The contribution of ionic currents to changes in refractoriness of human atrial myocytes associated with chronic atrial fibrillation

<b>Objective:</b> To investigate changes in human atrial single cell functional electrophysiological properties associated with chronic atrial fibrillation (AF), and the contribution to these of accompanying ion current changes. <b>Methods:</b> The whole cell patch clamp technique was used to record action potentials, the effective refractory period (ERP) and ion currents, in the absence and presence of drugs, in enzymatically isolated myocytes from 11 patients with chronic (<6 months) AF and 39 patients in sinus rhythm. <b>Results:</b> Stimulation at high rates (up to 600 beats/min) markedly shortened late repolarisation and the ERP in cells from patients in sinus rhythm, and depolarised the maximum diastolic potential (MDP). Chronic AF was associated with a reduction in the ERP at physiological rate (from 203±16 to 104±15 ms, P<0.05), and marked attenuation in rate effects on the ERP and repolarisation. The abbreviated terminal phase of repolarisation prevented fast rate-induced depolarisation of the MDP in cells from patients with AF. The density of L-type Ca<sup>2+</sup> (<i>I</i><sub>CaL</sub>) and transient outward K<sup>+</sup> (<i>I</i><sub>TO</sub>) currents was significantly reduced in cells from patients with AF (by 60–65%), whilst the inward rectifier K<sup>+</sup> current (IK1) was increased, and the sustained outward current (<i>I</i><sub>KSUS</sub>) was unaltered. Superfusion of cells from patients in sinus rhythm with nifedipine (10 micromol/l) moderately shortened repolarisation, but had no effect on the ERP (228±12 vs. 225±11 ms). 4-Aminopyridine (2 mmol/l) markedly prolonged repolarisation and the ERP (by 35%, P<0.05). However, the combination of these drugs had no effect on late repolarisation or refractoriness. <b>Conclusion:</b> Chronic AF in humans is associated with attenuation in adaptation of the atrial single cell ERP and MDP to fast rates, which may not be explained fully by accompanying changes in <i>I</i><sub>CaL</sub> and <i>I</i><sub>TO</sub>

A K_ATP channel opener inhibited myocardial reperfusion action potential shortening and arrhythmias

Low concentrations of certain K<sub>ATP</sub> channel openers have been reported to exert a moderate inhibitory effect on arrhythmias during post-ischaemic early myocardial reperfusion, but the accompanying effects on the time course of changes in action potentials in intact hearts have not yet been studied. We report that in rat isolated hearts, reperfusion following 10 min of regional no-flow ischaemia was associated with both an acute, marked, but transient, shortening of ventricular repolarisation (by 63%) during reperfusion, and a high incidence (90%) of ventricular tachyarrhythmias. The K<sub>ATP</sub> channel opener Ro 31-6930 [2-(6-cyano-2,2-dimethyl-2H-1-benzopyran-4-yl)-pyridine 1-oxide], delivered prior to ischaemia at a relatively low concentration (0.5 μM), significantly reduced the incidence and duration of reperfusion arrhythmias, and prevented the associated acute action potential shortening during reperfusion, each in a glibenclamide (1 μM)-sensitive manner (P<0.05, <i>n</i>=10–15 hearts). This was associated with a moderate and non-arrhythmogenic action potential shortening during ischaemia (a potentially “cardioprotective” effect). However, these data highlight the potential harm these drugs may cause, since a higher concentration of Ro 31-6930 caused marked shortening of action potentials and significant pro-arrhythmia during ischaemia

Characterisation of the Na, K pump current in atrial cells from patients with and without chronic atrial fibrillation

