOI: 10.1093/toxsci/kfx098] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Arsenic trioxide (As2O3) has been verified as a breakthrough in the management of acute promyelocytic leukemia in recent decades. However, cardiotoxicity, especially long QT syndrome (LQTS) has become the most important issue during As2O3 treatment. The characterized mechanisms behind this adverse effect are inhibition of cardiac hERG channel trafficking and increase of cardiac calcium currents. In our study, we found a new pathway underlying As2O3-induced cardiotoxicity that As2O3 accelerates lysosomal degradation of hERG on plasma membrane after using brefeldin A (BFA) to block protein trafficking. Then we explored pharmacological rescue strategies on As2O3-induced LQTS, and found that 4 therapeutic agents exert rescue efficacy via 3 different pathways: fexofenadine and astemizole facilitate hERG trafficking via promotion of channel-chaperone formation after As2O3 incubation; ranolazine slows hERG degradation in the presence of As2O3; and resveratrol shows significant attenuation on calcium current increase triggered by As2O3. Moreover, we used human-induced pluripotent stem cell derived cardiomyocytes (hiPS-CMs) to evaluate the rescue effects of the above agents on As2O3-induced prolongation of action potential duration (APD) and demonstrated that fexofenadine and resveratrol significantly ameliorate the prolonged APD. These observations suggested that pharmacological chaperone like fexofenadine and resveratrol might have the potential to protect against the cardiotoxicity of As2O3.
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Affiliation(s)
- Meng Yan
- Department of Pharmacology Harbin Medical University, Nangang District, Harbin, Heilongjiang Province 150086, China.,Translational Medicine Research and Cooperation Center of Northern China, Heilongjiang Academy of Medical Sciences, Nangang District, Harbin, Heilongjiang Province 150081, China
| | - Lifang Feng
- Translational Medicine Research and Cooperation Center of Northern China, Heilongjiang Academy of Medical Sciences, Nangang District, Harbin, Heilongjiang Province 150081, China
| | - Yanhui Shi
- Department of Pharmacology Harbin Medical University, Nangang District, Harbin, Heilongjiang Province 150086, China.,Translational Medicine Research and Cooperation Center of Northern China, Heilongjiang Academy of Medical Sciences, Nangang District, Harbin, Heilongjiang Province 150081, China
| | - Junnan Wang
- Translational Medicine Research and Cooperation Center of Northern China, Heilongjiang Academy of Medical Sciences, Nangang District, Harbin, Heilongjiang Province 150081, China
| | - Yan Liu
- Department of Pharmacology Harbin Medical University, Nangang District, Harbin, Heilongjiang Province 150086, China.,Translational Medicine Research and Cooperation Center of Northern China, Heilongjiang Academy of Medical Sciences, Nangang District, Harbin, Heilongjiang Province 150081, China
| | - Fengmei Li
- Department of Pharmacology Harbin Medical University, Nangang District, Harbin, Heilongjiang Province 150086, China.,Translational Medicine Research and Cooperation Center of Northern China, Heilongjiang Academy of Medical Sciences, Nangang District, Harbin, Heilongjiang Province 150081, China
| | - Baoxin Li
- Department of Pharmacology Harbin Medical University, Nangang District, Harbin, Heilongjiang Province 150086, China.,Translational Medicine Research and Cooperation Center of Northern China, Heilongjiang Academy of Medical Sciences, Nangang District, Harbin, Heilongjiang Province 150081, China
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23
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Novodvorsky P, Bernjak A, Robinson EJ, Iqbal A, Macdonald IA, Jacques RM, Marques JLB, Sheridan PJ, Heller SR. Salbutamol-induced electrophysiological changes show no correlation with electrophysiological changes during hyperinsulinaemic-hypoglycaemic clamp in young people with Type 1 diabetes. Diabet Med 2018; 35:1264-1272. [PMID: 29682793 PMCID: PMC6099209 DOI: 10.1111/dme.13650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 12/01/2022]
Abstract
AIMS Hypoglycaemia causes QT-interval prolongation and appears pro-arrhythmogenic. Salbutamol, a β2 -adrenoreceptor agonist also causes QT-interval prolongation. We hypothesized that the magnitude of electrophysiological changes induced by salbutamol and hypoglycaemia might relate to each other and that salbutamol could be used as a non-invasive screening tool for predicting an individual's electrophysiological response to hypoglycaemia. METHODS Eighteen individuals with Type 1 diabetes were administered 2.5 mg of nebulized salbutamol. Participants then underwent a hyperinsulinaemic-hypoglycaemic clamp (2.5 mmol/l for 1 h). During both experiments, heart rate and serum potassium (and catecholamines during the clamp) were measured and a high-resolution electrocardiogram (ECG) was recorded at pre-set time points. Cardiac repolarization was measured by QT-interval duration adjusted for heart rate (QTc ), T-wave amplitude (Tamp ), T-peak to T-end interval duration (Tp Tend ) and T-wave area symmetry (Tsym ). The maximum changes vs. baseline in both experiments were assessed for their linear dependence. RESULTS Salbutamol administration caused QTc and Tp Tend prolongation and a decrease in Tamp and Tsym . Hypoglycaemia caused increased plasma catecholamines, hypokalaemia, QTc and Tp Tend prolongation, and a decrease in Tamp and Tsym . No significant correlations were found between maximum changes in QTc [r = 0.15, 95% confidence interval (95% CI) -0.341 to 0.576; P = 0.553), Tp Tend (r = 0.075, 95% CI -0.406 to 0.524; P = 0.767), Tsym (r = 0.355, 95% CI -0.132 to 0.706; P = 0.149) or Tamp (r = 0.148, 95% CI -0.347 to 0.572; P = 0.558) in either experiment. CONCLUSIONS Both hypoglycaemia and salbutamol caused pro-arrhythmogenic electrophysiological changes in people with Type 1 diabetes but were not related in any given individual. Salbutamol does not appear useful in assessing an individual's electrophysiological response to hypoglycaemia.
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Affiliation(s)
- P. Novodvorsky
- Department of Oncology and MetabolismUniversity of Sheffield
- Sheffield Teaching Hospitals NHS Foundation Trust
| | - A. Bernjak
- Department of Oncology and MetabolismUniversity of Sheffield
- INSIGNEO Institute for in silico Medicine
| | - E. J. Robinson
- Department of Oncology and MetabolismUniversity of Sheffield
- Sheffield Teaching Hospitals NHS Foundation Trust
| | - A. Iqbal
- Department of Oncology and MetabolismUniversity of Sheffield
- Sheffield Teaching Hospitals NHS Foundation Trust
- Department of Infection, Immunity and Cardiovascular DiseaseUniversity of SheffieldSheffield
| | | | - R. M. Jacques
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | | | | | - S. R. Heller
- Department of Oncology and MetabolismUniversity of Sheffield
- Sheffield Teaching Hospitals NHS Foundation Trust
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24
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Iqbal A, Novodvorsky P, Heller SR. Recent Updates on Type 1 Diabetes Mellitus Management for Clinicians. Diabetes Metab J 2018; 42:3-18. [PMID: 29504302 PMCID: PMC5842299 DOI: 10.4093/dmj.2018.42.1.3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 01/31/2018] [Indexed: 01/11/2023] Open
Abstract
Type 1 diabetes mellitus (T1DM) is a chronic autoimmune condition that requires life-long administration of insulin. Optimal management of T1DM entails a good knowledge and understanding of this condition both by the physician and the patient. Recent introduction of novel insulin preparations, technological advances in insulin delivery and glucose monitoring, such as continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring and improved understanding of the detrimental effects of hypoglycaemia and hyperglycaemia offer new opportunities and perspectives in T1DM management. Evidence from clinical trials suggests an important role of structured patient education. Our efforts should be aimed at improved metabolic control with concomitant reduction of hypoglycaemia. Despite recent advances, these goals are not easy to achieve and can put significant pressure on people with T1DM. The approach of physicians should therefore be maximally supportive. In this review, we provide an overview of the recent advances in T1DM management focusing on novel insulin preparations, ways of insulin administration and glucose monitoring and the role of metformin or sodium-glucose co-transporter 2 inhibitors in T1DM management. We then discuss our current understanding of the effects of hypoglycaemia on human body and strategies aimed at mitigating the risks associated with hypoglycaemia.
