Clinic al Trial

nature publishing groupsee COMMENTARY page 534

Differentiating Drug-Induced Multichannel Blockon the Electrocardiogram: Randomized Study of
Dofetilide, Quinidine, Ranolazine, and Verapamil
L Johannesen1,2, J Vicente1,3, JW Mason4, C Sanabria4, K Waite-Labott4, M Hong5, P Guo5, J Lin5,JS Sørensen6, L Galeotti1, J Florian6, M Ugander1,2, N Stockbridge7 and DG Strauss1,2
Block of the hERG potassium channel and prolongation of the QT interval are predictors of drug-induced torsade depointes. However, drugs that block the hERG potassium channel may also block other channels that mitigate torsade
risk. We hypothesized that the electrocardiogram can differentiate the effects of multichannel drug block by separate
analysis of early repolarization (global J–Tpeak) and late repolarization (global Tpeak–Tend). In this prospective randomized
controlled clinical trial, 22 subjects received a pure hERG potassium channel blocker (dofetilide) and three drugs thatblock hERG and either calcium or late sodium currents (quinidine, ranolazine, and verapamil). The results show thathERG potassium channel block equally prolongs early and late repolarization, whereas additional inward current block(calcium or late sodium) preferentially shortens early repolarization. Characterization of multichannel drug effects onhuman cardiac repolarization is possible and may improve the utility of the electrocardiogram in the assessment ofdrug-related cardiac electrophysiology.

Fourteen drugs have been removed from the market worldwide
because they increase the risk for torsade de pointes,1 a ventricular arrhythmia that can cause sudden cardiac death. Drugs
that increase the risk for torsade can be identified by assessing whether they block the human ether-à-go-go-related gene(hERG) potassium channel (an outward current) and prolong
the QT interval on the electrocardiogram (ECG).1,2 In response,
the US Food and Drug Administration (FDA) requires almost
all new drugs to undergo “thorough QT” studies.3 A positive
thorough QT study does not preclude a drug from regulatory
approval but almost always increases the required cardiac safety
evaluations during later stages of drug development.3,4 Becauseof the increased risk and cost of developing drugs that block
the hERG potassium channel and/or prolong QT, some ofthese compounds are dropped from development, sometimes
inappropriately.1
Some drugs block the hERG potassium channel and prolong
QT with minimal torsade risk because they also block calcium

and/or sodium channels (inward currents). The most notable
example is amiodarone, which causes substantial QT prolongation but has a low risk of torsade.5 This is likely because blocking
inward currents can prevent early afterdepolarizations, which
trigger torsade.6–8
Previous studies have focused on capturing changes inT-wave morphology,9–11 but so far these efforts have been
focused primarily on detecting the presence of hERG potassium channel block. 12 Using data from 34 thorough QT­studies, we demonstrated previously that multichannel block
can be detected on the ECG and that not all QT prolongation is equal.13 That analysis suggested that hERG potassiumchannel block prolongs both early repolarization (J–Tpeak:end of QRS to global peak of T-wave) and late repolarization (Tpeak–Tend: global peak to end of T-wave), whereas calcium and late sodium current block preferentially shorten
early repolarization (Figure 1). The preferential effect of
calcium and late sodium currents on early repolarization is

1Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA;

2Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden; 3BSICoS Group, Aragón Institute of Engineering
Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Aragon, Spain; 4Spaulding Clinical Research, West Bend, Wisconsin, USA; 5Frontage Laboratories, Exton,
Pennsylvania, USA; 6Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Foodand Drug Administration, Silver Spring, Maryland, USA; 7Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research,
US Food and Drug Administration, Silver Spring, Maryland, USA. Correspondence: DG Strauss (david.strauss@fda.hhs.gov)

Received 5 May 2014; accepted 9 July 2014; advance online publication 17 September 2014. doi:10.1038/clpt.2014.155
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Calcium, late sodiumFirst cell’s AP
Last cell’s AP

Study Highlights
WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

hERG potassium

33 The QT interval is a sensitive biomarker of drug-inducedhERG potassium channel block and torsade de pointes risk;
however, it is not specific. Characterization of the effects ofadditional inward current block (calcium or late sodium) on
cardiac repolarization may improve risk assessment because
inward current block can offset the proarrhythmic effects ofhERG potassium channel block.

Cellular
AP
R

WHAT QUESTION DID THIS STUDY ADDRESS?