<b>Objective:</b> To assess the contribution of the Na, K pump current (<i>I</i><sub>p</sub>) to the action potential duration (APD) and effective refractory period (ERP) in human atrial cells, and to investigate whether <i>I</i><sub>p</sub> contributes to the changes in APD and ERP associated with chronic atrial fibrillation (AF). <b>Methods:</b> Action potentials and ion currents were recorded by whole-cell patch clamp in atrial myocytes isolated from consenting patients undergoing cardiac surgery, who were in sinus rhythm (SR) or AF (>3 months). <b>Results:</b> In cells from patients in SR, the <i>I</i><sub>p</sub> blocker, ouabain (10 μM) significantly depolarised the membrane potential, Vm, from -80±2 (mean±S.E.) to -73±2 mV, and lengthened both the APD (174±17 vs. 197±23 ms at 90% repolarisation) and ERP (198±22 vs. 266±14 ms; P<0.05 for each, Student's t-test, <i>n</i>=7 cells, 5 patients). With an elevated pipette [Na<sup>+</sup>] of 30 mM, <i>I</i><sub>p</sub> was measured by increasing extracellular [K<sup>+</sup>] ([K<sup>+</sup>]o) from 0 to 5.4 mM. This produced an outward shift in holding current at -40 mV, abolished by 10 muM ouabain. K± and ouabain-sensitive current densities were similar, at 0.99±0.13 and 1.12±0.11 pA/pF, respectively (P>0.05; <i>n</i>=9 cells), confirming the K±induced current as <i>I</i><sub>p</sub>. <i>I</i><sub>p</sub> increased linearly with increasing Vm between -120 and +60 mV (<i>n</i>=25 cells). Stepwise increments in [K<sup>+</sup>]<sub>o</sub> (between 0 and 10 mM) increased Ip in a concentration-dependent manner (maximum response, <i>E</i><sub>max</sub>=1.19±0.09 pA/pF; EC50=1.71±0.15 mM; n=27 cells, 9 patients). In cells from patients in AF, the sensitivity of Ip to both Vm and [K+]o (<i>E</i><sub>max</sub>=1.02±0.05 pA/pF, EC50=1.54±0.11 mM; <i>n</i>=44 cells, 9 patients) was not significantly different from that in cells from patients in SR. Within the group of patients in AF, long-term digoxin therapy (<i>n</i>=5 patients) was associated with a small, but significant, reduction in <i>E</i><sub>max</sub> (0.92±0.07 pA/pF) and EC<sub>50</sub> (1.35±0.15 mM) compared with non-treatment (<i>E</i><sub>max</sub>=1.13±0.08 pA/pF, EC<sub>50</sub>=1.76±0.14 mM; P<0.05 for each, <i>n</i>=4 patients). In cells from non-digoxin-treated patients in AF, the voltage- and [K<sup>+</sup>]<sub>o</sub>-sensitivity (<i>E</i><sub>max</sub> and EC<sub>50</sub>) were similar to those in cells from patients in SR. <b>Conclusions:</b> The Na, K pump current contributes to the human atrial cell Vm, action potential shape and ERP. However, the similarity in Ip sensitivity to both [K<sup>+</sup>]<sub>o</sub> and <i>V</i><sub>m</sub> between atrial cells from patients with and without chronic AF indicates that <i>I</i><sub>p</sub> is not involved in AF-induced electrophysiological remodelling in patients

Altered excitation-contraction coupling in human chronic atrial fibrillation

This review focuses on the (mal)adaptive processes in atrial excitation-contraction coupling occurring in patients with chronic atrial fibrillation. Cellular remodeling includes shortening of the atrial action potential duration and effective refractory period, depressed intracellular Ca<sup>2+</sup> transient, and reduced myocyte contractility. Here we summarize the current knowledge of the ionic bases underlying these changes. Understanding the molecular mechanisms of excitation-contraction-coupling remodeling in the fibrillating human atria is important to identify new potential targets for AF therapy

Ionic basis of a differential effect of adenosine on refractoriness in rabbit AV nodal and atrial isolated myocytes