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Affiliation(s)
- Ahmed Iqbal
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Peter Novodvorsky
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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25
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Kimura S, Nakao S, Kitaura A, Iwamoto T, Houri K, Matsushima M, Hamasaki S. Sevoflurane causes greater QTc interval prolongation in chronically hyperglycemic patients than in normoglycemic patients. PLoS One 2017; 12:e0188555. [PMID: 29194447 PMCID: PMC5711029 DOI: 10.1371/journal.pone.0188555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/13/2017] [Indexed: 11/30/2022] Open
Abstract
QTc interval prolongation is a serious diabetic complication and increases mortality rate. Hyperglycemia inhibits the rapid component of delayed rectifier potassium channel currents (Ikr) and prolongs the QTc interval on electrocardiograms. Sevoflurane also inhibits the Ikr and causes QTc interval prolongation. In fact, torsade de pointes occurred in a patient with poorly controlled diabetes mellitus during sevoflurane anesthesia. We enrolled 74 patients, including 37 normoglycemic patients (glycated hemoglobin [HbA1c]: <6.5%) (NG group) and 37 chronically hyperglycemic patients (HbA1c: ≥6.5%) (HG group). Anesthesia was induced with 2 mg/kg propofol and 0.3 μg/kg/min remifentanil, and maintained with 2% sevoflurane in 40% O2 and 0.2-0.3 μg/kg/min remifentanil. The QT interval and Tp-e interval (from the peak to the end of the T wave) were measured before and at 5, 10, 30, 60, 90, and 120 min after the administration of sevoflurane and adjusted for the patient's heart rate (QTc and Tp-ec, respectively). P-values of <0.05 were considered statistically significant. The QTc and the Tp-ec intervals of the two groups did not differ significantly before the administration of sevoflurane. The QTc interval gradually increased with time in both groups and was significantly longer than the baseline value at 10 min after the administration of sevoflurane in both groups. The QTc interval of the HG group was significantly longer than that of the NG group at 90 min and 120 min after the administration of sevoflurane. The Tp-ec interval was not affected by sevoflurane in either group.We have demonstrated that sevoflurane significantly prolongs the QTc interval, and that the extent of the prolongation is significantly greater in chronically hyperglycemic patients than in normoglycemic patients. Although Tp-ec is not affected by sevoflurane, it should be noted that the simultaneous blockade of potassium channels would increase the risk of arrhythmias.
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Affiliation(s)
- Seishi Kimura
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Shinichi Nakao
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Atsuhiro Kitaura
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Tatushige Iwamoto
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Kei Houri
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Mayuka Matsushima
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Shinichi Hamasaki
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
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Sarapultsev P, Yushkov B, Sarapultsev A. Prevalence of arrhythmias in patients with type 2 diabetes and the role of structural changes in myocardium in their development. Diabetes Metab Syndr 2017; 11 Suppl 2:S567-S576. [PMID: 28412149 DOI: 10.1016/j.dsx.2017.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the prevalence of arrhythmias in patients with type 2 diabetes and their relationships with the structural parameters of the heart. METHODS A retrospective case-control study was conducted using clinical and biochemical profiles of patients with diabetes at the Endocrinology Centre and City Clinical Hospital No. 40, Ekaterinburg, Russia. RESULTS The total study sample included 75 subjects. The average age (SD) was 48.2 (5.6) years, and the mean duration of diabetes (SD) was 6.2 (2.4) years. The most common type of extrasystoles were the single supraventricular extrasystoles, observed in 72.29% of cases (vs 38.89% in the control group) and paired supraventricular extrasystoles, which were identified in 30% of cases (vs 19.44% in the control group). Ventricular cardiac arrhythmias in the form of ventricular extrasystoles (VE) were identified in 25.71% of cases (13.89% in the control group). CONCLUSIONS This study revealed the signs of the morphological restructuring of the right chambers of the heart and a relatively high prevalence of supraventricular arrhythmias in the early stages of type 2 diabetes. Moreover, according to the results, the incidence of some types of supraventricular arrhythmias and the occurrence of tachycardia episodes in patients with type 2 diabetes mostly depends on the restructuring of the right chambers of the heart, which may be caused by the peculiarities of the cardiac innervation, with the higher density of choline and adrenergic plexuses in the right chambers.
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Affiliation(s)
- Petr Sarapultsev
- Ural Fed. Univ. named after the First Pres. of Russ. B.N. Yeltsin, 19 Mira street, Ekaterinburg, 620002, Russian Federation; Institute of Immunology and Physiology (IIP), Ural Division of Russian Academy of Sciences, 106 Pervomayskaya street, Ekaterinburg, 620049, Russian Federation
| | - Boris Yushkov
- Ural Fed. Univ. named after the First Pres. of Russ. B.N. Yeltsin, 19 Mira street, Ekaterinburg, 620002, Russian Federation; Institute of Immunology and Physiology (IIP), Ural Division of Russian Academy of Sciences, 106 Pervomayskaya street, Ekaterinburg, 620049, Russian Federation; Ural State Medical University, 3 Repina street, Ekaterinburg, 620014, Russian Federation
| | - Alexey Sarapultsev
- Ural Fed. Univ. named after the First Pres. of Russ. B.N. Yeltsin, 19 Mira street, Ekaterinburg, 620002, Russian Federation; Institute of Immunology and Physiology (IIP), Ural Division of Russian Academy of Sciences, 106 Pervomayskaya street, Ekaterinburg, 620049, Russian Federation.
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Sato H, Hosojima M, Ishikawa T, Aoki K, Okamoto T, Saito A, Tsuchida M. Glucose Variability Based on Continuous Glucose Monitoring Assessment Is Associated with Postoperative Complications after Cardiovascular Surgery. Ann Thorac Cardiovasc Surg 2017; 23:239-247. [PMID: 28717057 DOI: 10.5761/atcs.oa.17-00045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This purpose of this prospective study was to use a continuous glucose monitoring (CGM) system to evaluate the suitability of our institution's glucose management protocol after cardiovascular surgery and to clarify the impact of glycemic variability on postoperative complications. METHODS In all, 76 patients who underwent elective cardiovascular surgery and were monitored perioperatively using a CGM system were evaluated. Postoperative glucose management consisted of continuous intravenous insulin infusion (CIII) in the intensive care unit, and subcutaneous insulin injections (SQII) after oral food intake started. CIII and subcutaneous injections were initiated when blood glucose level exceeded 150 mg/dL. CGM data were used to analyze perioperative glycemic variability and association with postoperative complications. RESULTS Target glucose levels (71-180 mg/dL) were achieved during 97.1 ± 5.5% and 86.4 ± 19.0% of the continuous insulin infusion and subcutaneous injection periods, respectively. Major postoperative complications were surgical site infections, found in 6.6% of total patients, and atrial fibrillation, found in 44% of patients with off-pump coronary artery bypass grafting. High glycemic variability during SQII was associated with increased risk for both complications. CONCLUSION Data analysis revealed that our glucose management protocol during CIII was adequate. However, the management protocol during SQII required improvement.