Tpeak

33 This study tested the hypothesis that hERG potassium chan-

T
J

Surface
ECG
Q

S
QRS

Depolarization

J-Tpeak
Early repolarization

Tpeak-Tend
Late repolarization

Figure 1 An illustration of a ventricular action potential (AP) and thecorresponding surface electrocardiogram (ECG). Arrows pointing into the action
potential are inward currents (calcium and late sodium) and arrows pointingout denote outward currents (human ether-à-go-go-related gene (hERG)
potassium). Blocking the calcium or late sodium current primarily shortens theearly parts of repolarization (J–Tpeak), whereas hERG potassium channel block
prolongs both early (J–Tpeak) and late repolarization (Tpeak–Tend).

consistent with these inward currents being active during the early
repolarization phase of the action potential.13 However, the priorstudy13 was limited by the fact that in vitro ion channel data were
not available for all drugs and the risk of torsade de pointes was
not known for the drugs studied.
Therefore, we designed a prospective randomized controlled clinical trial, funded by the FDA’s Critical Path
Initiative, to assess the ECG effects of multiple marketeddrugs that either block the hERG potassium channel alone
or do so while also blocking calcium and sodium channels.
The selected drugs included four strong hERG potassiumchannel blockers with varying degrees of sodium and calcium channel block: dofetilide, quinidine, ranolazine, andverapamil.
Dofetilide is a strong pure hERG potassium channel
blocker14 with a high torsade risk.15 The second drug is quinidine, which is also a strong hERG potassium channel blocker,
but in addition to blocking the hERG potassium channel italso blocks calcium and sodium channels at high concentrations,14 and torsade has been observed to occur more frequently at lower plasma quinidine concentrations.16–18 The
last two drugs, ranolazine and verapamil, both block notonly the hERG potassium channel but also the late sodium
current (ranolazine) or L-type calcium channel (verapamil),likely explaining why they are both associated with a low riskof torsade.8,19
Administration of these four drugs to the same subjects enables the characterization of ECG signatures of pure hERG potassium channel block as compared with multichannel block. We
550

nel block prolongs both J–Tpeakc (early repolarization) andTpeak–Tend (late repolarization) intervals on the ECG, whereas
the addition of calcium or late sodium current block preferentially shortens J–Tpeakc.

Tend

WHAT THIS STUDY ADDS TO OUR KNOWLEDGE

33 This prospective clinical study demonstrated that pure hERG
potassium channel block equally prolongs both J–Tpeakc and
Tpeak–Tend, whereas additional inward current block (calcium
or late sodium) preferentially shortens J–Tpeakc.

HOW THIS MIGHT CHANGE CLINICAL PHARMACOLOGYAND THERAPEUTICS

33 Characterization of multichannel drug effects on human

ECGs is possible and may change cardiac safety assessment
by confirming comprehensive preclinical ion channel assessments and influence dosing strategies for drugs.

Table 1 Baseline characteristics
All subjects (N = 22)
Demographic
Age (years)

26.9 ± 5.5

Female11 (50%)Body mass index (kg/m2)

23.1 ± 2.6

Vital signs
Systolic blood pressure (mm Hg)

107.1 ± 8.5

Diastolic blood pressure (mm Hg)

59.7 ± 7.2

Heart rate (bpm)

56.8 ± 6.4

ECG
PR interval (ms)162.1 ± 21.6

QRS duration (ms)97.4 ± 6.7

J–Tpeakc (ms)225.6 ± 19.8

Tpeak–Tend (ms)73.1 ± 6.4

QTc (ms)

395.9 ± 17.1

Continuous variables are represented as mean ± SD.
ECG, electrocardiogram.

hypothesized that hERG potassium channel block prolongs both
the J–Tpeak and Tpeak–Tend intervals, whereas the addition of
calcium or late sodium current block preferentially shortens the
J–Tpeak interval.
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Clinic al Trialab

Quinidine ± 95% Cl (µg/ml)

Dofetilide ± 95% Cl (ng/ml)

Dofetilide

2

1

0

5

c

10
15
Time postdose (h)

20

1.5

1.0

0.5

25

0

5

d

Ranolazine
2.5

10
15
Time postdose (h)

20

25

20

25

Verapamil
150

2.0
Verapamil ± 95% Cl (ng/ml)

Ranolazine ± 95% Cl (µg/ml)

Quinidine

1.5

1.0

100

50

0.5

0
0

5

10
15
Time postdose (h)

20

25

0

5

10
15
Time postdose (h)Figure 2 Measured plasma concentrations (mean ± 95% confidence interval) for (a) dofetilide, (b) quinidine, (c) ranolazine, and (d) verapamil.

RESULTS

Twenty-two healthy subjects (11 females) participated inthis randomized controlled clinical trial with a mean age of
26.9 ± 5.5 years and a mean body mass index of 23.1 ± 2.6 kg/
m2; see Table 1 for baseline characteristics. All completed thestudy, except one subject who withdrew prior to the last treatment period. There were no unexpected treatment-related
adverse events.
Pharmacokinetic analysis