Methods: The whole cell patch clamp technique was used to record action potentials and ion currents in AV nodal and left atrial myocytes isolated enzymatically from rabbit hearts. Results: Adenosine (10 μM) caused similar hyperpolarisation and shortening of the action potential duration (APD) in both cell types: maximum diastolic potential was hyperpolarised from –59±3 to –66±2 and from –70±2 to –76±2 mV (mean±SEM) and APD90 was shortened by 31±4 and 30±7% in AV nodal (n=14) and atrial cells (n=8), respectively. Adenosine shortened the effective refractory period (ERP) in atrial cells, from 124±15 to 98±14 ms (n=8). In contrast, ERP in AV nodal cells was not significantly affected (112±13 vs. 102±12 ms, n=14), and post-repolarisation refractoriness was prolonged. By contrast, current injection, to induce an equal degree of hyperpolarisation to that produced by adenosine, shortened APD and ERP in both cell types, suggesting an additional action of adenosine in AV nodal cells. Adenosine (10 μM) did not affect peak ICaL in AV nodal cells, but significantly altered the biexponential time course of recovery of ICaL from inactivation. The proportion of recovery in the fast phase (time constant, {tau}=102±10 ms) was reduced from 71±3 to 55±5%, with shift to the slow phase ({tau}=858±168 ms), without altering {tau} in either phase. A similar effect of adenosine was seen in left atrial cells. Conclusion: Adenosine caused hyperpolarisation, APD-shortening and slowing of recovery of ICaL from inactivation, in both AV nodal and atrial cells, but prolonged post-repolarisation refractoriness in AV nodal cells only. This differential effect of adenosine on refractoriness in the two cell types could not be explained by effects on IKAdo, but may be due to slowed reactivation of ICaL, which is the predominant inward current in AV nodal but not left atrial cells

Do K_ATP channels open as a prominent and early feature during ischaemia in the Langendorff-perfused rat heart?

The objective was to investigate whether myocardial adenosine triphosphate-sensitive K<sup>+</sup> (K<sub>ATP</sub>) channels open during the first 10 min of regional ischaemia in Langendorff-perfused rat hearts. Changes in monophasic action potentials and arrhythmias were studied during myocardial ischaemia in both the presence and absence of pharmacological K<sub>ATP</sub> modulation. Ligation of the left main coronary artery for 10 min did not shorten the action potential duration (APD). The APD<sub>50</sub> and APD<sub>80</sub> (15.5 +/- 1.0 and 38.1 +/- 2.3 ms, respectively [mean +/- S.E., n = 15 hearts], immediately prior to ligation) increased transiently during the first 4 min of ligation (by 160 and 79% respectively, P < 0.05), before returning to pre-ligation values, but without a significant below-baseline-shortening. The cardiac electrogram showed no accompanying ventricular tachyarrhythmia (VT). These results raised the possibility that the myocardial K<sub>ATP</sub> channels had not opened during the ligation. The K<sub>ATP</sub> opener Ro 31-6930 (0.5 and 5 microM) shortened the APD50 and APD80 during coronary ligation, to significantly below both their control and pre-occlusion values (P < 0.05), and caused a concentration-dependent increase in both the incidence and duration of VT during the ligation. Ro 31-6930 at 5 microM also shortened APD50 and APD80 even before ligation (by 50 and 62% respectively, P < 0.05), and abolished the normal APD-lengthening seen during ischaemia. The K<sub>ATP</sub> blocker glibenclamide (1 μM) abolished both the APD-shortening and pro-arrhythmic effects of the K<sub>ATP</sub> opener, both before and during coronary ligation, yet when delivered on its own, at the same concentration which abolished the effects of K<sub>ATP</sub> activation, it had no significant effect on the APD changes seen during the coronary ligation alone. These results suggest that, in Langendorff-perfused rat hearts in the absence of drugs, K<sub>ATP</sub> channels do not open during early myocardial ischaemia

Anti-adrenergic effects of endothelin on human atrial action potentials are potentially anti-arrhythmic

