Molecular Basis of Hypokalemia-Induced Ventricular Fibrillation
Background—Hypokalemia is known to promote ventricular arrhythmias, especially in combination with Class III antiarrhythmic drugs like dofetilide. Here we evaluated the underlying molecular mechanisms.
Methods and Results—Arrhythmias were recorded in isolated rabbit and rat hearts or patch-clamped ventricular myocytes exposed to hypokalemia (1.0-3.5 mmol/l) in the absence or presence of dofetilide (1 µmol/l). Spontaneous early afterdepolarizations (EADs) and ventricular tachycardia/fibrillation (VF/VF) occurred in 50% of hearts at 2.7 mmol/l [K] in the absence of dofetilide, and 3.3 mmol/l [K] in its presence. Pre-treatment with the CaMKII inhibitor KN-93, but not its inactive analogue KN-92, abolished EADs and hypokalemia-induced VT/VF, as did the selective late Na current (INa) blocker GS-967. In intact hearts, moderate hypokalemia (2.7 mmol/l) significantly increased tissue CaMKII activity. Computer modeling revealed that EAD generation by hypokalemia (with or without dofetilide) required Na-K pump inhibition to induce intracellular Na and Ca overload with consequent CaMKII activation enhancing late INa and the L-type Ca current. K current suppression by hypokalemia and/or dofetilide alone in the absence of CaMKII activation were ineffective at causing EADs.
Conclusions—We conclude that Na-K pump inhibition by even moderate hypokalemia plays a critical role in promoting EAD-mediated arrhythmias by inducing a positive feedback cycle activating CaMKII and enhancing late INa. Class III antiarrhythmic drugs like dofetilide sensitize the heart to this positive feedback loop.
- Na-K ATPase
- Early afterdepolarizations
- antiarrhythmic drug
- arrhythmia (mechanisms)
- calcium/calmodulin-dependent protein kinase II
- Received February 25, 2015.
- Revision received August 3, 2015.
- Accepted August 5, 2015.