Effects of verapamil on atrial fibrillation and its electrophysiological determinants in dogs

Background: Atrial tachycardia-induced remodeling promotes the occurrence and maintenance of atrial fibrillation (AF) and decreases L-type Ca2+ current. There is also a clinical suggestion that acute L-type Ca2 channel blockade can promote AF, consistent with an AF promoting effect of Ca2+ channel inhibition. Methods: To evaluate the potential mechanisms of AF promotion by Ca2+ channel blockers, we administered verapamil to morphine-chloralose anesthetized dogs. Diltiazem was used as a comparison drug and autonomic blockade with atropine and nadolol was applied in some experiments. Epicardial mapping with 240 epicardial electrodes was used to evaluate activation during AF. Results: Verapamil caused AF promotion in six dogs, increasing mean duration of AF induced by burst pacing, from 8±4 s (mean±S.E.) to 95±39 s (P<0.01 vs. control) at a loading dose of 0.1 mg/kg and 228±101 s (P<0.0005 vs. control) at a dose of 0.2 mg/kg. Underlying electrophysiological mechanisms were studied in detail in five additional dogs under control conditions and in the presence of the higher dose of verapamil. In these experiments, verapamil shortened mean effective refractory period (ERP) from 122±5 to 114±4 ms (P<0.02) at a cycle length of 300 ms, decreased ERP heterogeneity (from 15±1 to 10±1%, P<0.05), heterogeneously accelerated atrial conduction and decreased the cycle length of AF (94±4 to 84±3 ms, P<0.005). Diltiazem did not affect ERP, AF cycle length or AF duration, but produced conduction acceleration similar to that caused by verapamil (n = 5). In the presence of autonomic blockade, verapamil failed to promote AF and increased, rather than decreasing, refractoriness. Neither verapamil nor diltiazem affected atrial conduction in the presence of autonomic blockade. Epicardial mapping suggested that verapamil promoted AF by increasing the number of simultaneous wavefronts reflected by separate zones of reactivation in each cycle. Conclusions: Verapamil promotes AF in normal dogs by promoting multiple circuit reentry, an effect dependent on intact autonomic tone and not shared by diltiaze

Idiopathic atrial fibrillation in dogs: Electrophysiologic determinants and mechanisms of antiarrhythmic action of flecainide

Objectives.This study sought to determine the mechanisms of idiopathic atrial fibrillation and the atrial antifibrillatory action of flecainide in dogs.Background.In a small subset of dogs, sustained atrial fibrillation can be readily induced in the absence of vagal tone. The electrophysiologic mechanisms underlying this ability to sustain atrial fibrillation, and of flecainide action on the arrhythmia, are unknown.Methods.Six dogs with inducible sustained atrial fibrillation were studied before and after flecainide administration and compared with a control group of 10 dogs.Results.Dogs with atrial fibrillation differed in displaying more shortening of the atrial refractory period with increased rate, resulting in a significantly shorter refractory period and wavelength for reentry at rapid rates, and in increased regional dispersion in refractoriness. Activation maps during sustained fibrillation showed a mean (± SE) of 6.3 ± 0.4 coexistent zones of reentry, compatible with short wavelengths, whereas in control dogs activation during self-limited atrial fibrillation was better organized, and the number of reentrant circuits was smaller. Quantitative analysis demonstrated significantly greater inhomogeneity of activation during atrial fibrillation in dogs with atrial fibrillation than in control animals. Flecainide terminated atrial fibrillation by increasing the duration and homogeneity of atrial refractoriness at rapid rates, thereby reducing the number of reentry circuits and the heterogeneity of activation.Conclusions.The ability of atrial fibrillation to sustain itself resulted from enhanced rate-dependent shortening of atrial refractoriness and increased regional heterogeneity. Flecainide reversed these changes and restored sinus rhythm. These results suggest potential mechanisms of idiopathic atrial fibrillation and are pertinent to understanding the clinical actions of flecainide

Differential efficacy of L- and T-type calcium channel blockers in preventing tachycardia-induced atrial remodeling in dogs

