European Heart Journal Supplements (2004) 6 (Supplement I), I3I7

Inhibition of late (sustained/persistent)

sodium current: a potential drug target to reduce
intracellular sodium-dependent calcium overload
and its detrimental effects on cardiomyocyte function
a,

Luiz Belardinelli *, Charles Antzelevitch , Heather Fraser

a

Senior Vice President of Pharmacology and Translational Biomedical Research, CV Therapeutics Inc,
b
USA Executive Director/Director of Research Masonic Medical Research Laboratory, Utica, NY, USA
c
Scientist, Department of Pharmacology and Drug Research, CV Therapeutics Inc, USA
sodium and calcium, and to
reduce
the
electrical
and
mechanical
abnormalities
This
KEYWORDS
associated with these conditions.
articl
Late sodium current; Intracellular
The new anti-anginal and antie
+
ischaemic drug ranolazine is a
descr
Na overload; Intracellular
2+
selective inhibitor of the late
ibes
Ca overload; Ischaemia; Sodium channel; Ranolazine
sodium current that is capable of
a
reducing the electrical instability
poten
and
mechanical
dysfunction
tial
associated with conditions (e.g.
target
ischaemia, heart failure) known to
for
+
thera
raise late INa and [Na ]i. Because
peuti
the scope of the review is narrow,
c
many
relevant
mechanisms
interv
involved in the regulation of
entio
intracellular sodium and calcium
n in
homeostasis are not discussed,
ischa
and
important
individual
emia
contributions are not cited. Hence,
and
the reader is referred to more
heart
comprehensive reviews of this
failur
subject.
e
2004 The European Society of
inhibi
Cardiology. Published by Elsevier
tion
Ltd. All rights reserved.
of the
late
(sust
ained
)
sodiu
m
curre
nt to
reduc
e the
rise
in
intrac
ellula
r

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C
A
9
4
3
0
Intracellular sodium and
4,
calcium overload in the
U
S
pathogenesis of
A.
ischaemia/reperfusion and
T
el
heart failure
.:
Ischaemia/reperfusion and heart+
failure
are
associated
with1disruptions in cellular sodium and6
calcium home-ostasis 13. Sodium5
overload may result from decreased0efflux and increased influx during3
ischaemia, with greater intracellular8
accumulation of sodium as the4duration of ischaemia increases 4 .85
This is followed by an increase in0
intracellular calcium through the0;
Na+/Ca2+ exchanger 4 . Failure tofa
maintain
the
intracellularx:
homeostasis of Na+ and Ca2+ leads+
to electrical instability (arrhythmias),1mechanical dysfunction (reduced6
contrac5
08
* Correspondence: Luiz Belardinelli. Senior 5
Vice President of Phar-macology and 8Translational
Biomedical
Research,
CV 0
Therapeutics Inc, 3172 Porter Drive, Palo Alto, 3
9

0.
E-mail address:
Luiz.Belardinelli@cvt.c
om (L. Belardinelli).

169-5002/$

dysfunction,
resulting
in
increased ATP
hydrolysis (and
decreased ATP
formation) and,
if left untreated,
cell injury and
death.
Considerable
data
support the
above
hypothesis
(illustrated in
of the various
of intracellular
sodium
homeostasis
(ion channels,
exchangers and
transporters) to
+
the rise in [Na ]i
remains
a
matter of debate
5
. Nevertheless,
as pointed out
by Murphy et al.
5
,
both
the

Na+/H+
exchanger and
the
noninactivating Na+
channels
are
likely
to
contribute to the
+
rise in [Na ]i.
The focus of this
brief review is
on the role of
late
(sustained/persi
stent)
sodium
current (INa) in
the
ionic
disturbances
associated with
ischaemia/
hypoxia
and
heart failure and
their
consequences,
as well as on the
effects of the
anti-anginal and
anti-ischaemic
drug ranolazine
6,7
, a selective
inhibitor of late
8,9
INa .

I4

L. Belardinelli et al.

hypothesis. Nevertheless,
out that sodium-channel blockers,
+
2+
Na /Ca
exchanger and antisense
+
2+
Na /Ca
exchanger attenuate the rise in [Ca
cellular
dysfunction
associated
with
ischaemia/hypoxia and
heart failure 1,1720.