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Affiliation(s)
- Hiroki Sato
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Science, Niigata, Niigata, Japan
| | - Michihiro Hosojima
- Department of Clinical Nutrition Science, Niigata University Graduate School of Medical and Dental Science, Niigata, Niigata, Japan
| | - Tomomi Ishikawa
- Division of Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, Niigata, Niigata, Japan
| | - Kenji Aoki
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Science, Niigata, Niigata, Japan
| | - Takeshi Okamoto
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Science, Niigata, Niigata, Japan
| | - Akihiko Saito
- Department of Applied Molecular Medicine, Niigata University Graduate School of Medical and Dental Science, Niigata, Niigata, Japan
| | - Masanori Tsuchida
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Science, Niigata, Niigata, Japan
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Hannoodi F, Alwash H, Shah K, Ali I, Kumar S, Zakaria K. A Case of Hypoglycemiainduced QT Prolongation Leading to Torsade de Pointes and a Review of Pathophysiological Mechanisms. Clin Pract 2017; 7:960. [PMID: 28652909 PMCID: PMC5475412 DOI: 10.4081/cp.2017.960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/02/2017] [Accepted: 06/05/2017] [Indexed: 11/30/2022] Open
Abstract
Torsades de pointes is a life-threatening cardiac arrhythmia. Occurrence of this arrhythmia as a result of hypoglycemia has not been reported in the literature. We describe an interesting case of an insulin-dependent diabetic patient presenting with torsades de pointes resulting from hypoglycemia. A 62-year-old male was admitted to the hospital following an episode of severe insulin-induced hypoglycemia and a cardiac arrest. He was found to unresponsive at home after taking insulin. His serum glucose was found to be 18. He was given juice initially to normalize his glucose and was then transferred by EMS to ER where he was given 5% dextrose infusion. Analysis of the LifeVest rhythm recording showed torsades de pointes that was terminated by defibrillation of the LifeVest. Several mechanisms are responsible for torsade, including QT interval prolongation, adrenalin secretion and calcium overload leading to intracellular calcium oscillations. These mechanisms are a trigger to torsade de pointes. Predisposing factors were present leading torsade to occur.
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29
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Kitaura A, Nakao S, Hamasaki S, Houri K, Tsujimoto T, Kimura S, Matsushima M. Sevoflurane prolonged the QTc interval and increased transmural dispersion of repolarization in a patient with long QT syndrome 3: a case report. JA Clin Rep 2017; 3:29. [PMID: 29457073 PMCID: PMC5804612 DOI: 10.1186/s40981-017-0093-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 05/02/2017] [Indexed: 02/02/2023] Open
Abstract
We report that sevoflurane not only caused marked QTc interval prolongation but also increased transmural dispersion of repolarization in a patient with long QT syndrome 3 (LQT3). A 16-year-old male with LQT3 underwent a shoulder operation. He experienced no episode of syncope or cardiac arrest, but his preoperative electrocardiography (ECG) showed marked QTc interval prolongation (631 ms) and Tp-e interval prolongation (126 ms). Anesthesia was induced with propofol and maintained with 2% sevoflurane and remifentanil. Although no lethal arrhythmias occurred in the perioperative period, not only the QTc interval but also Tp-e interval was further prolonged by sevoflurane. While sevoflurane has been recognized as a safe anesthetic in terms of QT interval prolongation, even in patients with long QT syndromes, we believe that sevoflurane might be avoided for poorly controlled LQT3 patients.
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Affiliation(s)
- Atsuhiro Kitaura
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Shinichi Nakao
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Shinichi Hamasaki
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Kei Houri
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Takatoshi Tsujimoto
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Seishi Kimura
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
| | - Mayuka Matsushima
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, 589-8511 Osaka Japan
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30
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Hyltén-Cavallius L, Iepsen EW, Christiansen M, Graff C, Linneberg A, Pedersen O, Holst JJ, Hansen T, Torekov SS, Kanters JK. Glucose ingestion causes cardiac repolarization disturbances in type 1 long QT syndrome patients and healthy subjects. Heart Rhythm 2017; 14:1165-1170. [PMID: 28400316 DOI: 10.1016/j.hrthm.2017.04.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Both hypoglycemia and severe hyperglycemia constitute known risk factors for cardiac repolarization changes potentially leading to malignant arrhythmias. Patients with loss of function mutations in KCNQ1 are characterized by long QT syndrome (LQTS) and may be at increased risk for glucose-induced repolarization disturbances. OBJECTIVE The purpose of this study was to test the hypothesis that KCNQ1 LQTS patients are at particular risk for cardiac repolarization changes during the relative hyperglycemia that occurs after an oral glucose load. METHODS Fourteen KCNQ1 LQTS patients and 28 control participants matched for gender, body mass index, and age underwent a 3-hour oral 75-g glucose tolerance test with ECGs obtained at 7 time points. Fridericia corrected QT interval (QTcF), Bazett corrected QT interval (QTcB), and the Morphology Combination Score (MCS) were calculated. RESULTS QTc and MCS increased in both groups. MCS remained elevated until 150 minutes after glucose ingestion, and the maximal change from baseline was larger among KCNQ1 LQTS patients compared with control subjects (0.28 ± 0.27 vs 0.15 ± 0.13; P <.05). CONCLUSION Relative hyperglycemia induced by ingestion of 75-g glucose caused cardiac repolarization disturbances that were more severe in KCNQ1 LQTS patients compared with control subjects.
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Affiliation(s)
- Louise Hyltén-Cavallius
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Eva W Iepsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michael Christiansen
- Department of Clinical Biochemistry, Statens Serum Institut, Copenhagen, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Allan Linneberg
- Research Centre for Prevention and Health, The Capital Region, Copenhagen, Denmark; Department of Clinical Experimental Research, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Oluf Pedersen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Signe S Torekov
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen K Kanters
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology S, Gentofte University Hospital, Copenhagen, Denmark.
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Inhibition of rapid delayed rectifier potassium current (I Kr) by ischemia/reperfusion and its recovery by vitamin E in ventricular myocytes. J Electrocardiol 2017. [PMID: 28646979 DOI: 10.1016/j.jelectrocard.2017.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ischemia/reperfusion (I/R) induces prolongation of QT interval and action potential duration (APD), which is a major cardiac electrical disorder in patients with arrhythmias. However, the mechanism of QT interval prolongation induced by I/R remains unclear. In the present study, we hypothesized that the rapid component of delayed rectifier potassium (IKr) channel plays an important role in I/R-induced QT interval prolongation. We observed a marked attenuation of IKr and a significant prolongation of action potential duration (APD) in a simulated I/R system with sodium dithionite (Na2S2O4) in ventricular myocytes of guinea pigs. The IKr current density was inhibited by 64% and APD increased by 87% respectively. Moreover, the inhibition of IKr is primarily ascribed to overproduction of reactive oxygen species (ROS) by I/R, which can be partly reversed by antioxidant vitamin E (100μmol/L). The value of IKr tail current density increased from 0.516±0.040 pA/pF in I/R to 0.939±0.091 pA/pF when treated with vitamin E. Moreover, we also demonstrated that QTc interval was increased by I/R and reversed by Vitamin E in isolated guinea pig hearts. In conclusion, the inhibition of IKr is one of the underlying mechanisms of prolongation of QT interval and APD in I/R. Vitamin E might have a benefit in coronary reperfusion therapy.
