ecently, arsenic trioxide (As2O3) has been shown to induce complete remission of acute promyelocytic leukemia (APL) 1 and both the USA Food and Drug Administration (FDA) and the Ministry of Health, Labor and Welfare of Japan have approved As2O3 for the treatment of APL. However, As2O3 is also a poison that causes multiple organ failure. Toxic effects on the cardiac system include: torsades de pointes (TdP), T-U wave alternans, ST-T change and QT interval prolongation. 2-4 The FDA reported that the incidence of QT interval prolongation was 40%, and recommended particular attention be paid to QT interval prolongation. We previously reported that QT interval prolongation occurred in all of 8 APL patients treated with As2O3, and recent studies in isolated guinea pig papillary muscles have also shown that As2O3 prolongs the action potential duration (APD) in a reverse frequency-dependent way, as well as blocking both Ikr and Iks in HERGor KCNQ1 + KCNE1-transfected CHO cells. 5,6 However, Circulation Journal Vol.70, November 2006 the toxic effects of As2O3 are complex and the involvement of other undetermined mechanisms other than prolongation of APD is implied. Previous studies have shown cellular Ca 2+ overload, generation of reactive oxygen species (ROS), and decreased intracellular ATP concentration ([ATP]i), 7-9 which may provoke triggered activities because of earlyand delayed afterdepolarization (EAD and DAD). In fact, we have observed not only TdP but also non-sustained monomorphic ventricular tachycardias in patients treated with As2O3. 2 In order to investigate the arrhythmogenesis of As2O3, we evaluated the changes of in ECG parameters in patients with APL during As2O3 therapy, and also examined the electromechanical effects of As2O3 in isolated guinea pig papillary muscles.
Methods
ECG ChangesThis investigation conforms to the principles outlined in the Declaration of Helsinki (Cardiovascular Research 1997; 35: 2-4). Twenty patients with APL who had relapsed after previous extensive therapies with all-trans retinoic acid and other chemotherapies were treated with As2O3 (0.15 mg· kg -1 ·day -1 ). The 12-lead ECG and chest X-ray were recorded once a week and telemetry ECG was monitored throughout the admission period. The following parameters Background Arsenic trioxide (As2O3) is a new promising regimen for patients with a relapse of acute promyelocytic leukemia (APL), but causes life-threatening arrhythmias. This study aimed to investigate the incidence and mechanism of arrythmogenesis caused by As2O3.
Methods and ResultsStandard 12-lead ECGs were monitored throughout As2O3 therapy in 20 APL patients. As2O3 (0.15 mg/kg) significantly prolonged the corrected QT interval (QTc: 445±7 to 517±17 ms, means±SE, p<0.01), and also increased the QTc dispersion and transmural dispersion of repolarization. Non-sustained ventricular tachycardias and torsades de pointes occurred in 4 and 1 patients, respectively. The action potentials and isometric contraction were measured in guinea pig papillary muscles during A...