Endothelin-1 (ET-1) is elevated in patients with atrial fibrillation (AF) and heart failure. We investigated effects of ET-1 on human atrial cellular electrophysiological measurements expected to influence the genesis and maintenance of AF. Action potential characteristics and L-type Ca<sup>2+</sup> current (I<sub>CaL</sub>) were recorded by whole cell patch clamp, in atrial isolated myocytes obtained from patients in sinus rhythm. Isoproterenol (ISO) at 0.05 μM prolonged the action potential duration at 50% repolarisation (APD<sub>50</sub>: 54 ± 10 vs. 28 ± 5 ms; <i>P</i> < 0.05, <i>N</i> = 15 cells, 10 patients), but neither late repolarisation nor cellular effective refractory period (ERP) were affected. ET-1 (10 nM) reversed the effect of ISO on APD<sub>50</sub>, and had no basal effect (in the absence of ISO) on repolarisation or ERP. During repetitive stimulation, ISO (0.05 μM) produced arrhythmic depolarisations (<i>P</i> < 0.05). Each was abolished by ET-1 at 10 nM (<i>P</i> < 0.05). ISO (0.05 μM) increased peak I<sub>CaL</sub> from –5.5 ± 0.4 to –14.6 ± 0.9 pA/pF (P < 0.05; N = 79 cells, 34 patients). ET-1 (10 nM) reversed this effect by 98 ± 10% (P < 0.05), with no effect on basal I<sub>CaL</sub>. Chronic treatment of patients with a β-blocker did not significantly alter basal APD50 or I<sub>CaL</sub>, the increase in APD50 or I<sub>CaL</sub> by 0.05 μM ISO, nor the subsequent reversal of this effect on APD50 by 10 nM ET-1. The marked anti-adrenergic effects of ET-1 on human atrial cellular action potential plateau, arrhythmic depolarisations and I<sub>CaL</sub>, without affecting ERP and independently of β-blocker treatment, may be expected to contribute a potentially anti-arrhythmic influence in the atria of patients with AF and heart failure

Chronic beta-adrenoceptor blockade and human atrial cell electrophysiology: evidence of pharmacological remodelling

<b>Objective:</b> Chronic beta-adrenoceptor antagonist (β-blocker) treatment reduces the incidence of reversion to AF in patients, possibly via an adaptive myocardial response. However, the underlying electrophysiological mechanisms are presently unclear. We aimed to investigate electrophysiological changes in human atrial cells associated with chronic treatment with β-blockers and other cardiovascular-acting drugs. <b>Methods:</b> Myocytes were isolated enzymatically from the right atrial appendage of 40 consenting patients who were in sinus rhythm. The cellular action potential duration (APD), effective refractory period (ERP), L-type Ca<sup>2+</sup> current (<i>I</i><sub>CaL</sub>), transient (<i>I</i><sub>TO</sub>) and sustained (<i>I</i><sub>KSUS</sub>) outward K<sup>+</sup> currents, and input resistance (<i>R</i><sub>i</sub>) were recorded using the whole cell patch clamp. Drug treatments and clinical characteristics were compared with electrophysiological measurements using simple and multiple regression analyses. P<0.05 was taken as statistically significant. <b>Results:</b> In atrial cells from patients treated chronically with β-blockers, the APD<sub>90</sub> and ERP (75 beats/min stimulation) were significantly longer, at 213±11 and 233±11 ms, respectively (<i>n</i> = 15 patients), than in cells from non-β-blocked patients, at 176±12 and 184±12 ms (n = 11). These cells also displayed a significantly reduced action potential phase 1 velocity (22±3 vs. 34±3 V/s). Chronic β-blockade was also associated with a significant reduction in the heart rate (58±3 vs. 69±5 beats/min) and in the density of ITO (8.7±1.3 vs. 13.7±2.1 pA/pF), an increase in the Ri (214±24 vs. 132±14 MΩ), but no significant change in <i>I</i><sub>CaL</sub> or <i>I</i><sub>KSUS</sub>. The <i>I</i><sub>TO</sub> blocker 4-aminopyridine largely mimicked the changes in phase 1 and ERP associated with chronic β-blockade, in cells from non-β-blocked patients. Chronic treatment of patients with calcium channel blockers or angiotensin converting enzyme inhibitors (<i>n</i> = 11–13 patients) was not associated with any significant changes in atrial cell electrophysiology. <b>Conclusion:</b> The observed atrial cellular electrophysiological changes associated with chronic β-blockade are consistent with a long-term adaptive response, a type of ‘pharmacological remodelling’, and provide mechanistic evidence supportive of the anti-arrhythmic actions of β-blockade

