Mechanistic insights into ventricular arrhythmogenesis of hydroxychloroquine and azithromycin for the treatment of COVID-19
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Abstract
Aims
We investigate mechanisms for potential pro-arrhythmic effects of hydroxychloroquine (HCQ) alone, or combined with azithromycin (AZM), in Covid-19 management supplementing the limited available experimental cardiac safety data.
Methods
We integrated patch-clamp studies utilizing In Vitro ProArrhythmia Assay (CiPA) Schema IC 50 paradigms, molecular modelling, cardiac multi-electrode array and voltage (RH237) mapping, ECG studies, and Ca 2+ (Rhod-2 AM) mapping in isolated Langendorff-perfused guinea-pig hearts with human in-silico ion current modelling.
Results
HCQ blocked I Kr and I K1 with IC 50 s (10±0.6 and 34±5.0 μM) within clinical therapeutic ranges, I Na and I CaL at higher IC 50 s, leaving I to and I Ks unaffected. AZM produced minor inhibition of I Na , I CaL , I Ks , and I Kr ,, sparing I K1 and I to . HCQ+AZM combined inhibited I Kr and I K1 with IC 50 s of 7.7±0.8 μM and 30.4±3.0 μM, sparing I Na , I CaL and I to . Molecular modelling confirmed potential HCQ binding to hERG. HCQ slowed heart rate and ventricular conduction. It prolonged PR, QRS and QT intervals, and caused prolonged, more heterogeneous, action potential durations and intracellular Ca 2+ transients. These effects were accentuated with combined HCQ+AZM treatment, which then elicited electrical alternans, re-entrant circuits and wave break. Modelling studies attributed these to integrated HCQ and AZM actions reducing I Kr and I K1 , thence altering cell Ca 2+ homeostasis.
Conclusions
Combined HCQ+AZM treatment exerts pro-arrhythmic ventricular events by synergetically inhibiting I Kr , I Ks with resulting effects on cellular Ca 2+ signalling, and action potential propagation and duration. These findings provide an electrophysiological basis for recent FDA cardiac safety guidelines cautioning against combining HCQ/AZM when treating Covid-19.
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SciScore for 10.1101/2020.05.21.108605: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement IACUC: Study Approval: All procedures were approved by The Institutional Animals Ethics Committees at Henan University, Kaifeng, China under and the national guidelines under which the institution operates, and also conform with the NIH Guide for the Care and Use of Laboratory Animals. Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Cell Line Authentication not detected. Table 2: Resources
Experimental Models: Cell Lines Sentences Resources Single-cell electrophysiological recordings: Core human cardiac channels were heterologously expressed in recombinant HEK293 or CHO cell lines and studied using … SciScore for 10.1101/2020.05.21.108605: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement IACUC: Study Approval: All procedures were approved by The Institutional Animals Ethics Committees at Henan University, Kaifeng, China under and the national guidelines under which the institution operates, and also conform with the NIH Guide for the Care and Use of Laboratory Animals. Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Cell Line Authentication not detected. Table 2: Resources
Experimental Models: Cell Lines Sentences Resources Single-cell electrophysiological recordings: Core human cardiac channels were heterologously expressed in recombinant HEK293 or CHO cell lines and studied using conventional patch clamp methods. CHOsuggested: CLS Cat# 603479/p746_CHO, RRID:CVCL_0213)Perforated whole-cell recordings of KCNQ1/E1 and Cav1.2 were obtained following perforation with 200 μg/ml Amphotericin included in the pipette solution. Cav1.2suggested: NoneSoftware and Algorithms Sentences Resources All currents were recorded using a MultiClamp 700A amplifier, 1550A digitizer and pCLAMP 10.6 software (Molecular devices, USA). pCLAMPsuggested: (pClamp, RRID:SCR_011323)The HCQ structure was obtained from PubChem and prepared for docking using LigPrep. PubChemsuggested: (PubChem, RRID:SCR_004284)LigPrepsuggested: (Ligprep, RRID:SCR_016746)Poses from Glide, FlexX, and AutoDock Vina were also re-scored using RF-Score-VS. FlexXsuggested: (FlexX, RRID:SCR_000186)AutoDocksuggested: (AutoDock, RRID:SCR_012746)ECP signals were recorded at a 10 kHz sampling using synchronized 64 channel EMS64-USB-1003 recording systems and recorded using EMapRecord 5.0 software (MapingLab Ltd., UK) and stored in a computer for subsequent off-line analysis. EMapRecordsuggested: NoneThe conduction velocity (CV) was calculated from the difference in timing and the known distance between the recording points using EMapScope 5.0 software (MappingLab Ltd.). EMapScopesuggested: NoneThe cameras of the optical mapping system, LED lights and stimulator and ECG recording were simultaneously driven by an 8 channel TTL analog-digital converter and OMapRecord 4.0 software (MappingLab Ltd.). OMapRecordsuggested: NoneFor the analysis of optical mapping signals and generation of isochronal maps, data were semi-automatically processed using OMapScope 5.0 software (MappingLab Ltd). OMapScopesuggested: NoneStatistical analysis: All patch clamp recorded data were analyzed using Clampfit 10.6 (Molecular Devices, USA), OriginPro 8.0 (Origin Lab, USA) and Adobe Illustrator 10 (Adobe, USA). OriginProsuggested: NoneAdobe Illustratorsuggested: (Adobe Illustrator, RRID:SCR_010279)Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: An explicit section about the limitations of the techniques employed in this study was not found. We encourage authors to address study limitations.Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We found bar graphs of continuous data. We recommend replacing bar graphs with more informative graphics, as many different datasets can lead to the same bar graph. The actual data may suggest different conclusions from the summary statistics. For more information, please see Weissgerber et al (2015).
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
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