The results of the pharmacokinetic analysis are shown in Figure 2
for each drug: dofetilide (a), quinidine (b), ranolazine (c), andverapamil (d). Dofetilide and quinidine exhibited similar pharmacokinetic profiles, with maximum concentration occurring
at 2.5 h (range: 1–4.0 h) for dofetilide and at 2.0 h (0.5–4.0 h) for
quinidine, and with similar half-lives: (mean ± SD) 7.2 ± 1.1 h(dofetilide) and 7.8 ± 1.5 h (quinidine). The maximum concentrations for dofetilide and quinidine were 2.7 ± 0.3 ng/ml and
1.8 ± 0.4 µg/ml, respectively. Ranolazine peaked later at 4.0 h(1.0–14 h), with a concentration of 2.3 ± 1.4 µg/ml, and had a
half-life of 7.5 ± 4.0 h. Finally, verapamil peaked at 1.0 h (0.5–
2.0 h), with a plasma concentration of 130.3 ± 75.8 ng/ml, andhad a half-life of 10.4 ± 3.2 h.
Dofetilide: Pure hERG potassium channel block prolongs earlyand late repolarization equally

Dofetilide prolonged the heart rate–corrected global QT (QTc)interval by 79.3 ms (95% confidence interval (CI): 72.2–86.3 ms,
P < 0.001; Figure 3a), with equal prolongation of the heart rate–
corrected J–Tpeak (J–Tpeakc: 39.5 (32.8–46.2) ms, P < 0.001)
and Tpeak–Tend (40.0 (33.0–46.9) ms, P < 0.001). Similarly, theconcentration-dependent analysis showed that the QTc prolongation by dofetilide equally affected J–Tpeakc and Tpeak–Tend(J–Tpeakc: 14.1 (11.0–17.3) ms per ng/ml, P < 0.001; Tpeak–Tend:
14.5 (11.0–17.9) ms per ng/ml, P < 0.001; P = 0.89 for J–Tpeakc
vs. Tpeak–Tend; Figure 4a). These findings support the notionthat hERG potassium channel block prolongs both J–Tpeakc and
Tpeak–Tend.

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Dofetilide (hERG block)75

Quinidine (hERG>calcium>sodium block)75
QTc∆∆ ± 95% CI (ms)∆∆ ± 95% CI (ms)QTc
50
J–Tpeakc

Tpeak–Tend

25

0

50
Tpeak–Tend
J–Tpeakc
25

0

0

c

5

10
15
Time postdose (h)

20

25

0

d

Tpeak–Tend

QTc

10

∆∆ ± 95% CI (ms)∆∆ ± 95% CI (ms)0J–Tpeakc
5

10

25

20

10

0

20

Verapamil (calcium>hERG block)Tpeak–Tend

QTc

−10

15

Time postdose (h)Ranolazine (late sodium>hERG block)20

5

J–Tpeakc

10

0

−10
15

20

0

25

5

Time postdose (h)

10

15

20

25

Time postdose (h)QTc

J–Tpeakc

Tpeak–Tend

Figure 3 Drug-induced changes (mean ± 95% confidence interval) for the placebo-corrected change from baseline (ΔΔ) of QTc (gray), J–Tpeakc (orange), andTpeak–Tend (blue) for (a) dofetilide, (b) quinidine, (c) ranolazine, and (d) verapamil. The y-axis in each row of panels has been scaled to enhance interpretation.

Quinidine: strong hERG potassium channel block withadditional calcium and sodium channel block prolongs latemore than early repolarization

reducing the J–Tpeakc prolongation associated with hERG potassium channel block.

Similar to dofetilide, quinidine prolonged the global QTc by
78.1 ms (70.9–85.2 ms, P < 0.001; Figure 3b); however, quinidine
was more strongly associated with prolongation of Tpeak–Tend
than of J–Tpeakc (J–Tpeakc: 29.1 (22.4–35.9) ms, P < 0.001; Tpeak–Tend: 49.8 (42.8–56.8) ms, P < 0.001; Figure 3b). Similarly, theconcentration-dependent analysis showed a stronger relationship for Tpeak–Tend as compared with J–Tpeakc (J–Tpeakc: 11.6
(3.3–19.8) ms per µg/ml, P = 0.008; Tpeak–Tend: 29.9 (19.2–40.7)
ms per µg/ml; P < 0.001; P = 0.025 for J–Tpeakc vs. Tpeak–Tend;
Figure 4b). The preferential prolongation of Tpeak–Tend associated with quinidine is likely due to calcium channel block

Ranolazine: late sodium current block opposes hERG effects
on early repolarization

552

The global QTc prolongation associated with ranolazine was
12.6 ms (5.5–19.6 ms, P < 0.001; Figure 3c), primarily via prolonged Tpeak–Tend (J–Tpeakc: 3.3 (−3.4 to 9.9) ms, P = 0.34;
Tpeak–Tend: 8.8 (1.9–15.8) ms, P = 0.013; Figure 3c). A similar
observation was seen in the concentration-dependent analysis, in which ranolazine concentrations were associated with anincrease in Tpeak–Tend (4.4 (2.6–6.2) ms per µg/ml, P <0.001;
Figure 4c); however, there was no association with J–Tpeakc(P = 0.42) (P < 0.001 for J–Tpeakc vs. Tpeak–Tend; Figure 4c).
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Dofetilide (hERG block)

