Metoprolol (Lopressor, Toprol XL) Oral: 50, 100 mg tablets; 25, 50, 100, 200 mg extended-release tablets Parenteral: 1 mg/mL for IV injection Other Drugs Inamrinone Parenteral: 5 mg/mL for IV injection Milrinone (generic, Primacor) Parenteral: 1 mg/mL for IV injection; 200 g/mL premixed for IV infusion Nesiritide (Natrecor) Parenteral: 1.58 mg powder for IV injection Bosentan (Tracleer) Oral: 62.5, 125 mg tablets Chapter 14. Agents Used in Cardiac Arrhythmias Katzung PHARMACOLOGY, 9e > Section III. Cardiovascular-Renal Drugs > Chapter 14. Agents Used in Cardiac Arrhythmias > Agents Used in Cardiac Arrhythmias: Introduction *The authors acknowledge the contributions of the previous authors of this chapter, Drs L Hondeghem and D Roden. Cardiac arrhythmias are a frequent problem in clinical practice, occurring in up to 25% of patients treated with digitalis, 50% of anesthetized patients, and over 80% of patients with acute myocardial infarction. Arrhythmias may require treatment because rhythms that are too rapid, too slow, or asynchronous can reduce cardiac output. Some arrhythmias can precipitate more serious or even lethal rhythm disturbances—eg, early premature ventricular depolarizations can precipitate ventricular fibrillation. In such patients, antiarrhythmic drugs may be lifesaving. On the other hand, the hazards of antiarrhythmic drugs—and in particular the fact that they can precipitate lethal arrhythmias in some patients—has led to a reevaluation of their relative risks and benefits. In general, treatment of asymptomatic or minimally symptomatic arrhythmias should be avoided for this reason. Arrhythmias can be treated with the drugs discussed in this chapter and with nonpharmacologic therapies such as pacemakers, cardioversion, catheter ablation, and surgery. This chapter describes the pharmacology of drugs that suppress arrhythmias by a direct action on the cardiac cell membrane. Other modes of therapy are discussed briefly. Electrophysiology of Normal Cardiac Rhythm The electrical impulse that triggers a normal cardiac contraction originates at regular intervals in the sinoatrial node (Figure 14–1), usually at a frequency of 60–100 beats per minute. This impulse spreads rapidly through the atria and enters the atrioventricular node, which is normally the only conduction pathway between the atria and ventricles. Conduction through the atrioventricular node is slow, requiring about 0.15 s. (This delay provides time for atrial contraction to propel blood into the ventricles.) The impulse then propagates over the His-Purkinje system and invades all parts of the ventricles. Ventricular activation is complete in less than 0.1 s; therefore, contraction of all of the ventricular muscle is synchronous and hemodynamically effective. Figure 14–1. Schematic representation of the heart and normal cardiac electrical activity (intracellular recordings from areas indicated and ECG). Sinoatrial node, atrioventricular node, and Purkinje cells display pacemaker activity (phase 4 depolarization). The ECG is the body surface manifestation of the depolarization and repolarization waves of the heart. The P wave is generated by atrial depolarization, the QRS by ventricular muscle depolarization, and the T wave by ventricular repolarization. Thus, the PR interval is a measure of conduction time from atrium to ventricle, and the QRS duration indicates the time required for all of the ventricular cells to be activated (ie, the intraventricular conduction time). The QT interval reflects the duration of the ventricular action potential. Arrhythmias consist of cardiac depolarizations that deviate from the above description in one or more aspects– ie, there is an abnormality in the site of origin of the impulse, its rate or regularity, or its conduction. Ionic Basis of Membrane Electrical Activity The transmembrane potential of cardiac cells is determined by the concentrations of several ions— chiefly sodium (Na+), potassium (K+), calcium (Ca2+), and chloride (Cl–)—on either side of the membrane and the permeability of the membrane to each ion. These water-soluble ions are unable to freely diffuse across the lipid cell membrane in response to their electrical and concentration gradients; they require aqueous channels (specific pore-forming proteins) for such diffusion. Thus, ions move across cell membranes in response to their gradients only at specific times during the cardiac cycle when these ion channels are open. The movements of these ions produce currents that form the basis of the cardiac action potential. Individual channels are relatively ion-specific, and the flux of ions through them is thought to be controlled by "gates" (probably flexible peptide chains or energy barriers). Each type of channel has its own type of gate (sodium, calcium, and some potassium channels are each thought to have two types of gates), and each type of gate is opened and closed by specific transmembrane voltage, ionic, or metabolic conditions. At rest, most cells are not significantly permeable to sodium, but at the start of each action potential, they become quite permeable (see below). Similarly, calcium enters and potassium leaves