Hydroxychloroquine induces long QT syndrome by blocking hERG channel

Xin Zhao; Lihua Sun; Chao Chen; Jieru Xin; Yan Zhang; Yunlong Bai; Zhenwei Pan; Yong Zhang; Baoxin Li; Yanjie Lv; Baofeng Yang

doi:10.2478/fzm-2023-0014

Hydroxychloroquine induces long QT syndrome by blocking hERG channel

doi: 10.2478/fzm-2023-0014

Department of Pharmacology (State-Province Key Laboratories of BiomedicinePharmaceutics of China, Key Laboratory of Cardiovascular Medicine Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin 150086, China

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Corresponding author: Baofeng Yang, E-mail: yangbf@hrbmu.edu.cn

摘要

Abstract: Objective In March 2022, more than 600 million cases of Corona Virus Disease 2019 (COVID-19) and about 6 million deaths have been reported worldwide. Unfortunately, while effective antiviral therapy has not yet been available, chloroquine (CQ)/hydroxychloroquine (HCQ) has been considered an option for the treatment of COVID-19. While many studies have demonstrated the potential of HCQ to decrease viral load and rescue patients' lives, controversial results have also been reported. One concern associated with HCQ in its clinical application to COVID-19 patients is the potential of causing long QT interval (LQT), an electrophysiological substrate for the induction of lethal ventricular tachyarrhythmias. Yet, the mechanisms for this cardiotoxicity of HCQ remained incompletely understood. Materials and methods Adult New Zealand white rabbits were used for investigating the effects of HCQ on cardiac electrophysiology and expression of ion channel genes. HEK-293T cells with sustained overexpression of human-ether-a-go-go-related gene (hERG) K⁺ channels were used for whole-cell patch-clamp recordings of hERG K⁺ channel current (I_hERG). Quantitative RT-PCR analysis and Western blot analysis were employed to determine the expression of various genes at mRNA and protein levels, respectively. Results electrocardiogram (ECG) recordings revealed that HCQ prolonged QT and RR intervals and slowed heart rate in rabbits. Whole-cell patch-clamp results showed that HCQ inhibited the tail current of hERG channels and slowed the reactivation process from inactivation state. HCQ suppressed the expression of hERG and hindered the formation of the heat shock protein 90 (Hsp90)/hERG complex. Moreover, the expression levels of connexin 43 (CX43) and Kir2.1, the critical molecular/ionic determinants of cardiac conduction thereby ventricular arrythmias, were decreased by HCQ, while those of Cav1.2, the main Ca²⁺ handling proteins, remained unchanged and SERCA2a was increased. Conclusion HCQ could induce LQT but did not induce arrhythmias, and whether it is suitable for the treatment of COVID-19 requires more rigorous investigations and validations in the future.
- COVID-19 /
- hydroxychloroquine /
- LQT /
- hERG /
- Hsp90

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Figure 1. HCQ blocks the hERG potassium channel current (I_hERG) in hERG-overexpressing HEK293T cells (hERG-HEK293T)

(A) Whole-cell voltage-clamp protocol and representative hERG current traces recorded from different experimental groups after expose of 1, 3, and 10 μmol/L HCQ. (B) Normalized I-V relationships for tail current in the presence of HCQ. N = 6, ^***P < 0.001 vs. control.

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Figure 2. The effect of HCQ on hERG channel kinetics in hERG-overexpressing HEK293T cells (hERG-HEK293T)

(A) Voltage-dependent activation curves for the control cells and the cells after exposure to HCQ for 24 h and the V₅₀ and (B) slope value. (C) Whole-cell voltage-clamp protocol and representative current tracing for steady-state inactivation. (D) I-V relationships for inactivation current in the presence of HCQ. (E) The effect of HCQ on inactivation curve after incubated for 24 h and the V₅₀ and (F) slope value. (G) Voltage-clamp protocol and representative current tracing for the onset of inactivation. (H) Voltage-clamp protocol and representative current tracing for the recovery from inactivation. (I) The effect of HCQ on the time constants of inactivation and recovery from inactivation after incubation for 48 h. Data are presented as mean ± SEM N = 6, ^*P < 0.01, ^**P < 0.05, ^***P < 0.001 vs. control.

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Figure 3. The effects of HCQ on cardiac electrophysiology

(A) The representative diagram of ECG in rabbits. (B-G) HCQ prolongs QTc (B), QT interval (C) and max-RR interval (D), min-RR interval (E), mean RR interval (F) and decreases heart rate (G) in rabbit heart. (H-I) Whole-cell voltage-clamp protocol and representative hERG current traces recorded from hERG-HEK293T cell line treated with 1, 3, and 10 μmol/L HCQ. Normalized I-V relationships for tail current in the presence of HCQ. N = 6, ^*P < 0.01, ^***P < 0.001 vs. control.

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Figure 4. Effects of HCQ on the expression of cardiac ion channels and their regulatory proteins in rabbit hearts

(A) Relative mRNA level after HCQ administration for 1 week. HCQ incubation remarkably reduced the mRNA level of hERG and had no effect on (B) Hsp90 and (C) HSP70. (D) Western blots results and statistics of HSP70 expression. HCQ incubation does not decrease the expression level of Hsp70. (E-H) Relative mRNA or protein level after HCQ administration for 1 week. HCQ incubation remarkably reduced the mRNA level of (E) Cx43 and (F) Kir2.1 and increased the expression of (G-H) SERCA2a and had no effect on (I-J) CaV1.2. N = 5-7, ^*P < 0.01, ^**P < 0.05 vs. control.

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