Quinidine (hERG>calcium>sodium block)

J−Tpeakc

50

25
Tpeak−Tend∆∆± 95% CI (ms)QTc∆∆± 95% CI (ms)

QTc

75

75

Tpeak−Tend

50

25

0

0

0

1

2
3
Concentration (ng/ml)

0

4

c

J−Tpeakc

1
2Concentration (µg/ml)dRanolazine (late sodium>hERG block)Tpeak−Tend

QTc

QTc

20

∆∆± 95% CI (ms)∆∆± 95% CI (ms)20

Verapamil (calcium>hERG block)100

Tpeak−Tend

J−Tpeak100

J−Tpeakc

−10

−10

0

1
2
3
Concentration (µg/ml)

4
QTc

0
J−Tpeakc

50
100
150
Concentration (ng/ml)

200

Tpeak−Tend

Figure 4 Drug-induced changes (mean ± 95% confidence interval) for the placebo-corrected change from baseline (ΔΔ) for QTc (gray), J–Tpeakc (orange),
and Tpeak–Tend (blue) from model predictions vs. plasma concentrations for (a) dofetilide, (b) quinidine, (c) ranolazine, and (d) verapamil. For clarity,
the observed data are not shown in this figure but are included in Supplementary Figure S1 online. The range of the x-axis is 1.5 times the observed
maximum concentration. The y-axis in each row of panels has been scaled to enhance interpretation. In each plot, the line represents the predicted meaneffect of the linear model and the shaded area represents 95% confidence intervals.

These findings suggest that late sodium current block primarily
reduces the J–Tpeakc prolongation associated with hERG potassium channel block.
Verapamil: strong calcium block opposes effects of hERG
block on early and late repolarization

Verapamil did not cause a significant change in global QTc (5.2(−1.8–12.2) ms, P = 0.15; Figure 2d), J–Tpeakc (−2.4 (−9.0–4.3)
ms, P = 0.49; Figure 2d), or Tpeak–Tend (4.8 (−2.2–11.7) ms,
P = 0.18; Figure 3d). Similar observations were made in theconcentration-dependent analysis (Figure 3d). The lack of prolongation of J–Tpeakc and Tpeak–Tend with verapamil suggeststhat strong calcium block may attenuate the effects of hERG
potassium channel block on both J–Tpeakc and Tpeak–Tend.

Effect of drugs on PR, QRS, and heart rate

The PR interval is most commonly prolonged by slowing conduction through the atrioventricular node, where primarily
calcium current regulates depolarization.20 Verapamil, a strong
calcium channel blocker, was related to PR prolongation (32.1(26.7–37.4) ms, P < 0.001), which was concentration dependent(0.2 (0.2–0.3) ms per ng/ml, P < 0.001). Quinidine, which blocks
the calcium channel,14 trended toward PR prolongation (5.1(−0.3–10.5) ms, P = 0.065); however, there was no concentration
dependence (P = 0.91). The lack of PR prolongation observedin this study with quinidine despite its calcium channel block
is likely because of competing autonomic effects on atrioventricular conduction.21 Consistent with minimal calcium channel
block, only a small amount of PR prolongation was observed

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Dofetilide (hERG block)40

Tpeak−Tend∆∆± 95% CI (ms)∆∆± 95% CI (ms)40

Ranolazine (late sodium>hERG block)

J−Tpeakc

20

QTc

0

Tpeak−Tend

20

QTc

0
J−Tpeakc

0.00

0

0.25
0.50
0.75
Concentration (ng/ml)
QTc

J−Tpeakc

12
34
Concentration (µg/ml)

5

Tpeak−Tend

Figure 5 Drug-induced changes in J–Tpeakc and Tpeak–Tend for (a) a pure hERG potassium channel blocker (dofetilide) and (b) a hERG + late sodium current
blocker (ranolazine). This zoomed plot of the concentrations of dofetilide that produce an amount of QTc prolongation comparable to that of ranolazine shows
the ability of J–Tpeakc and Tpeak–Tend to detect multichannel block. hERG, human ether-à-go-go-related gene.