Background: Tachycardia-induced remodeling likely plays an important role in atrial fibrillation (AF) maintenance and recurrence after cardioversion, and Ca2+ overload may be an important mediator. This study was designed to evaluate the relative efficacies of selective T-type (mibefradil) and L-type (diltiazem) Ca2+-channel blockers in preventing tachycardia-induced atrial remodeling. Methods: Dogs were given daily doses of mibefradil (100 mg), diltiazem (240 mg) or placebo in a blinded fashion, beginning 4 days before and continuing through a 7-day period of atrial pacing at 400 bpm. An electrophysiological study was then performed to assess changes in refractoriness, refractoriness heterogeneity and AF duration. Results: Mean duration of burst-pacing induced AF was similar in placebo (567±203 s) and diltiazem-treated (963±280 s, P = NS) animals, but was much less in mibefradil-treated dogs (3.6±0.9 s, P<0.002) and non-paced controls (6.6±2.7 s). In contrast to mibefradil, diltiazem did not alter tachycardia-induced refractoriness abbreviation or heterogeneity. To exclude inadequate dosing as an explanation for diltiazem's inefficacy, we studied an additional group of dogs treated with 720 mg/day of diltiazem, and again noted no protective effect. Acute intravenous administration of diltiazem to control dogs failed to alter atrial refractoriness or AF duration, excluding a masking of remodeling suppression by offsetting profibrillatory effects of the drug. Conclusions: Whereas the selective T-type Ca2+-channel blocker mibefradil protects against atrial remodeling caused by 7-day atrial tachycardia, the selective L-type blocker diltiazem is without effect. These findings are potentially important for understanding the mechanisms and prevention of clinically-relevant atrial-tachycardia-induced remodelin

Atrial-Selective Approaches for the Treatment of Atrial Fibrillation

Atrial-selective pharmacologic approaches represent promising novel therapeutic options for the treatment of atrial fibrillation (AF). Medical treatment for AF is still more widely applied than interventional therapies but is hampered by several important weaknesses. Besides limited clinical efficacy (cardioversion success and sinus-rhythm maintenance), side effects like ventricular proarrhythmia and negative inotropy are important limitations to present class I and III drug therapy. Although no statistically significant detrimental survival consequences have been documented in trials, constitutional adverse effects might also limit applicability. Cardiac targets for novel atrial-selective antiarrhythmic compounds have been identified, and a large-scale search for safe and effective medications has begun. Several ionic currents (IKACh, IKur) and connexins (Cx-40) are potential targets, because atrial-selective expression makes them attractive in terms of reduced ventricular side-effect liability. Data on most agents are still experimental, but some clinical findings are available. Atrial fibrillation generates a specifically remodeled atrial milieu for which other therapeutic interventions might be effective. Some drugs show frequency-dependent action, whereas others target structurally remodeled atria. This review focuses on potential atrial-selective compounds, summarizing mechanisms of action in vitro and in vivo. It also mentions favorable interventions on the milieu in terms of conventional (such as antifibrotic effects of angiotensin-system antagonism) and innovative gene-therapy approaches that might add to future AF therapeutic options

The classification and analysis of terrace houses and the rationalization of their design process

Thesis (M. Arch.)--Massachusetts Institute of Technology, Dept. of Architecture, 1979.MICROFICHE COPY AVAILABLE IN ARCHIVES AND ROTCH.Includes bibliographical references.This study was done in relation to contextual levels; A general level of structural-methodical rationalization problems of the planning and design process. This general level was related mainly to the building types which respond to extreme external conditions (such as topography,climate or social economic conditions) The specific level of terrace houses as an example of buildings of that kind and their adaptation process and mechanisms to the external conditions as rational, systematic development process. The S.A.R. approach serves as a background reference for this study. Some proposals were made to adopt the S.A.R design methodology in the case of terrace houses. The 'Morphogical Box' method which was developed by F. Zwicky for the systematic generation of alternative planning solutions was modified and applied in the classification and analysis purposes as well as in structuring the planning and design process to accommodate different external conditions and changing design objectives. These two systematic approaches were applied in the proposals for the rationalization of terrace houses.by Gabriel M. Nattel.M.Arch

Role of the Autonomic Nervous System in Atrial Fibrillation: Pathophysiology and Therapy