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Sertbas Y, Ozdemir A, Sertbas M, Dayan A, Sancak S, Uyan C. The Effect of Glucose Variability on QTc Duration and Dispersion in Patients with Type 2 Diabetes Mellitus. Pak J Med Sci 2017; 33:22-26. [PMID: 28367166 PMCID: PMC5368313 DOI: 10.12669/pjms.331.11440] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Objective: Glycemic variability (GV) is a new term with the episodes of hyper and hypoglycemia in diabetic patients. Both prolonged QT interval and QTd are potential risk factors for malignant ventricular arrhythmias affecting the mortality of different groups of patients including diabetes mellitus. In this study, we aimed to evaluate if the glucose variability increasing the QTc interval and QTc dispersion in type 2 diabetes mellitus. Methods: We included 275 consecutive patients with type 2 diabetes. We quantified the GV with standard deviation (SD) and coefficient of variation (CV) from 7 point glucose measures. We investigated the relationship of GV parameters with QT parameters. Results: The prevalence of prolonged QTc duration was 21%, no patients have prolonged QTc dispersion (> 80 ms). SD of the patients with prolonged QTc duration was significantly higher than the others (45.14 ±24.45 vs. 37.78 ±9.03 p<0.05). There was also a significant relationship between SD and QTc dispersion (r: 0.164; p: 0.007). There were no relationship between the QT parameters and microvascular diabetic complications. SD and HbA1c levels were significantly higher on the patients having peripheral neuropathy (p<0.005). Conclusion: The result of this study demonstratess that increased glycemic variability is associated with prolonged QTc duration and QTc dispersion. It is important to focus on targeting optimal glycemic control with GV as an additional goal point along with the traditional following parameters such as fasting-postprandial blood glucose and HbA1c.
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Affiliation(s)
- Yasar Sertbas
- Yasar Sertbas, MD. Doctor, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Ali Ozdemir
- Ali Ozdemir, MD. Associate Professor, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Meltem Sertbas
- Meltem Sertbas, MD. Doctor, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Akin Dayan
- Akin Dayan, MD, Doctor, Department of Family Medicine, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey
| | - Seda Sancak
- Seda Sancak, MD. Associate Professor, Department of Endocrinology, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Cihangir Uyan
- Cihangir Uyan, MD. Professor, Department of Cardiology, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
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Vasculo-Neuronal Coupling: Retrograde Vascular Communication to Brain Neurons. J Neurosci 2016; 36:12624-12639. [PMID: 27821575 DOI: 10.1523/jneurosci.1300-16.2016] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 10/27/2016] [Accepted: 10/30/2016] [Indexed: 12/25/2022] Open
Abstract
Continuous cerebral blood flow is essential for neuronal survival, but whether vascular tone influences resting neuronal function is not known. Using a multidisciplinary approach in both rat and mice brain slices, we determined whether flow/pressure-evoked increases or decreases in parenchymal arteriole vascular tone, which result in arteriole constriction and dilation, respectively, altered resting cortical pyramidal neuron activity. We present evidence for intercellular communication in the brain involving a flow of information from vessel to astrocyte to neuron, a direction opposite to that of classic neurovascular coupling and referred to here as vasculo-neuronal coupling (VNC). Flow/pressure increases within parenchymal arterioles increased vascular tone and simultaneously decreased resting pyramidal neuron firing activity. On the other hand, flow/pressure decreases evoke parenchymal arteriole dilation and increased resting pyramidal neuron firing activity. In GLAST-CreERT2; R26-lsl-GCaMP3 mice, we demonstrate that increased parenchymal arteriole tone significantly increased intracellular calcium in perivascular astrocyte processes, the onset of astrocyte calcium changes preceded the inhibition of cortical pyramidal neuronal firing activity. During increases in parenchymal arteriole tone, the pyramidal neuron response was unaffected by blockers of nitric oxide, GABAA, glutamate, or ecto-ATPase. However, VNC was abrogated by TRPV4 channel, GABAB, as well as an adenosine A1 receptor blocker. Differently to pyramidal neuron responses, increases in flow/pressure within parenchymal arterioles increased the firing activity of a subtype of interneuron. Together, these data suggest that VNC is a complex constitutive active process that enables neurons to efficiently adjust their resting activity according to brain perfusion levels, thus safeguarding cellular homeostasis by preventing mismatches between energy supply and demand. SIGNIFICANCE STATEMENT We present evidence for vessel-to-neuron communication in the brain slice defined here as vasculo-neuronal coupling. We showed that, in response to increases in parenchymal arteriole tone, astrocyte intracellular Ca2+ increased and cortical neuronal activity decreased. On the other hand, decreasing parenchymal arteriole tone increased resting cortical pyramidal neuron activity. Vasculo-neuronal coupling was partly mediated by TRPV4 channels as genetic ablation, or pharmacological blockade impaired increased flow/pressure-evoked neuronal inhibition. Increased flow/pressure-evoked neuronal inhibition was blocked in the presence of adenosine A1 receptor and GABAB receptor blockade. Results provide evidence for the concept of vasculo-neuronal coupling and highlight the importance of understanding the interplay between basal CBF and resting neuronal activity.