for ranolazine (6.5 (1.1–11.8) ms, P = 0.018 and 1.1 (0.1–2.0)
ms per µg/ml, P = 0.033).19 No PR prolongation was observed
for dofetilide, consistent with a lack of calcium channel block.14
Blocking the sodium current increases QRS duration by slowing ventricular conduction.22 Quinidine is a sodium channel
blocker, but at the concentrations observed in this study, quinidine is expected to block the sodium current only minimally.14
Quinidine only trended toward QRS prolongation (2.1 (−0.2
to 4.3) ms, P = 0.071), and there was no correlation between
plasma levels and QRS increase (P = 0.95). Ranolazine is also a
sodium channel blocker, but it has weak peak sodium current
block,19 and was associated with only a slight QRS prolongation(2.7 (0.5–4.9) ms, P = 0.018); however, there was no correlation between plasma levels and QRS (P = 0.060). Neither dofetilide nor verapamil is associated with sodium channel block.14
Dofetilide produced no QRS prolongation, and verapamil produced a slight QRS prolongation (2.6 (0.4–4.8) ms, P = 0.020);
however, there was no positive relationship between concentration and QRS (P = 0.39).
Finally, verapamil and quinidine caused an increase inheart rate of 9.4 bpm ((6.4–12.4), P < 0.001) and 9.8 bpm((6.8–12.9), P < 0.001), respectively. In both cases, there wasa relationship between plasma concentration and heart rate(verapamil: 0.07 (0.05–0.09) bpm per ng/ml, P < 0.001; quinidine: 4.7 (3.4–6.1) bpm per µg/ml, P < 0.001). Dofetilide did
not cause any change in heart rate (P = 0.12), and ranolazine
increased heart rate slightly (4.2 (1.2–7.2) bpm, P = 0.007);
however, there was no relationship between concentration andheart rate (P = 0.22).
DISCUSSION

This prospective randomized controlled clinical trial demonstrated that by separating the QT interval into early554

repolarization (global J–Tpeakc) and late repolarization (global
Tpeak–Tend), a pure hERG potassium channel–blocking drugwith high torsade risk can be differentiated from multichannelblocking drugs that also block inward currents (calcium or latesodium) during repolarization. Detecting additional calcium
or late sodium current block is of importance because boththe calcium and sodium current support early afterdepolarizations, which can trigger torsade de pointes.6–8 Thus, being able
to detect multichannel effects using the ECG may have implications for the future of cardiac safety evaluation of drugs andclinical dosing strategies.
The results of this study demonstrate that pure hERG potassium channel block (dofetilide) equally prolongs J–Tpeakc and
Tpeak–Tend, whereas additional calcium and late sodium current block (quinidine, ranolazine, and verapamil) preferentiallyshorten J–Tpeakc. Of note, the pure hERG potassium channel
blocker dofetilide and the multichannel blocker quinidine
caused equal QTc prolongation. Despite the comparable QTc
prolongation, dofetilide and quinidine were associated with different effects on J–Tpeakc and Tpeak–Tend, suggesting that the
QTc interval cannot differentiate pure hERG potassium channel
block from multichannel block. As an example of this, Figure 5
shows a comparison between concentrations of dofetilide andranolazine that produce equal amounts of QTc prolongation.
From this figure, it is clear that the QTc interval cannot differentiate multichannel block, whereas evaluation of J–Tpeak and
Tpeak–Tend intervals provides insight into multichannel blockthat is of relevance for cardiac safety evaluation. These findings
suggest that future studies should consider reporting the ratioof the changes in J–Tpeakc and Tpeak–Tend.
It is notable that dofetilide and quinidine caused substantial
QTc prolongation (~78 ms) in the present study. These results are
consistent with those from prior single-dose studies of dofetilide
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Clinic al Trialand quinidine. Coz et al.23 reported a slope of dofetilide concentration vs. QTc of 31 ms per ng/ml, compared with 29 ms per
ng/ml in our study. Benton et al. 24 reported a slope of quinidine
concentration vs. QTc of 29 ms per µg/ml in men and 42 ms perµg/ml in women, compared with 43 ms per µg/ml in our study.
However, a separate study of dofetilide 750 µg twice daily for 4days only observed a QTc prolongation of ~60 ms.25 This could
be due to differences in measurement of the end of the T-wave,
differences in study design, or decreased sensitivity to dofetilide
over time as reported in the dofetilide label.26
The lack of Tpeak–Tend prolongation with verapamil suggeststhat when calcium channel block is stronger than hERG potassium channel block, it may also attenuate the effect of hERG
potassium channel block on Tpeak–Tend. These findings withverapamil are consistent with those in the rabbit heart, in whichchanges in QT and Tpeak–Tend were not observed at concentrations similar to those observed in this study.27 Previously,
calcium channel block has been proposed to be detected by anincrease in the PR interval,13 which was the case for verapamilin this study but not for quinidine. The reason for the lack of PR
prolongation with quinidine is likely due to quinidine’s competing autonomic effects on atrioventricular node conduction, as
quinidine has been shown to prolong PR in heart transplantpatients.21 Therefore, PR prolongation is not always present withcalcium channel block, and other markers such as J–Tpeakc and
Tpeak–Tend might prove more universally useful to detect thepresence of calcium channel block.
Interestingly, these drug-induced ECG signature patterns
have been observed previously with electrolyte abnormalities and with genetic abnormalities of ion channels. As earlyas the 1950s,28 it was observed that hypokalemia prolongs the
QT interval and flattens and widens the T-wave. This is in contrast to QT prolongation from hypocalcemia, which causes ST
segment lengthening without T-wave changes.28 Hypokalemic
QT prolongation has been attributed to increasing the rate at
which hERG potassium channels inactivate.29,30 Similarly, therate of inactivation for calcium channels is dependent on calcium concentrations and has been shown to be the reason for
hypercalcemia-induced action potential shortening.31 Thus,
hypokalemia creates the equivalent of hERG potassium channel
block, whereas hypercalcemia creates the equivalent of calcium
channel block. Similarly, genetic abnormalities in the hERG
potassium channel (congenital long QT type 2) cause flattening and widening of the T-wave, as with drug-induced hERG
potassium channel block. Genetic abnormalities in the sodium
channel (congenital long QT type 3) cause prolongation of the
ST segment with a normal T-wave.32
Therapeutic implications of multiple ion channel effects