the cell with each action potential. Therefore, the cell must have a mechanism to maintain stable transmembrane ionic conditions by establishing and maintaining ion gradients. The most important of these active mechanisms is the sodium pump, Na+/K+ ATPase, described in Chapter 13: Drugs Used in Heart Failure. This pump and other active ion carriers contribute indirectly to the transmembrane potential by maintaining the gradients necessary for diffusion through channels. In addition, some pumps and exchangers produce net current flow (eg, by exchanging three Na+ for two K+ ions) and hence are termed "electrogenic." When the cardiac cell membrane becomes permeable to a specific ion (ie, when the channels selective for that ion are open), movement of that ion across the cell membrane is determined by Ohm's law: current = voltage ÷ resistance, or current = voltage x conductance. Conductance is determined by the properties of the individual ion channel protein. The voltage term is the difference between the actual membrane potential and the reversal potential for that ion (the membrane potential at which no current would flow even if channels were open). For example, in the case of sodium in a cardiac cell at rest, there is a substantial concentration gradient (140 mmol/L Na+ outside; 10–15 mmol/L Na+ inside) and electrical gradient (0 mV outside; –90 mV inside) that would drive Na+ into cells. Sodium does not enter the cell at rest because sodium channels are closed; when sodium channels open, the very large influx of Na+ ions accounts for phase 0 depolarization. The situation for K+ ions in the resting cardiac cell is quite different. Here, the concentration gradient (140 mmol/L inside; 4 mmol/L outside) would drive the ion out of the cell, but the electrical gradient would drive it in, ie, the inward gradient is in equilibrium with the outward gradient. In fact, certain potassium channels ("inward rectifier" channels) are open in the resting cell, but little current flows through them because of this balance. The equilibrium, or reversal potential, for ions is determined by the Nernst equation: where C and C are the extracellular and intracellular concentrations, respectively, multiplied by e i their activity coefficients. Note that raising extracellular potassium makes E less negative. When K this occurs, the membrane depolarizes until E is reached. Thus, extracellular potassium K concentration and inward rectifier channel function are the major factors determining the membrane potential of the resting cardiac cell. The conditions required for application of the Nernst equation are approximated at the peak of the overshoot and during rest in most nonpacemaker cardiac cells. If the permeability is significant for both potassium and sodium, the Nernst equation is not a good predictor of membrane potential, but the Goldman-Hodgkin-Katz equation may be used. In pacemaker cells (whether normal or ectopic), spontaneous depolarization (the pacemaker potential) occurs during diastole (phase 4, Figure 14–1). This depolarization results from a gradual increase of depolarizing current through special hyperpolarization-activated ion channels in pacemaker cells. The effect of changing extracellular potassium is more complex in a pacemaker cell than it is in a nonpacemaker cell because the effect on permeability to potassium is much more important in a pacemaker (see Effects of Potassium). In a pacemaker—especially an ectopic one— the end result of an increase in extracellular potassium will usually be to slow or stop the pacemaker. Conversely, hypokalemia will often facilitate ectopic pacemakers. The Active Cell Membrane In normal atrial, Purkinje, and ventricular cells, the action potential upstroke (phase 0) is dependent on sodium current. From a functional point of view, it is convenient to describe the behavior of the sodium current in terms of three channel states (Figure 14–2). The cardiac sodium channel protein has been cloned, and it is now recognized that these channel states actually represent different protein conformations. In addition, regions of the protein that confer specific behaviors, such as voltage sensing, pore formation, and inactivation, are now being identified. The gates described below and in Figure 14–2 represent such regions. Figure 14–2. A schematic representation of Na+ channels cycling through different conformational states during the cardiac action potential. Transitions between resting, activated, and inactivated states are dependent on membrane potential and time. The activation gate is shown as m and the inactivation gate as h. Potentials typical for each state are shown under each channel schematic as a function of time. The dashed line indicates that part of the action potential during which most Na+ channels are completely or partially inactivated and unavailable for reactivation. Depolarization to the threshold voltage results in opening of the activation (m) gates of sodium channels (Figure 14–2, middle). If the inactivation (h) gates of these channels have not already closed, the channels are now open or activated, and sodium permeability is markedly increased, greatly exceeding