Mechanisms of termination and prevention of atrial fibrillation by drug therapy

Atrial fibrillation (AF) is a disorder of the rhythm of electrical activation of the cardiac atria. It is the most common cardiac arrhythmia, has multiple aetiologies, and increases the risk of death from stroke. Pharmacological therapy is the mainstay of treatment for AF, but currently available anti-arrhythmic drugs have limited efficacy and safety. An improved understanding of how anti-arrhythmic drugs affect the electrophysiological mechanisms of AF initiation and maintenance, in the setting of the different cardiac diseases that predispose to AF, is therefore required. A variety of animal models of AF has been developed, to represent and control the pathophysiological causes and risk factors of AF, and to permit the measurement of detailed and invasive parameters relating to the associated electrophysiological mechanisms of AF. The purpose of this review is to examine, consolidate and compare available relevant data on in-vivo electrophysiological mechanisms of AF suppression by currently approved and investigational anti-arrhythmic drugs in such models. These include the Vaughan Williams class I–IV drugs, namely Na+ channel blockers, β-adrenoceptor antagonists, action potential prolonging drugs, and Ca2+ channel blockers; the “upstream therapies”, e.g., angiotensin converting enzyme inhibitors, statins and fish oils; and a variety of investigational drugs such as “atrial-selective” multiple ion channel blockers, gap junction-enhancers, and intracellular Ca2+-handling modulators. It is hoped that this will help to clarify the main electrophysiological mechanisms of action of different and related drug types in different disease settings, and the likely clinical significance and potential future exploitation of such mechanisms. Keywords: Atrial fibrillation; Cardiac arrhythmia mechanisms: reentry, afterdepolarisations; In-vivo animal models; Pathological electrical remodelling; Pharmacological treatment; Anti-arrhythmic drug mechanisms Abbreviations: ACE, angiotensin-converting enzyme; AF, atrial fibrillation; AFCL, AF cycle length; APD, action potential duration; DAD, delayed afterdepolarisation; EAD, early afterdepolarisation; ERP, effective refractory period; ICaL, L-type Ca2+ current; ICaT, T-type Ca2+ current; If, funny current; IK1, inward rectifier K+ current; IKACh, acetylcholine-activated K+ current; IKr, rapid delayed rectifier K+ current; IKS, slow delayed rectifier K+ current; IKur, ultra-rapid delayed rectifier K+ current; INa, Na+ current; INa/Ca, Na+-Ca2+ exchanger current; INa/H, Na+-H+ exchanger current; INaL, late INa; ISKCa, small conductance Ca2+-activated K+ current; ITO, transient outward K+ curren

Atrial cellular electrophysiological changes in patients with ventricular dysfunction may predispose to AF

<b>Background:</b> Left ventricular systolic dysfunction (LVSD) is a risk factor for atrial fibrillation (AF), but the atrial cellular electrophysiological mechanisms in humans are unclear. Objective This study sought to investigate whether LVSD in patients who are in sinus rhythm (SR) is associated with atrial cellular electrophysiological changes that could predispose to AF. <b>Methods:</b> Right atrial myocytes were obtained from 214 consenting patients in SR who were undergoing cardiac surgery. Action potentials or ion currents were measured using the whole-cell-patch clamp technique. <b>Results:</b> The presence of moderate or severe LVSD was associated with a shortened atrial cellular effective refractory period (ERP) (209 ± 8 ms; 52 cells, 18 patients vs 233 ± 7 ms; 134 cells, 49 patients; P <0.05); confirmed by multiple linear regression analysis. The left ventricular ejection fraction (LVEF) was markedly lower in patients with moderate or severe LVSD (36% ± 4%, n = 15) than in those without LVSD (62% ± 2%, n = 31; P <0.05). In cells from patients with LVEF ≤ 45%, the ERP and action potential duration at 90% repolarization were shorter than in those from patients with LVEF > 45%, by 24% and 18%, respectively. The LVEF and ERP were positively correlated (r = 0.65, P <0.05). The L-type calcium ion current, inward rectifier potassium ion current, and sustained outward ion current were unaffected by LVSD. The transient outward potassium ion current was decreased by 34%, with a positive shift in its activation voltage, and no change in its decay kinetics. <b>Conclusion:</b> LVSD in patients in SR is independently associated with a shortening of the atrial cellular ERP, which may be expected to contribute to a predisposition to AF