With pure hERG potassium channel block, there is likely a direct
relationship between increasing plasma drug concentration andtorsade risk. For example, with dofetilide, there is a relationshipamong dose, QTc, and torsade risk.33 However, with quinidine,torsade has been observed to occur more frequently at lower
plasma quinidine concentrations.16 This has been confirmed in
preclinical models in which the number of quinidine-induced

arrhythmias was greater at lower rather than higher quinidine
concentrations,17,18 which is associated with more calcium andlate sodium current block.
The development of torsade requires an electrical trigger andthen a substrate to support re-entry.34 Because of the differential
expression of ion channels throughout the heart, hERG potassium channel block accentuates dispersion of repolarization,
thus creating the substrate for re-entry.35 The trigger for torsade
is believed to be early afterdepolarizations, which can occur as aresult of increased calcium or sodium current during repolarization.6,7 Thus, calcium and late sodium current block can prevent
early afterdepolarizations (the trigger for torsade).
The Tpeak–Tend interval, as measured in a precordial lead, hasbeen proposed as a measure of transmural dispersion of repolarization.36 The relationship between transmural dispersion and
Tpeak–Tend is subject to controversy as it has been proposed that
Tpeak–Tend instead reflects total dispersion and not transmuraldispersion.37,38 Tpeak–Tend has, however, been shown to be prolonged by hERG potassium channel block and to be longer in long
QT2 patients (abnormalities in the hERG potassium channel) as
compared with long QT1 (abnormalities in the slow potassiumchannel) and long QT3 (abnormalities in the sodium channel)
patients.13,39 In this study, we quantified Tpeak–Tend globally on
the vector magnitude derived lead, which is likely more consistent than measuring Tpeak–Tend in a single lead in the presence ofcomplex T-wave patterns.
Many drugs remain on the market with a known torsade risk,
including numerous antibiotics and antimalarial, antiviral, psychiatric, oncology, and cardiac drugs.40 This raises the questionof whether adding a late sodium- or calcium current–blocking drug to a hERG potassium channel–blocking drug could
decrease torsade risk. This concept has been evaluated in canine
studies, in which mexiletine (late sodium current blocker)
decreased the torsade risk associated with sotalol (strong hERG
potassium channel blocker).41 Mexiletine has also been evaluated as a potential “gene-specific” therapy for patients withcongenital long QT syndrome. In patients with congenital
long QT type 3 (abnormalities in the sodium channel), it has
been shown that administering mexiletine shortened their QTintervals.42 Similar observations have been made with ranolazine.43 In the mexiletine study, the investigators also evaluatedthe effects of mexiletine treatment in patients with long QTtype 2 (abnormalities in the hERG potassium channel). Theyobserved a numerical decrease in QTc that was not statisticallysignificant; however, only six patients were studied. In addition,
mexiletine has been shown to decrease the QTc interval in a
subject with Timothy syndrome (abnormalities in the calcium
channel).44 Furthermore, the potential antiarrhythmic effectof mexiletine was evaluated in clinical studies in which mexiletine was administered in combination with quinidine. When
mexiletine was administered on its own, there were no significant changes in QTc, but when mexiletine was administeredto patients already receiving quinidine, there was a significant
shortening of the quinidine-induced QTc prolongation.45,46
These studies suggest that coadministering an inward current
blocker with a hERG potassium channel blocker could offset

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555

Clinic al Trial

I

avR

V1

V4

II

avL

V2

V5

III

avF

V3

V6

Transform tovectorcardiogram

QRS loop

Tpeak
Vector magnitude
lead
Tend

T-wave loop

Figure 6 Method for assessment of the global Tpeak and Tend. The 12-lead electrocardiogram is transformed to the vectorcardiogram via a publishedtransformation matrix.55 The peak and end of the T-wave are located in the vector magnitude lead. The end of the T-wave is determined using the tangent
method,56 which involves locating the intersection between the line through the terminal descending part of the T-wave and the isoelectric line.

the hERG potassium channel blocking effects, which should be
evaluated in further studies.
Limitations