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Kang J, Luo Y, Searles M, Rampe D. Observations on conducting whole-cell patch clamping of the hERG cardiac K + channel in pure human serum. J Appl Toxicol 2016; 37:445-453. [PMID: 27553911 DOI: 10.1002/jat.3377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/06/2016] [Accepted: 07/22/2016] [Indexed: 01/01/2023]
Abstract
Inhibition of the human ether-a-go-go-related gene (hERG) K+ channel by drugs leads to QT prolongation on the electrocardiogram and can result in serious cardiac arrhythmia. For this reason, screening of drugs on hERG is mandatory during the drug development process. Patch clamp electrophysiology in a defined physiological saline solution (PSS) represents the standard method for assaying drug effects on the channel. To make the assay more translatable to clinical studies, we have conducted whole-cell patch clamping of hERG using pure human serum as the extracellular medium. Pure human serum had little effect on the hERG channel waveform or the current-voltage relationship when compared to PSS. hERG current recordings were highly stable in serum at room temperature, but prolonged recordings at the physiological temperature required prior heat inactivation of the serum. Compared to PSS, the IC50 values, conducted at room temperature, of the classic hERG blocking drugs cisapride, moxifloxacin, and terfenadine were shifted to the right by an extent predicted by their known plasma protein binding, but we did not detect any differences in IC50 s between male and female serum. Total plasma levels of these drugs associated with clinical QT prolongation corresponded to small (<15%) inhibition of hERG current in pure serum suggesting that minor inhibition of the channel leads to observable pharmacodynamic effects. Conducting whole-cell patch clamping of hERG in human serum has the potential to make the assay more translatable to clinical studies and improve its predictive value for safety testing. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jiesheng Kang
- Departments of Disposition, Safety, and Animal Research Sanofi, Inc., Waltham, Massachusetts, USA
| | - Yongyi Luo
- Departments of Disposition, Safety, and Animal Research Sanofi, Inc., Waltham, Massachusetts, USA
| | - Michelle Searles
- Departments of Disposition, Safety, and Animal Research Sanofi, Inc., Framingham, Massachusetts, USA
| | - David Rampe
- Departments of Disposition, Safety, and Animal Research Sanofi, Inc., Bridgewater, New Jersey, USA
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Hanefeld M, Frier BM, Pistrosch F. Hypoglycemia and Cardiovascular Risk: Is There a Major Link? Diabetes Care 2016; 39 Suppl 2:S205-9. [PMID: 27440834 DOI: 10.2337/dcs15-3014] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Severe hypoglycemia is recognized to be one of the strongest predictors of macrovascular events, adverse clinical outcomes, and mortality in patients with type 2 diabetes. However, it is uncertain whether a direct pathophysiological link exists or whether hypoglycemia is primarily a marker of vulnerability to these events. Large clinical trials have reported an increased hazard ratio for all-cause mortality and cardiovascular events in patients with type 2 diabetes and severe hypoglycemia, but such an association has not been demonstrated in prospective trials of people with type 1 diabetes. Several cardiovascular effects occur during hypoglycemia either as a result of low blood glucose levels per se or through activation of the sympathoadrenal response: hemodynamic changes with an increase in cardiac work load and potential attenuation of myocardial perfusion, electrophysiological changes that may be arrhythmogenic, induction of a prothrombotic state, and release of inflammatory markers. Although the potential for a causal relationship has been demonstrated in mechanistic studies, the evidence from large prospective studies that hypoglycemia is a major causal contributor to cardiovascular events is limited to date. Other preexisting cardiovascular risk factors in addition to hypoglycemia may be the major link to the final cardiovascular event, but a low blood glucose level can trigger these events in patients with a high cardiovascular risk.
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Affiliation(s)
- Markolf Hanefeld
- Study Centre Professor Hanefeld, GWT-TU Dresden GmbH, Dresden, Germany Medical Clinic III, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
| | - Brian M Frier
- British Heart Foundation Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, Scotland, U.K
| | - Frank Pistrosch
- Study Centre Professor Hanefeld, GWT-TU Dresden GmbH, Dresden, Germany Medical Clinic III, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
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Vedel-Larsen E, Iepsen EW, Lundgren J, Graff C, Struijk JJ, Hansen T, Holst JJ, Madsbad S, Torekov S, Kanters JK. Major rapid weight loss induces changes in cardiac repolarization. J Electrocardiol 2016; 49:467-72. [PMID: 26925492 DOI: 10.1016/j.jelectrocard.2016.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Obesity is associated with increased all-cause mortality, but weight loss may not decrease cardiovascular events. In fact, very low calorie diets have been linked to arrhythmias and sudden death. The QT interval is the standard marker for cardiac repolarization, but T-wave morphology analysis has been suggested as a more sensitive method to identify changes in cardiac repolarization. We examined the effect of a major and rapid weight loss on T-wave morphology. METHODS AND RESULTS Twenty-six individuals had electrocardiograms (ECG) taken before and after eight weeks of weight loss intervention along with plasma measurements of fasting glucose, HbA1c, and potassium. For assessment of cardiac repolarization changes, T-wave Morphology Combination Score (MCS) and ECG intervals: RR, PR, QT, QTcF (Fridericia-corrected QT-interval), and QRS duration were derived. The participants lost on average 13.4% of their bodyweight. MCS, QRS, and RR intervals increased at week 8 (p<0.01), while QTcF and PR intervals were unaffected. Fasting plasma glucose (p<0.001) and HbA1c both decreased at week 8 (p<10(-5)), while plasma potassium was unchanged. MCS but not QTcF was negatively correlated with HbA1c (p<0.001) and fasting plasma glucose (p<0.01). CONCLUSION Rapid weight loss induces changes in cardiac repolarization. Monitoring of MCS during calorie restriction makes it possible to detect repolarization changes with higher discriminative power than the QT-interval during major rapid weight loss interventions. MCS was correlated with decreased HbA1c. Thus, sustained low blood glucose levels may contribute to repolarization changes.
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Affiliation(s)
- Esben Vedel-Larsen
- Laboratory of Experimental Cardiology, Departtment of Biomedical Sciences, University of Copenhagen, Denmark; Danish National Research Foundation Centre for Cardiac Arrhythmia, Denmark; Department of Clinical Neurophysiology, Glostrup Hospital, Denmark
| | - Eva Winning Iepsen
- NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark; Endocrinology Research Section, Department of Biomedical Sciences, University of Copenhagen, Denmark
| | - Julie Lundgren
- NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark; Endocrinology Research Section, Department of Biomedical Sciences, University of Copenhagen, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Denmark
| | - Johannes J Struijk
- Department of Health Science and Technology, Aalborg University, Denmark
| | - Torben Hansen
- NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Jens Juul Holst
- NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark; Endocrinology Research Section, Department of Biomedical Sciences, University of Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, Denmark
| | - Signe Torekov
- NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark; Endocrinology Research Section, Department of Biomedical Sciences, University of Copenhagen, Denmark
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Departtment of Biomedical Sciences, University of Copenhagen, Denmark.
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LIANG WEIJIE, CHEN JINGFU, MO LIQIU, KE XIAO, ZHANG WENZHU, ZHENG DONGDAN, PAN WANYING, WU SHAOYUN, FENG JIANQIANG, SONG MINGCAI, LIAO XINXUE. ATP-sensitive K+ channels contribute to the protective effects of exogenous hydrogen sulfide against high glucose-induced injury in H9c2 cardiac cells. Int J Mol Med 2016; 37:763-72. [DOI: 10.3892/ijmm.2016.2467] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 01/15/2016] [Indexed: 11/06/2022] Open
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Tse G, Lai ETH, Tse V, Yeo JM. Molecular and Electrophysiological Mechanisms Underlying Cardiac Arrhythmogenesis in Diabetes Mellitus. J Diabetes Res 2016; 2016:2848759. [PMID: 27642609 PMCID: PMC5011530 DOI: 10.1155/2016/2848759] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 04/28/2016] [Indexed: 01/11/2023] Open
Abstract
Diabetes is a common endocrine disorder with an ever increasing prevalence globally, placing significant burdens on our healthcare systems. It is associated with significant cardiovascular morbidities. One of the mechanisms by which it causes death is increasing the risk of cardiac arrhythmias. The aim of this article is to review the cardiac (ion channel abnormalities, electrophysiological and structural remodelling) and extracardiac factors (neural pathway remodelling) responsible for cardiac arrhythmogenesis in diabetes. It is concluded by an outline of molecular targets for future antiarrhythmic therapy for the diabetic population.