Effects of
ranolazine
Fig. 2. Relation between peak
and late sodium current and
ventricular action potential (AP)
and contraction (tracings are not
actual recordings). Late INa is the
Fig. 1. Ionic disturbances in ischaemia and heart failure, and their current associated with the slow
inactivating component of the INa
consequences. See text for a detailed description of this hypothesis.
, and is also referred to in the
literature
as
sustained,
persistent, slowly inactivating or
+
inactivation-resistant Na current.
Sodium-channel abnormalities
Panels A and B illustrate a
and an increased late INa
Sodium channels are activated on depolarisation of the normal
(due to impaired inactivation of
+
+
membrane; the Na current flowing through these chan-nelsNa channel), respectively. The
late
INa
is
is responsible for the upstroke (phase 0) of the actionenhanced
by
delayed
potential (AP), and contributes to the plateau phase of the accompanied
ventricular repolarisation (long
AP. On depolarisation, INa increases rapidly, reaching aAPs, and occasional early afterdepolarisation) and abnormal
transient peak lasting a few milliseconds, before beginningtwitch (contraction composed of
to inactivate. The inactivation of I has a fast componenta phasic and a tonic component.)
Na

(fast inactivation) that lasts a couple of milliseconds and is

followed by a slowly inactivating component that can last results in a prolonged
10
potential
with
hundreds of milliseconds . The current associated with the action
slow inactivating component has been referred to as late, potential for the induction
of
early
sustained or persistent INa
(I

Inhibition of late
(persistent, sustained)
INa
Ranolazine causes a
concentration-,
voltageand
frequency-dependent
inhibition of the late
(sustained)
INa
on
ventricular
myocytes
from dog and guineapig hearts 8,9,15. Not
surprisingly,
as
summarised in Table 1,
the
potency
of
ranolazine to inhibit
late
INa
varies
depending
on
the
experimental
conditions
(for
example, voltage and
frequency
of
depolarisation),
and
possibly species 8,21.

INa, sus, INa, p) to distinguish it from the peakafterdepolarisations,

abnormal
relaxation
transient INa.
including
An enhanced late INa is likely to
contribute to
and
the sodium overload observed in ischaemia/hypoxia andaftercontractions,
To date, the most
comprehensive study
heart failure, and consequently may play a role in the contractions with both
of the effects of
and
tonic
abnormalities
of
ventricular
contractility
andphasic
ranolazine on late INa,
repolarisation. In normal circumstances, the amplitude ofcomponents (Fig. 2).
compared with peak
late INa is less than 1% of peak INa. It can, however, be Central
to
the
INa, has been carried
increased as a result of delayed or incomplete hypothesis discussed in
out
in
isolated
inactivation of INa due to impaired inactivation of thethis review, and illustrated
ventricular myocytes of
dogs with chronic heart
sodium channel, leading to abnormal ventricularin Fig. 1, is the rise in
failure 9. In this study,
repolarisation and contraction (Fig. 2) 4,10. Importantly, itcytosolic calcium that
ranolazine was found
remains to be shown that the amount of sodium carried is,
cellular
calcium
to inhibit late INa with a
into the cell by the non-inactivating component of INa isoverload.
There
is
potency (IC50 value:
sufficient to cause a rise in cytosolic or restrictedgeneral agreement that
+
subsarcolemma space (fuzzy space) [Na ] that results inthe calcium overload
+
2+
activation of the reverse mode of the Na /Ca during ischaemia/hypoxia
exchanger.
and
Sodium channelopathies associated with increasedreperfusion/reoxygenatio
late INa include congenital conditions resulting from n is a result of the
mutations of the sodium-channel gene in the heart,increase in the influx of
skeletal muscle or central nervous system, as well as 2+
11
via the reverse
acquired conditions such as the presence of hypoxia Ca
and ischaemic metabolites such as the amphiphilesmode of the Na+/Ca2+
lyso-phosphatidylcholine (LPC) 12 and palmitoyl-l-exchanger triggered by
carnitine 13. Late INa has also been found to bethe
increased by twofold in myocytes from canine failingrise in [Na+]i 3,4 . Likewise, the rise in [Na
14
hearts
. In addition, certain toxins and drugs can also to the calcium overload via the
+
have this effect (that is, delayed inactivation of the Na in heart failure 16. It is beyond
15
current); an example is the sea-anemone toxin ATX-II .review to discuss the
The increased late INa
literature that supports
this
Na, L

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Inhibition of late INa: potential drug target to reduce intracellular sodium-dependent calcium overload

