Cardiac action potential repolarization re-visited: early repolarization shows all-or-none behaviour

Abstract

In healthy mammalian hearts the action potential (AP) waveform initiates and modulates each contraction, or heartbeat. As a result, action potential height and duration are key physiological variables. In addition, rate-dependent changes in ventricular action potential duration (APD), and variations in APD at a fixed heart rate, are both reliable biomarkers of electrophysiological stability. Present guidelines for the likelihood that candidate drugs will increase arrhythmias rely on small changes in APD and Q-T intervals as criteria for Safety Pharmacology decisions. However, both of these measurements correspond to the final repolarization of the AP. Emerging clinical evidence also draws attention to the early repolarization phase of the action potential (and the J wave of the ECG) as a biomarker for arrhythmogenesis.

Here we provide mechanistic background to this Early Repolarization Syndrome by summarizing the evidence that both the initial depolarization and repolarization phases of the cardiac action potential can exhibit distinct time- and voltage-dependent thresholds; and demonstrating that both can show regenerative all-or-none behaviour. An important consequence of this is that not all of the dynamics of action potential repolarization in human ventricle can be captured by data from single myocytes when these results are expressed as 'repolarization reserve'. For example, the complex pattern of cell-to-cell current flow that is responsible for AP conduction (propagation) within the mammalian myocardium can change APD and the Q-T interval of the electrocardiogram as well as alter APD stability, and modulate responsiveness to pharmacological agents (such as Class III anti-arrhythmic drugs).

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