Autonomic nervous system activation can induce significant and heterogeneous changes of atrial electrophysiology and induce atrial tachyarrhythmias, including atrial tachycardia (AT) and atrial fibrillation (AF). The importance of the autonomic nervous system in atrial arrhythmogenesis is also supported by circadian variation in the incidence of symptomatic AF in humans. Methods that reduce autonomic innervation or outflow have been shown to reduce the incidence of spontaneous or induced atrial arrhythmias, suggesting that neuromodulation may be helpful in controlling AF. In this review we focus on the relationship between the autonomic nervous system and the pathophysiology of AF, and the potential benefit and limitations of neuromodulation in the management of this arrhythmia. We conclude that autonomic nerve activity plays an important role in the initiation and maintenance of AF, and modulating autonomic nerve function may contribute to AF control. Potential therapeutic applications include ganglionated plexus ablation, renal sympathetic denervation, cervical vagal nerve stimulation, baroreflex stimulation, cutaneous stimulation, novel drug approaches and biological therapies. While the role of the autonomic nervous system has long been recognized, new science and new technologies promise exciting prospects for the future

Electrophysiological effects of 5-hydroxytryptamine on isolated human atrial myocytes, and the influence of chronic beta-adrenoceptor blockade

&lt;b&gt;1.&lt;/b&gt; 5-Hydroxytryptamine (5-HT) has been postulated to play a proarrhythmic role in the human atria via stimulation of 5-HT&lt;sub&gt;4&lt;/sub&gt; receptors. &lt;b&gt;2.&lt;/b&gt; The aims of this study were to examine the effects of 5-HT on the L-type Ca&lt;sup&gt;2+&lt;/sup&gt; current (&lt;i&gt;I&lt;/i&gt;&lt;sub&gt;CaL&lt;/sub&gt;) action potential duration (APD), the effective refractory period (ERP) and arrhythmic activity in human atrial cells, and to assess the effects of prior treatment with &#946;-adrenoceptor antagonists. &lt;b&gt;3.&lt;/b&gt; Isolated myocytes, from the right atrial appendage of 27 consenting patients undergoing cardiac surgery who were in sinus rhythm, were studied using the whole-cell perforated patch-clamp technique at 37&#186;C. &lt;b&gt;4.&lt;/b&gt; 5-HT (1 n-10 &#956;M) caused a concentration-dependent increase in &lt;i&gt;I&lt;/i&gt;&lt;sub&gt;CaL&lt;/sub&gt;, which was potentiated in cells from &#946;-blocked (maximum response to 5-HT, E&lt;sub&gt;max&lt;/sub&gt;=299&#177;12% increase above control) compared to non-&#946;-blocked patients (E&lt;sub&gt;max&lt;/sub&gt;=220&#177;6%, P&#60;0.05), but with no change in either the potency (log EC&lt;sub&gt;50&lt;/sub&gt;: -7.09&#177;0.07 vs -7.26&#177;0.06) or Hill coefficient (&lt;i&gt;n&lt;/i&gt;&lt;sub&gt;H&lt;/sub&gt;: 1.5&#177;0.6 vs 1.5&#177;0.3) of the 5-HT concentration-response curve. &lt;b&gt;5.&lt;/b&gt; 5-HT (10 &#956;M) produced a greater increase in the APD at 50% repolarisation (APD50) in cells from &#946;-blocked patients (of 37&#177;10 ms, i.e. 589&#177;197%) vs non-&#946;-blocked patients (of 10&#177;4 ms, i.e. 157&#177;54%; P&#60;0.05). Both the APD&lt;sub&gt;90&lt;/sub&gt; and the ERP were unaffected by 5-HT. &lt;b&gt;6.&lt;/b&gt; Arrhythmic activity was observed in response to 5-HT in five of 17 cells (29%) studied from &#946;-blocked, compared to zero of 16 cells from the non-&#946;-blocked patients (P&#60;0.05). &lt;b&gt;7.&lt;/b&gt; In summary, the 5-HT-induced increase in calcium current was associated with a prolonged early plateau phase of repolarisation, but not late repolarisation or refractoriness, and the enhancement of these effects by chronic &#946;-adrenoceptor blockade was associated with arrhythmic potential