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Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
- *Gary Tse:
| | - Eric Tsz Him Lai
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Vivian Tse
- Department of Physiology, McGill University, Montreal, QC, Canada H3G 1Y6
| | - Jie Ming Yeo
- School of Medicine, Imperial College London, London SW7 2AZ, UK
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Agarwal R, Jurney P, Raythatha M, Singh V, Sreenivasan SV, Shi L, Roy K. Effect of shape, size, and aspect ratio on nanoparticle penetration and distribution inside solid tissues using 3D spheroid models. Adv Healthc Mater 2015; 4:2269-80. [PMID: 26376024 DOI: 10.1002/adhm.201500441] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 07/30/2015] [Indexed: 12/12/2022]
Abstract
Efficient penetration and uniform distribution of nanoparticles (NPs) inside solid tissues and tumors is paramount to their therapeutic and diagnostic success. While many studies have reported the effect of NP size and charge on intratissue distribution, role of shape, and aspect ratio on NP transport inside solid tissues remain unclear. Here experimental and theoretical studies are reported on how nanoscale geometry of Jet and Flash Imprint Lithography-fabricated, polyethylene-glycol-based anionic nanohydrogels affect their penetration and distribution inside 3D spheroids, a model representing the intervascular region of solid, tumor-like tissues. Unexpectedly, low aspect ratio cylindrical NPs (H/D ≈0.3; disk-like particles, 100 nm height, and 325 nm diameter) show maximal intratissue delivery (>50% increase in total cargo delivered) and more uniform penetration compared to nanorods or smaller NPs of the same shape. This is in contrast to spherical NPs where smaller NP size resulted in deeper, more uniform penetration. Our results provide fundamental new knowledge on NP transport inside solid tissues and further establish shape and aspect ratio as important design parameters in developing more efficient, better penetrating, nanocarriers for drug, or contrast-agent delivery.
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Affiliation(s)
- Rachit Agarwal
- The Woodruff School of Mechanical Engineering; Georgia Institute of Technology; Atlanta GA 30332 USA
| | - Patrick Jurney
- Department of Mechanical EngineeringThe University of Texas at Austin; Austin TX 78712 USA
| | - Mansi Raythatha
- Department of Biomedical Engineering; The University of Texas at Austin; Austin TX 78712 USA
| | - Vikramjit Singh
- Department of Mechanical EngineeringThe University of Texas at Austin; Austin TX 78712 USA
| | | | - Li Shi
- Department of Mechanical EngineeringThe University of Texas at Austin; Austin TX 78712 USA
| | - Krishnendu Roy
- The Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University; Georgia Institute of Technology; Atlanta GA 30332 USA
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Zaccardi F, Webb DR, Kurl S, Khunti K, Davies MJ, Laukkanen JA. Inverse association between fasting plasma glucose and risk of ventricular arrhythmias. Diabetologia 2015; 58:1797-802. [PMID: 26032023 DOI: 10.1007/s00125-015-3646-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/13/2015] [Indexed: 12/25/2022]
Abstract
AIMS/HYPOTHESIS In nondiabetic individuals, low values of fasting plasma glucose (FPG) have been associated with an increased risk of cardiovascular events. Identification of the potential mechanisms behind this association could help to elucidate the relationship between glycaemia and cardiovascular disease. We aimed to determine the association between FPG and ventricular arrhythmias. METHODS FPG and other cardiometabolic risk factors were measured in a population-based cohort of 2,482 men without a known history of type 2 diabetes mellitus at baseline. Associations between FPG levels and incident cases of ventricular arrhythmias (ventricular tachycardia or fibrillation events ascertained using the National Hospital Discharge Register) were estimated using Cox regression analysis adjusted for potential confounders. RESULTS During a median follow-up of 23.3 (interquartile range 18.5-25.3) years, 74 (2.9%) incident events were recorded. In a multivariable analysis adjusted for age, systolic BP, smoking status, LDL- and HDL-cholesterol, and C-reactive protein, the HR for ventricular arrhythmia per 1 mmol/l higher baseline FPG was 0.58 (95% CI 0.34, 0.98); this estimate did not materially change after further adjustment for BMI, alcohol consumption, triacylglycerols and history of ischaemic heart disease (0.50 [95% CI 0.28, 0.89]). CONCLUSIONS/INTERPRETATION In this nondiabetic male population, FPG was inversely associated with incident risk of ventricular arrhythmias. While our results could help clarify the relationship between low glucose levels and cardiovascular risk, further studies are required to confirm these findings in other populations.
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Affiliation(s)
- Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, LE5 4PW, UK,
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Ouyang Z, Cao W, Zhu S, Liu X, Zhong Z, Lai X, Xiao C, Jiang S, Wang Y. Protective effect of 2-deoxy-D-glucose on the cytotoxicity of cyclosporin A in vitro. Mol Med Rep 2015; 12:2814-20. [PMID: 25976221 DOI: 10.3892/mmr.2015.3777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 02/17/2015] [Indexed: 11/05/2022] Open
Abstract
The present study aimed to investigate the mechanism underlying the protective effect of 2-deoxy-D-glucose (2-DG) on the cytotoxicity of cyclosporin A (CsA) in vitro using NRK-52E cells. Staining with Hoechst 33342/propidium iodide prior to flow cytometric analysis was performed to assess the rate of cellular apoptosis and necrosis induced by CsA. The expression levels of lactate dehydrogenase (LDH), caspase 3, receptor-interacting protein kinase 3 (RIP3), reactive oxygen species (ROS), glutathione (GSH) and malondialdehyde (MDA) were detected using colorimetry, ELISA, western blotting or flow cytometric analysis to determine the protective effects of 2-DG on CsA-induced cell death. The results demonstrated that 2-DG inhibited the release of LDH, the activation of caspase 3 and the generation of ROS induced by CsA, but had no effect on the expression of RIP3. Treatment with 2-DG increased the expression of GSH and decreased the expression of MDA in dose-dependent manner, and reduced the rate of the cellular apoptosis and necrosis induced by CsA. Therefore, 2-DG inhibited CsA-induced cellular apoptosis and necrosis, possibly by reducing the production of ROS. Inhibiting the activation of caspase 3 is one of the protective mechanisms of 2-DG, however, the expression of RIP3 remained unaltered following treatment with 2-DG. Whether 2-DG inhibits the CsA-induced necrosis and apoptosis by inhibiting the RIP3 signaling pathway remains to be elucidated.