Two of the drugs (dofetilide and quinidine) are associated withmassive QTc increases and T-wave changes, including notching, which can make Tpeak and Tend determination difficult.
However, there was strong agreement between two independent
assessments of all ECGs and less than 5 ms difference in 98.6%of the ECGs. It should also be recognized that because the QTinterval is subject to rate dependency and delayed adaptation toheart rate, it is likely that the J–Tpeak and Tpeak–Tend intervals
are as well. Rate dependency for both the J–Tpeak and Tpeak–
Tend intervals has been established previously, but the effect on
Tpeak–Tend at near-resting heart rates is minimal,13,47 and thus
the Tpeak–Tend interval was not corrected for heart rate.
It is possible that using individualized heart rate correction
would lead to results different from those using populationbased heart rate correction (i.e., the same correction factor
for all subjects) as was done in this study for QT and J–Tpeak.
Different heart rate correction methods are likely to influence
results only for drugs that significantly affect heart rate.48 In ourstudy, quinidine and verapamil increased heart rate by 10 and
9 bpm, respectively. For quinidine, it is unlikely that a different
heart rate correction method would change the results because
J–Tpeakc, Tpeak–Tend, and QTc prolongation were strongly associated with quinidine concentration, and the effect of quinidine
on Tpeak–Tend was almost twice that of its effect on J–Tpeakc.
For verapamil, it is possible that an individualized correction556

for heart rate could cause different results. Finally, the potential
effects of delayed adaptation of repolarization to heart rate (hysteresis) were minimized by measuring the intervals in ECGs at
stable heart rates.49
Conclusion

This study supports the hypothesis that ECG measures of early
repolarization (global J–Tpeakc) and late repolarization (global
Tpeak–Tend) can differentiate pure hERG potassium channel blockassociated with a high torsade risk from combined hERG potassium channel and inward current block (calcium or late sodium),
which may lower torsade risk. By contrast, evaluating only the
QTc interval does not detect multichannel block. This clinicalstudy investigating the ECG signatures of multichannel blockis one of three efforts studying potential approaches to improvethe current regulatory paradigm of focusing almost exclusively
on hERG potassium channel block and QTc. This includes aComprehensive in vitro Proarrhythmia Assay (CiPA),50 in which
the effects of drugs on multiple ion channels would be assessed,
and the use of detailed ECG collection in early clinical studies
with exposure–response analysis.51 Ultimately, future approaches
will likely use a more mechanistic approach to evaluate the riskfor drug-induced torsade de pointes.
METHODS

