Genetic in long QT syndromes

The long QT syndrome (LQTS) is a genetic disorder characterized by prolongation of the QT interval in the electrocardiogram (ECG) and a propensity to "torsades de pointes" ventricular tachycardia frequently leading to syncope, cardiac arrest, or sudden death usually in young otherwise healthy individuals. LQTS caused by mutations of predominantly potassium and sodium ion channel genes or channel-interacting proteins leading to positive overcharge of myocardial cell with consequent heterogeneous prolongation of repolarization in various layers and regions of myocardium. These conditions facilitate the early after-depolarization and reentry phenomena underlying development of polymorphic ventricular tachycardia observed in patients with LQTS. Obtaining detailed patient history regarding cardiac events in the patient and his/her family members combined with careful interpretation of standard 12-lead ECG (with precise measurement of QT interval in all available ECGs and evaluation of T-wave morphology) usually is sufficient to diagnose the syndrome. The LQTS show great genetic heterogeneity and has been identified more than 500 mutations distributed in 10 genes: KCNQ1, HERG, SCN5A, KCNE1, KCNE2, ANKB, KCNJ2, CACNA1A, CAV3 and SCN4B. Despite advances in the field, 25-30% of patients remain undiagnosed genetic. Genetic testing plays an important role and is particularly useful in cases with nondiagnostic or borderline ECG findings.

The RYR2-encoded ryanodine receptor/calcium release channel in patients diagnosed previously with either catecholaminergic polymorphic ventricular tachycardia or genotype negative, exercise-induced long QT syndrome: a comprehensive open reading frame mutational analysis.

OBJECTIVES This study was undertaken to determine the spectrum and prevalence of mutations in the RYR2-encoded cardiac ryanodine receptor in cases with exertional syncope and normal corrected QT interval (QTc). BACKGROUND Mutations in RYR2 cause type 1 catecholaminergic polymorphic ventricular tachycardia (CPVT1), a cardiac channelopathy with increased propensity for lethal ventricular dysrhythmias. Most RYR2 mutational analyses target 3 canonical domains encoded by <40% of the translated exons. The extent of CPVT1-associated mutations localizing outside of these domains remains unknown as RYR2 has not been examined comprehensively in most patient cohorts. METHODS Mutational analysis of all RYR2 exons was performed using polymerase chain reaction, high-performance liquid chromatography, and deoxyribonucleic acid sequencing on 155 unrelated patients (49% females, 96% Caucasian, age at diagnosis 20 +/- 15 years, mean QTc 428 +/- 29 ms), with either clinical diagnosis of CPVT (n = 110) or an initial diagnosis of exercise-induced long QT syndrome but with QTc <480 ms and a subsequent negative long QT syndrome genetic test (n = 45). RESULTS Sixty-three (34 novel) possible CPVT1-associated mutations, absent in 400 reference alleles, were detected in 73 unrelated patients (47%). Thirteen new mutation-containing exons were identified. Two-thirds of the CPVT1-positive patients had mutations that localized to 1 of 16 exons. CONCLUSIONS Possible CPVT1 mutations in RYR2 were identified in nearly one-half of this cohort; 45 of the 105 translated exons are now known to host possible mutations. Considering that approximately 65% of CPVT1-positive cases would be discovered by selective analysis of 16 exons, a tiered targeting strategy for CPVT genetic testing should be considered.

Syntrophin mutation associated with long QT syndrome through activation of the nNOS-SCN5A macromolecular complex.