the permeability for any other ion. Extracellular sodium therefore diffuses down its electrochemical gradient into the cell, and the membrane potential very rapidly approaches the sodium equilibrium potential, E (about +70 mV when Na = 140 mmol/L and Na = 10 mmol/L). Na e i This intense sodium current is very brief because opening of the m gates upon depolarization is promptly followed by closure of the h gates and inactivation of the sodium channels (Figure 14–2, right). Most calcium channels become activated and inactivated in what appears to be the same way as sodium channels, but in the case of the most common type of cardiac calcium channel (the "L" type), the transitions occur more slowly and at more positive potentials. The action potential plateau (phases 1 and 2) reflects the turning off of most of the sodium current, the waxing and waning of calcium current, and the slow development of a repolarizing potassium current. Final repolarization (phase 3) of the action potential results from completion of sodium and calcium channel inactivation and the growth of potassium permeability, so that the membrane potential once again approaches the potassium equilibrium potential. The major potassium currents involved in phase 3 repolarization include a rapidly activating potassium current (I ) and a slowly activating Kr potassium current (I ). These processes are diagrammed in Figure 14–3. Ks Figure 14–3. Schematic diagram of the ion permeability changes and transport processes that occur during an action potential and the diastolic period following it. The size and weight of the arrows indicate approximate magnitudes of the ion channel currents; arrows pointing down indicate inward (depolarizing) membrane currents, arrows pointing up indicate outward (repolarizing) membrane currents. Multiple subtypes of potassium and calcium currents, with different sensitivities to blocking drugs, have been identified. Chloride currents (dotted arrows) produce both inward and outward membrane currents during the cardiac action potential. The Effect of Resting Potential on Action Potentials A key factor in the pathophysiology of arrhythmias and the actions of antiarrhythmic drugs is the relationship between the resting potential of a cell and the action potentials that can be evoked in it (Figure 14–4, left panel). Because the inactivation gates of sodium channels in the resting membrane close over the potential range –75 to –55 mV, fewer sodium channels are "available" for diffusion of sodium ions when an action potential is evoked from a resting potential of –60 mV than when it is evoked from a resting potential of –80 mV. Important consequences of the reduction in peak sodium permeability include reduced upstroke velocity (called , for maximum rate of max change of membrane voltage), reduced action potential amplitude, reduced excitability, and reduced conduction velocity. Figure 14–4. Dependence of sodium channel function on the membrane potential preceding the stimulus. Left: The fraction of sodium channels available for opening in response to a stimulus is determined by the membrane potential immediately preceding the stimulus. The decrease in the fraction available when the resting potential is depolarized in the absence of a drug (control curve) results from the voltage-dependent closure of h gates in the channels. The curve labeled Drug illustrates the effect of a typical local anesthetic antiarrhythmic drug. Most sodium channels are inactivated during the plateau of the action potential. Right: The time constant for recovery from inactivation after repolarization also depends on the resting potential. In the absence of drug, recovery occurs in less than 10 ms at normal resting potentials (–85 to –95 mV). Depolarized cells recover more slowly (note logarithmic scale). In the presence of a sodium channel-blocking drug, the time constant of recovery is increased, but the increase is far greater at depolarized potentials than at more negative ones. During the plateau of the action potential, most sodium channels are inactivated. Upon repolarization, recovery from inactivation takes place (in the terminology of Figure 14–2, the h gates reopen), making the channels again available for excitation. The time between phase 0 and sufficient recovery of sodium channels in phase 3 to permit a new propagated response to external stimulus is the refractory period. Changes in refractoriness (determined by either altered recovery from inactivation or altered action potential duration) can be important in the genesis or suppression of certain arrhythmias. Another important effect of less negative resting potential is prolongation of this recovery time, as shown in Figure 14–4 (right panel). The prolongation of recovery time is reflected in an increase in the effective refractory period. A brief depolarizing stimulus, whether caused by a propagating action potential or by an external electrode arrangement, causes the opening of large numbers of activation gates before a significant number of inactivation gates can close. In contrast, slow reduction (depolarization) of the resting potential, whether brought about by