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Affiliation(s)
- Zizhang Ouyang
- Department of Pharmacy, Renmin Hospital of Qingyuan, The Fifth Affiliated Hospital of Jinan University, Qingyuan, Guangdong 511515, P.R. China
| | - Weiwei Cao
- Department of Pharmacy, Renmin Hospital of Qingyuan, The Fifth Affiliated Hospital of Jinan University, Qingyuan, Guangdong 511515, P.R. China
| | - Shaohua Zhu
- Department of Pharmacy, School of Pharmaceutical Sciences, Sun Yat‑sen University, Guangzhou, Guangdong 510006, P.R. China
| | - Xiaoping Liu
- Department of Pharmacy, Renmin Hospital of Qingyuan, The Fifth Affiliated Hospital of Jinan University, Qingyuan, Guangdong 511515, P.R. China
| | - Zhihua Zhong
- Department of Pharmacy, Renmin Hospital of Qingyuan, The Fifth Affiliated Hospital of Jinan University, Qingyuan, Guangdong 511515, P.R. China
| | - Xiangmao Lai
- Department of Pharmacy, Renmin Hospital of Qingyuan, The Fifth Affiliated Hospital of Jinan University, Qingyuan, Guangdong 511515, P.R. China
| | - Chengyin Xiao
- Department of Pharmacy, Renmin Hospital of Qingyuan, The Fifth Affiliated Hospital of Jinan University, Qingyuan, Guangdong 511515, P.R. China
| | - Sheng Jiang
- Department of Pharmacy, Renmin Hospital of Qingyuan, The Fifth Affiliated Hospital of Jinan University, Qingyuan, Guangdong 511515, P.R. China
| | - Yan Wang
- Department of Pharmacy, Renmin Hospital of Yichang, First College of Clinical Medicine, China Three Gorges University, Yichang, Hubei 443003, P.R. China
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Heller S, Darpö B, Mitchell MI, Linnebjerg H, Leishman DJ, Mehrotra N, Zhu H, Koerner J, Fiszman ML, Balakrishnan S, Xiao S, Todaro TG, Hensley I, Guth BD, Michelson EL, Sager P. Considerations for assessing the potential effects of antidiabetes drugs on cardiac ventricular repolarization: A report from the Cardiac Safety Research Consortium. Am Heart J 2015; 170:23-35. [PMID: 26093861 DOI: 10.1016/j.ahj.2015.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Abstract
Thorough QT studies conducted according to the International Council on Harmonisation E14 guideline are required for new nonantiarrhythmic drugs to assess the potential to prolong ventricular repolarization. Special considerations may be needed for conducting such studies with antidiabetes drugs as changes in blood glucose and other physiologic parameters affected by antidiabetes drugs may prolong the QT interval and thus confound QT/corrected QT assessments. This review discusses potential mechanisms for QT/corrected QT interval prolongation with antidiabetes drugs and offers practical considerations for assessing antidiabetes drugs in thorough QT studies. This article represents collaborative discussions among key stakeholders from academia, industry, and regulatory agencies participating in the Cardiac Safety Research Consortium. It does not represent regulatory policy.
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Shahreyar M, Mupiddi V, Choudhuri I, Sra J, Tajik AJ, Jahangir A. Implantable cardioverter defibrillators in diabetics: efficacy and safety in patients at risk of sudden cardiac death. Expert Rev Cardiovasc Ther 2015; 13:897-906. [PMID: 26098816 DOI: 10.1586/14779072.2015.1059276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Diabetes mellitus is a major risk factor for arrhythmogenesis and is associated with a two-fold increase in all-cause mortality and a four-fold increase in cardiovascular mortality including sudden cardiac death when compared with nondiabetics. Implantable cardioverter defibrillators (ICD) have been shown to effectively reduce arrhythmic death and all-cause mortality in patients with severe myocardial dysfunction. With a high competing risk of nonarrhythmic cardiac and noncardiac death, survival benefit of ICD in patients with diabetes mellitus could be reduced, but the subanalysis of diabetic patients in randomized clinical trials provides reassurance regarding a similar beneficial survival effect of ICD and cardiac resynchronization therapy in diabetics, as observed in the overall population with advanced heart disease. In this article, the authors highlight some of the clinical issues related to diabetes, summarize the data on the efficacy of ICD in diabetics when compared with nondiabetics and discuss concerns related to ICD implantation in patients with diabetes.
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Affiliation(s)
- Muhammad Shahreyar
- Sheikh Khalifa bin Hamad Al Thani Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora University of Wisconsin Medical Group, Milwaukee, WI, USA
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Abstract
BACKGROUND The QT interval on an electrocardiogram represents ventricular repolarization time. Increased length of this interval, known as corrected QT (QTc) prolongation, can be a precursor to torsade de pointes, a potentially life-threatening ventricular dysrhythmia. An association exists between blood glucose and QTc interval in ambulatory populations. Because both hyperglycemia and QTc prolongation are common in critically ill patients, we sought to examine the relationship between blood glucose, QTc interval prolongation, and all-cause mortality in critically ill patients. METHODS We studied adult patients admitted to cardiac monitoring units. Blood glucose and other clinical variables were abstracted from the medical record. Corrected QT measurements were automatically derived from continuous bedside cardiac monitoring systems. RESULTS Twenty-five percent (233/940) of the patients had QTc prolongation, and 53% had elevated blood glucose (>140 mg/dL) during hospitalization. Adjusted odds for QTc prolongation were 2.1 (95% confidence interval, 1.5-3.1) for moderately elevated blood glucose (140-180 mg/dL) and 3.7 (95% confidence interval, 2.5-5.4) for severely elevated blood glucose (>180 mg/dL). Mortality rate was highest (16%) in patients experiencing both severely elevated blood glucose (>180 mg/dL) and QTc interval prolongation. CONCLUSIONS Hyperglycemia is linked with QTc prolongation, and both are associated with increased odds of mortality in critically ill patients. Further studies are needed to extrapolate the relationship between glucose and ventricular repolarization, as well as appropriate glucose control parameters and QTc interval monitoring in critical care units.
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Chishaki A, Chishaki H. Postoperative high blood glucose – a potentially treatable marker related to atrial fibrillation after coronary artery bypass grafting. Circ J 2014; 79:45-6. [PMID: 25482385 DOI: 10.1253/circj.cj-14-1277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akiko Chishaki
- Department of Health Sciences, Faculty of Medicine, Kyushu University
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Tatsuishi W, Adachi H, Murata M, Tomono J, Okonogi S, Okada S, Hasegawa Y, Ezure M, Kaneko T, Ohshima S. Postoperative hyperglycemia and atrial fibrillation after coronary artery bypass graft surgery. Circ J 2014; 79:112-8. [PMID: 25392072 DOI: 10.1253/circj.cj-14-0989] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation (AF) is a common complication following coronary artery bypass grafting (CABG). We investigated the risk factors for postoperative AF and analyzed the relationship between blood sugar concentration (BS) and AF after CABG. METHODS AND RESULTS A total of 199 consecutive patients who underwent isolated CABG were retrospectively examined and classified according to the presence (n=95) or absence (n=104) of postoperative AF. On univariate analysis mean postoperative BS (P<0.001), postoperative drainage volume (P<0.001), age (P=0.034), presence of diabetes mellitus (DM; P=0.004), and postoperative estimated glomerular filtration rate (P=0.032) were significant risk factors for postoperative AF. On multivariate analysis mean postoperative BS (OR, 1.041; 95% CI: 1.008-1.079; P<0.001), postoperative drainage volume (OR, 1.003; 95% CI: 1.001-1.006; P=0.001), and age (OR, 1.040; 95% CI: 1.002-1.083; P=0.041) were significant risk factors for postoperative AF. Postoperative AF often occurred in patients with high postoperative BS, irrespective of DM. The BS cut-off that predicted postoperative AF occurrence was 180 mg/dl. A strong positive correlation existed between the time of the maximum postoperative BS and AF onset time (ρ=0.746). CONCLUSIONS Mean postoperative BS and postoperative drainage volume are risk factors for AF after CABG. AF was strongly associated with maximum postoperative BS. Intensive glycemic control could reduce AF occurrence after CABG.
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Affiliation(s)
- Wataru Tatsuishi
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Medical Center East, Tokyo; Department of Cardiovascular Surgery, Gunma Prefectural Cardiovascular Center, Maebashi, Japan.