In terms of mechanical
dysfunction,
ranolazine
Table 1
decreases
postVoltage- and frequency-dependent inhibition of late INa byischaemic
contracture
8,21
ranolazine in canine left-ventricular myocytes
(increase
in
leftventricular
end-diastolic
Voltage (mV)
BCL = 2000 ms
BCL = 300 ms
pressure on reperfusion),
28
20.75 mM
11.5 mM im-proves left-ventricular
+13 and +20
5.86 mM
5.04 mM developed pressure and
reduces creatine-kinase
Values are potencies (IC50) of ranolazine to inhibit late INarelease (a marker of the
obtained in 312 canine left-ventricular mid-myocardial cells. degree of cell injury) in
Late INa (TTX-sensitive) was recorded using the action rabbit isolated perfused
potential (AP) clamp technique. AP command waveforms were hearts
subjected
to
elicited at basic cycle lengths (BCL) of 2000 and 300 ms.
ischaemia
and
23
the concentration of ranolazine that inhibits the current reperfusion . As shown
by 50%) of 6.5 mM, compared with an IC50 value ofin Fig. 4, the postischaemic increase in left244 mM for the inhibition of peak INa 9. This representsventricular end-diastolic
a potency ratio (peak versus late) of 38, indicating that pressure
(LVEDP),
ranolazine is relatively selective for late INa.
decrease in LV+dP/dt and
increase
Reversal of ventricular repolarisation and contractile
abnormalities in disease and in the presence of drugs
associated with enhanced late INa
The intracellular Na+/Ca2+ overload associated with
enhancement of the late INa results in both electrical and
mechanical dysfunction (Fig. 1). The electrical instability
includes afterpotentials (e.g. early afterdepolarisations,
EADs), beat-to-beat variability in duration of action
potential, and arrhythmias (e.g. ventricular tachycar-dia).
The mechanical dysfunction includes
reduced
contractility, aftercontractions, slow relaxation and
increased diastolic pressure/tension.
In terms of electrical dysfunction, ranolazine has been
shown to reverse the prolongation, induced by ATX-II (a
late INa enhancer), of the action potential in guinea-pig
single ventricular myocytes, with an IC50 of 410 nM (Fig.
3) 15. Ranolazine shortened the action potential, and
suppressed the early afterdepolarisations, in a
concentration-dependent manner (concentrations of 1,
3, 10 and 30 mM). Consistent with this finding, in
guinea-pig isolated perfused hearts, ranolazine ( 5 mM)
terminated polymorphic ventricular tachycardia caused
by the late-INa enhancer ATX-II 22. It is worth noting
that the therapeutic plasma levels of ranolazine are
in the range of 26 mM. Similarly, in failing canine
myocytes, ranolazine (5 and 10 mM) was found to
shorten the ventricular action potentials and to reduce
the dispersion of action-potential durations 9. Thus, early
afterdepolarisations and heterogeneity of ventricular
repolarisation, both well-established harbingers of arrhythmia, are suppressed and reduced by ranolazine.

I5

r
e
I
n

Fig.
3.
Reversal
and
suppression by ranolazine of
ATX-II-induced prolongation
of the action potential and
early
afterdepolarisation
(EAD),
respectively,
in
guinea-pig isolated ventricular
myocytes.
Panel
A:
Recordings
of
action
potentials from ventricular
myocytes (a) in the absence
of drug (control), (b) in the
presence of 10 nM ATX-II,
and (cf) in the presence of
ATX-II (10 nM) and increasing
concentrations (1, 3, 10 and
30 mM) of ranolazine. Panel
B: Concentrationresponse
relationship for ranolazine to
decrease
action-potential
duration
(APD)
in
the
presence of 10 nM ATX-II.
Bars indicate the mean and
SEM of measurements from 5
to 10 myocytes. Reproduced
15

from Song et al. 2004

with
permission from author and
publisher.

in LVdP/dt (indices of
contracture,
contractility
and
relaxation,

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I6

L. Belardinelli et al.

Fig. 4. Effect of ranolazine on left-ventricular end-diastolic pressure (LVEDP), rate of LV pressure development (LV+dP/dt) and rate of
LV pressure decline (i.e. relaxation; LVdP/dt) of rabbit isolated Langendorff perfused hearts. Hearts were subjected to 20 min of
normal aerobic perfusion prior to 30 min of global ischaemia followed by 60 min of reperfusion. Hearts treated with 5.4 mM ranolazine
(n = 9) 10 min prior to ischaemia were compared with hearts treated with DMSO as vehicle (n = 12). * Values significantly different ( p
< 0.05) from DMSO.

Conclusion
Intracellular sodium and calcium overload play a key
role in both electrical and mechanical dysfunction in
ischaemia and heart failure. Inhibition of the late sodium
current is expected to decrease intracellular sodium and
calcium overload, and thereby reduce their deleterious
effects. Ranolazine selectively inhibits late sodium
current and attenuates the abnormalities of ventricular
repolarisation and contractility associated with
ischaemia/reperfusion and heart failure. The findings
reported here suggest that inhibition of late INa may
contribute to the cardioprotective effects of ranolazine.
Results of ongoing and future studies are needed to
conclusively establish the validity of inhibiting late INa as
a therapeutic target for treatment of ischaemic heart
disease and heart failure.

Acknowledgement
We thank Dr. A. Undrovinas for his valuable input on the
role of late INa in the abnormal ventricular repolarization
of myocytes from failing dog hearts.

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