hyperkalemia, sodium pump blockade, or ischemic cell damage, results in depressed sodium currents during the upstrokes of action potentials. Depolarization of the resting potential to levels positive to –55 mV abolishes sodium currents,since all sodium channels are inactivated. However, such severely depolarized cells have been found to support special action potentials under circumstances that increase calcium permeability or decrease potassium permeability. These "slow responses"—slow upstroke velocity and slow conduction— depend on a calcium inward current and constitute the normal electrical activity in the sinoatrial and atrioventricular nodes, since these tissues have a normal resting potential in the range of –50 to –70 mV. Slow responses may also be important for certain arrhythmias. Modern techniques of molecular biology and electrophysiology can identify multiple subtypes of calcium and potassium channels. One way in which such subtypes may differ is in sensitivity to drug effects, so drugs targeting specific channel subtypes may be developed in the future. Mechanisms of Arrhythmias Many factors can precipitate or exacerbate arrhythmias: ischemia, hypoxia, acidosis or alkalosis, electrolyte abnormalities, excessive catecholamine exposure, autonomic influences, drug toxicity (eg, digitalis or antiarrhythmic drugs), overstretching of cardiac fibers, and the presence of scarred or otherwise diseased tissue. However, all arrhythmias result from (1) disturbances in impulse formation, (2) disturbances in impulse conduction, or (3) both. Disturbances of Impulse Formation The interval between depolarizations of a pacemaker cell is the sum of the duration of the action potential and the duration of the diastolic interval. Shortening of either duration results in an increase in pacemaker rate. The more important of the two, diastolic interval, is determined primarily by the slope of phase 4 depolarization (pacemaker potential). Vagal discharge and - receptor-blocking drugs slow normal pacemaker rate by reducing the phase 4 slope (acetylcholine also makes the maximum diastolic potential more negative). Acceleration of pacemaker discharge is often brought about by increased phase 4 depolarization slope, which can be caused by hypokalemia, -adrenoceptor stimulation, positive chronotropic drugs, fiber stretch, acidosis, and partial depolarization by currents of injury. Latent pacemakers (cells that show slow phase 4 depolarization even under normal conditions, eg, some Purkinje fibers) are particularly prone to acceleration by the above mechanisms. However, all cardiac cells, including normally quiescent atrial and ventricular cells, may show repetitive pacemaker activity when depolarized under appropriate conditions, especially if hypokalemia is also present. Afterdepolarizations (Figure 14–5) are depolarizations that interrupt phase 3 (early afterdepolarizations, EADs) or phase 4 (delayed afterdepolarizations, DADs). DADs, discussed in Chapter 13: Drugs Used in Heart Failure, often occur when intracellular calcium is increased. They are exacerbated by fast heart rates and are thought to be responsible for some arrhythmias related to digitalis excess, to catecholamines, and to myocardial ischemia. EADs, on the other hand, are usually exacerbated at slow heart rates and are thought to contribute to the development of long QT- related arrhythmias (see Molecular & Genetic Bases of Cardiac Arrhythmias). Figure 14–5. Two forms of abnormal activity, early (top) and delayed afterdepolarizations (bottom). In both cases, abnormal depolarizations arise during or after a normally evoked action potential. They are therefore often referred to as "triggered" automaticity, ie, they require a normal action potential for their initiation. Disturbances of Impulse Conduction Severely depressed conduction may result in simple block, eg, atrioventricular nodal block or bundle branch block. Because parasympathetic control of atrioventricular conduction is significant, partial atrioventricular block is sometimes relieved by atropine. Another common abnormality of conduction is reentry (also known as "circus movement"), in which one impulse reenters and excites areas of the heart more than once (Figure 14–6). The path of the reentering impulse may be confined to very small areas, eg, within or near the atrioventricular node, or it may involve large portions of the atrial or ventricular walls. Some forms of reentry are strictly anatomically determined; for example, in the Wolff-Parkinson-White syndrome, the reentry circuit consists of atrial tissue, the AV node, ventricular tissue, and an accessory atrioventricular connection (a "bypass tract"). In other cases (eg, atrial or ventricular fibrillation), multiple reentry circuits, determined by the properties of the cardiac tissue, may meander through the heart in apparently random paths. Furthermore, the circulating impulse often gives off "daughter impulses" that can spread to the rest of the heart. Depending on how many round trips through the pathway the impulse makes before dying out, the arrhythmia may be manifest as one or a few extra beats or as a sustained tachycardia. Figure 14–6.