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47
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Abstract
SIGNIFICANCE Voltage-gated K+ channels are a large family of K+-selective ion channel protein complexes that open on membrane depolarization. These K+ channels are expressed in diverse tissues and their function is vital for numerous physiological processes, in particular of neurons and muscle cells. Potentially reversible oxidative regulation of voltage-gated K+ channels by reactive species such as reactive oxygen species (ROS) represents a contributing mechanism of normal cellular plasticity and may play important roles in diverse pathologies including neurodegenerative diseases. RECENT ADVANCES Studies using various protocols of oxidative modification, site-directed mutagenesis, and structural and kinetic modeling provide a broader phenomenology and emerging mechanistic insights. CRITICAL ISSUES Physicochemical mechanisms of the functional consequences of oxidative modifications of voltage-gated K+ channels are only beginning to be revealed. In vivo documentation of oxidative modifications of specific amino-acid residues of various voltage-gated K+ channel proteins, including the target specificity issue, is largely absent. FUTURE DIRECTIONS High-resolution chemical and proteomic analysis of ion channel proteins with respect to oxidative modification combined with ongoing studies on channel structure and function will provide a better understanding of how the function of voltage-gated K+ channels is tuned by ROS and the corresponding reducing enzymes to meet cellular needs.
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Affiliation(s)
- Nirakar Sahoo
- 1 Department of Biophysics, Center for Molecular Biomedicine, Friedrich Schiller University Jena and Jena University Hospital , Jena, Germany
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48
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Chow E, Bernjak A, Williams S, Fawdry RA, Hibbert S, Freeman J, Sheridan PJ, Heller SR. Risk of cardiac arrhythmias during hypoglycemia in patients with type 2 diabetes and cardiovascular risk. Diabetes 2014; 63:1738-47. [PMID: 24757202 DOI: 10.2337/db13-0468] [Citation(s) in RCA: 273] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Recent trials of intensive glycemic control suggest a possible link between hypoglycemia and excess cardiovascular mortality in patients with type 2 diabetes. Hypoglycemia might cause arrhythmias through effects on cardiac repolarization and changes in cardiac autonomic activity. Our aim was to study the risk of arrhythmias during spontaneous hypoglycemia in type 2 diabetic patients with cardiovascular risk. Twenty-five insulin-treated patients with type 2 diabetes and a history of cardiovascular disease or two or more risk factors underwent simultaneous continuous interstitial glucose and ambulatory electrocardiogram monitoring. Frequency of arrhythmias, heart rate variability, and markers of cardiac repolarization were compared between hypoglycemia and euglycemia and between hyperglycemia and euglycemia matched for time of day. There were 134 h of recording at hypoglycemia, 65 h at hyperglycemia, and 1,258 h at euglycemia. Bradycardia and atrial and ventricular ectopic counts were significantly higher during nocturnal hypoglycemia compared with euglycemia. Arrhythmias were more frequent during nocturnal versus daytime hypoglycemia. Excessive compensatory vagal activation after the counterregulatory phase may account for bradycardia and associated arrhythmias. QT intervals, corrected for heart rate, >500 ms and abnormal T-wave morphology were observed during hypoglycemia in some participants. Hypoglycemia, frequently asymptomatic and prolonged, may increase the risk of arrhythmias in patients with type 2 diabetes and high cardiovascular risk. This is a plausible mechanism that could contribute to increased cardiovascular mortality during intensive glycemic therapy.
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Affiliation(s)
- Elaine Chow
- Department of Cardiovascular Science, University of Sheffield, Sheffield, U.K
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49
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Nordin C. The proarrhythmic effect of hypoglycemia: evidence for increased risk from ischemia and bradycardia. Acta Diabetol 2014; 51:5-14. [PMID: 24212718 DOI: 10.1007/s00592-013-0528-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/24/2013] [Indexed: 12/13/2022]
Abstract
Hypoglycemia increases the risk for both overall and sudden death. At a cellular level, hypoglycemia causes alterations in the physiology of myocardial tissue that are identical to proarrhythmic medications. Reduced serum glucose blocks the repolarizing K(+) channel HERG, which leads to action potential and QT prolongation and is uniformly associated with risk for torsades de pointes ventricular tachycardia. The sympathetic response induced by hypoglycemia also increases the risk of arrhythmias from Ca(2+) overload, which occur with sympathomimetic medications and excessive beta adrenergic stimulation. Thus, hypoglycemia can be considered a proarrhythmic event. This review focuses on emerging evidence for two other important changes induced by hypoglycemia that promote arrhythmias: ischemia and bradycardia. Studies of patients with "insulin shock" therapy from the early twentieth century and other more recent data strongly suggest that hypoglycemia can cause ischemia of myocardial tissue, both in association with coronary artery obstructions and by cellular mechanisms. Ischemia induces multiple proarrhythmic responses. Since ischemia itself reduces the possibility of using energy substrates other than glucose, hypoglycemia may generate positive feedback for electrophyisologic destabilization. Recent studies also show that hypoglycemia can cause bradycardia and heart block. Bradycardia is known to cause action potential prolongation and potentiate the development of torsades de pointes, particularly with low-serum K(+) which can be induced by hypoglycemic episodes. Thus, hypoglycemia-induced bradycardia may also create a dynamic, positive feedback for the development of arrhythmias and sudden death. These studies further support the hypothesis that hypoglycemia is a proarrhythmic event.
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Affiliation(s)
- Charles Nordin
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA,
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50
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Zhang P, Guan P, Bai XL, Song ZP. New aspects of HERG K⁺ channel function depending upon cardiac spatial heterogeneity. PLoS One 2014; 9:e72181. [PMID: 24475014 PMCID: PMC3903466 DOI: 10.1371/journal.pone.0072181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 07/07/2013] [Indexed: 11/18/2022] Open
Abstract
HERG K+ channel, the genetic counterpart of rapid delayed rectifier K+ current in cardiac cells, is responsible for many cases of inherited and drug-induced long QT syndromes. HERG has unusual biophysical properties distinct from those of other K+ channels. While the conventional pulse protocols in patch-clamp studies have helped us elucidate these properties, their limitations in assessing HERG function have also been progressively noticed. We employed AP-clamp techniques using physiological action potential waveforms recorded from various regions of canine heart to study HERG function in HEK293 cells and identified several novel aspects of HERG function. We showed that under AP-clamp IHERG increased gradually with membrane repolarization, peaked at potentials around 20–30 mV more negative than revealed by pulse protocols and at action potential duration (APD) to 60%-70% full repolarization, and fell rapidly at the terminal phase of repolarization. We found that the rising phase of IHERG was conferred by removal of inactivation and the decaying phase resulted from a fall in driving force, which were all determined by the rate of membrane repolarization. We identified regional heterogeneity and transmural gradient of IHERG when quantified with the area covered by IHERG trace. In addition, we observed regional and transmural differences of IHERG in response to dofetilide blockade. Finally, we characterized the influence of HERG function by selective inhibition of other ion currents. Based on our results, we conclude that the distinct biophysical properties of HERG reported by AP-clamp confer its unique function in cardiac repolarization thereby in antiarrhythmia and arrhythmogenesis.
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Affiliation(s)
- Pen Zhang
- Department of Cardiology, Minhang Central Hospital, Shanghai, China
| | - Ping Guan
- Department of Cardiology, Minhang Central Hospital, Shanghai, China
| | - Xiao-Lu Bai
- Department of Cardiology, Minhang Central Hospital, Shanghai, China
| | - Zhi-Ping Song
- Department of Cardiology, Minhang Central Hospital, Shanghai, China
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