Clinical study design. We conducted a randomized controlled five-way

single-dose crossover clinical trial in 22 healthy volunteers (11 females)
at a phase I clinical research unit (Spaulding Clinical, West Bend, WI).
The study was approved by the US Food and Drug Administration
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Clinic al Trial
Research Involving Human Subjects Committee and the local institutional review board. All subjects gave written informed consent. The
drugs evaluated in this study were dofetilide (500 µg, Tikosyn, Pfizer,
New York, NY), quinidine sulfate (400 mg, Watson Pharma, Corona,CA), ranolazine (1,500 mg, Ranexa, Gilead, Foster City, CA), and verapamil hydrochloride (120 mg, Heritage Pharmaceuticals, Edison, NJ).
The inclusion criteria required subjects to be of general good healthas determined by a physician, without a history of heart disease or unexplained syncope or a family history of long QT syndrome; to be 18–35
years of age, weigh at least 50 kg, and have a body mass index of 18–27 kg/m2; and to be able to read and understand the informed consent. In addition, subjects were excluded if they had more than 10 ectopic beats during
a 3-h continuous ECG recording at screening.
In the morning of each treatment period, the subjects received one of
the four drugs or placebo under fasting conditions. There was a 7-day
washout period between each 24-h treatment period, so subjects received
treatment on days 1, 9, 17, 25, and 33. Prior to dosing, a continuous
12-lead ECG recorder (Surveyor, Mortara Instrument, Milwaukee, WI)
using the Mason–Likar52 electrode configuration was connected to eachsubject. The continuous ECG recordings were made at 500 Hz and with
an amplitude resolution of 2.5 µV. From the continuous recording, three
replicate 10-s ECGs (pre- and postdose) were extracted at 16 predefinedtime-points (predose and 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 5, 6, 7, 8, 12, 14, 24 h
postdose), during which the subjects were resting in a supine position for
10 min. After each ECG extraction time-point period, a blood sample
was drawn for pharmacokinetic analysis. Plasma drug concentration wasdetermined using a validated liquid chromatography with tandem mass
spectroscopy method by Frontage Laboratories (Exton, Philadelphia, PA).
ECG assessment. At each of the 16 time-points, three optimal ECGs
were extracted with stable heart rates and maximum signal quality
using Antares software (AMPS, New York, NY).49 This resulted in a
total of 48 ECGs per subject per treatment period and 5,280 planned
ECGs in total, which were all evaluated with computerized intervalannotations on high-resolution images by the ECG reader, who was
blinded to treatment and time. The same ECG reader evaluated all
ECGs from the same subject and determined Ponset, QRSonset, and
QRSoffset using lead II. To quantify the global repolarization intervals, two ECG readers blinded to treatment and time determined theglobal peak and end of the T-wave independently using previously
developed software53,54 on the vector magnitude of the vectorcardiogram (obtained from the Mason–Likar 12-lead ECG by applying
the Guldenring transformation matrix).55 The end of the T-wave wasdetermined using the tangent method,56 which involves locating theintersection between the line through the terminal descending part of
the T-wave and the isoelectric line (Figure 6). This approach of using
the tangent method in the vector magnitude lead produces more consistent measurements of the QT interval.57 Of note, the U-wave was
not included in the measurement of the end of the T-wave.
Notably, globally measured Tpeak–Tend is different as compared with
Tpeak–Tend measured in a precordial lead, which has been proposed asa measure of transmural dispersion.36 The relationship between Tpeak–
T end and transmural dispersion, is, however, subject todiscussion.37,38 Tpeak–Tend was measured globally, which is likely moreconsistent in the presence of complex T-wave patterns. Tpeak was definedas the first discernable peak in the T-wave. Disagreements on a T-wave
being measureable, presence of a notch, or a difference of more than 5 ms
in either Tpeak or T-waveoffset were re-reviewed and adjudicated by anexpert ECG reader. This was the case for 73 ECGs (or ~1.4%). From themeasured fiducial points, the PR, QRS, J–Tpeak (QRSoffset to global T-wavepeak), Tpeak–Tend (global Tpeak to Tend), and QT intervals were obtained(based on the global Tend). J–Tpeak was corrected for heart rate using a
coefficient obtained from a previous analysis of pooled subjects from 34
thorough QT studies13 (J–Tpeakc = J–Tpeak/RR0.58 with RR in seconds),
and QT was corrected with Fridericia’s correction58 (QTc = QT/RR1/3
with RR in seconds). Although heart rate dependency for Tpeak–Tend has
been reported,47 rate correction was not performed for Tpeak–Tend. Ratec­ orrection was not done because previous studies, including a pooled
analysis of subjects from 34 thorough QT studies, have shown that at
resting heart rates Tpeak–Tend exhibits minimal heart rate dependency.13,47
Statistical analysis. The placebo-corrected change from baseline wascomputed using PROC MIXED in SAS 9.3 (SAS Institute, Cary, NC).
The change from baseline for each ECG biomarker (e.g., the average
QTc, Tpeak–Tend) by time-point was the dependent variable, for whichbaseline was defined as the average predose value. Sequence, period,time, treatment, and an interaction between treatment and time were
included as fixed effects, and subject was included as a random effect.
In addition, exposure–response analysis was performed with a linear
mixed-effects model to evaluate the relationship between plasma drugconcentrations and ECG measurements.59 Differences in J–Tpeakc
and Tpeak–Tend for each drug were compared using a paired t-test in
R 2.15.3 (R Foundation for Statistical Computing, Vienna, Austria). P
values <0.05 were considered statistically significant.
SUPPLEMENTARY MATERIAL is linked to the online version of the paper at
http://www.nature.com/cpt
ACKNOWLEDGMENTS
We thank Jill Coker, FDA extramural clinical studies coordinator, and staff
at Spaulding Clinical Research for executing the study. This project was
supported in part by appointments to the Research Participation Programs
at the Oak Ridge Institute for Science and Education through an interagency
agreement between the Department of Energy and the FDA. The opinions
presented here are those of the authors. No official support or endorsementby the FDA is intended nor should be inferred. The mention of commercial
products, their sources, or their use in connection with material reported
herein is not to be construed as either an actual or implied endorsement ofsuch products by the FDA. This project was supported by the FDA’s Critical
Path Initiative and Office of Women’s Health.
AUTHOR CONTRIBUTIONS
D.G.S., L.J., J.V., J.W.M., C.S., K.W.-L., M.H., P.G., J.S.S., L.G., J.L., J.F., M.U., and N.S.
wrote the manuscript. D.G.S., L.J., J.V., J.W.M., L.G., J.F., and N.S. designed thestudy. D.G.S., L.J., J.V., J.W.M., C.S., K.W.-L., M.H., P.G., and J.L. performed thestudy. D.G.S., L.J., J.V., J.W.M., C.S., K.W.-L., M.H., P.G., J.S.S., L.G., J.L., J.F., M.U.,
and N.S. analyzed the data.
CONFLICT OF INTEREST
J.W.M., K.W.-L., and C.S. are employees of Spaulding Clinical Research, and
M.H., P.G., and J.L. are employees of Frontage Laboratories, which are contract
research organizations. The other authors declared no conflict of interest.
© 2014 American Society for Clinical Pharmacology and Therapeutics

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