Mutations in 11 genes that encode ion channels or their associated proteins cause inherited long QT syndrome (LQTS) and account for approximately 75-80% of cases (LQT1-11). Direct sequencing of SNTA1, the gene encoding alpha1-syntrophin, was performed in a cohort of LQTS patients that were negative for mutations in the 11 known LQTS-susceptibility genes. A missense mutation (A390V-SNTA1) was found in a patient with recurrent syncope and markedly prolonged QT interval (QTc, 530 ms). SNTA1 links neuronal nitric oxide synthase (nNOS) to the nNOS inhibitor plasma membrane Ca-ATPase subtype 4b (PMCA4b); SNTA1 also is known to associate with the cardiac sodium channel SCN5A. By using a GST-fusion protein of the C terminus of SCN5A, we showed that WT-SNTA1 interacted with SCN5A, nNOS, and PMCA4b. In contrast, A390V-SNTA1 selectively disrupted association of PMCA4b with this complex and increased direct nitrosylation of SCN5A. A390V-SNTA1 expressed with SCN5A, nNOS, and PMCA4b in heterologous cells increased peak and late sodium current compared with WT-SNTA1, and the increase was partially inhibited by NOS blockers. Expression of A390V-SNTA1 in cardiac myocytes also increased late sodium current. We conclude that the A390V mutation disrupted binding with PMCA4b, released inhibition of nNOS, caused S-nitrosylation of SCN5A, and was associated with increased late sodium current, which is the characteristic biophysical dysfunction for sodium-channel-mediated LQTS (LQT3). These results establish an SNTA1-based nNOS complex attached to SCN5A as a key regulator of sodium current and suggest that SNTA1 be considered a rare LQTS-susceptibility gene.

Clinical and genetic characteristics of long QT syndrome

Long QT syndrome (LQTS) is an arrhythmogenic ion channel disorder characterized by severely abnormal ventricular repolarization, which results in prolongation of the electrocardiographic QT interval. The condition is associated with sudden cardiac death due to malignant ventricular arrhythmias similar in form to the hallmark torsade de pointes. Eleven years after the identification of the principle cardiac channels involved in the condition, hundreds of mutations in, to date, 10 genes have been associated with the syndrome. Genetic investigations carried out up until the present have shown that, although the severe form of the disease is sporadic, there are a number of common polymorphisms in genes associated with the condition that may confer susceptibility to the development of torsade de pointes in some individuals, particularly when specific drugs are being administered. Moreover, some polymorphisms have been shown to have regulatory properties that either enhance or counteract a particular mutation's impact. Understanding of the molecular processes underlying the syndrome has enabled treatment to be optimized and has led to better survival among sufferers, thereby demonstrating a key correspondence between genotype, phenotype and therapy. Despite these developments, a quarter of patients do not have mutations in the genes identified to date. Consequently, LQTS continues to be an area of active research. This article contains a summary of the main clinical and genetic developments concerning the syndrome that have taken place during the last decade.

SCN4B-encoded sodium channel beta4 subunit in congenital long-QT syndrome.

BACKGROUND Congenital long-QT syndrome (LQTS) is potentially lethal secondary to malignant ventricular arrhythmias and is caused predominantly by mutations in genes that encode cardiac ion channels. Nearly 25% of patients remain without a genetic diagnosis, and genes that encode cardiac channel regulatory proteins represent attractive candidates. Voltage-gated sodium channels have a pore-forming alpha-subunit associated with 1 or more auxiliary beta-subunits. Four different beta-subunits have been described. All are detectable in cardiac tissue, but none have yet been linked to any heritable arrhythmia syndrome. METHODS AND RESULTS We present a case of a 21-month-old Mexican-mestizo female with intermittent 2:1 atrioventricular block and a corrected QT interval of 712 ms. Comprehensive open reading frame/splice mutational analysis of the 9 established LQTS-susceptibility genes proved negative, and complete mutational analysis of the 4 Na(vbeta)-subunits revealed a L179F (C535T) missense mutation in SCN4B that cosegregated properly throughout a 3-generation pedigree and was absent in 800 reference alleles. After this discovery, SCN4B was analyzed in 262 genotype-negative LQTS patients (96% white), but no further mutations were found. L179F was engineered by site-directed mutagenesis and heterologously expressed in HEK293 cells that contained the stably expressed SCN5A-encoded sodium channel alpha-subunit (hNa(V)1.5). Compared with the wild-type, L179F-beta4 caused an 8-fold (compared with SCN5A alone) and 3-fold (compared with SCN5A + WT-beta4) increase in late sodium current consistent with the molecular/electrophysiological phenotype previously shown for LQTS-associated mutations. CONCLUSIONS We provide the seminal report of SCN4B-encoded Na(vbeta)4 as a novel LQT3-susceptibility gene.

New perspectives in long QT syndrome

Long QT Syndrome (LQTS) is a cardiac channelopathy characterized by prolonged ventricular repolarization and increased risk to sudden death secondary to ventricular dysrrhythmias. Was the first cardiac channelopathy described and is probably the best understood. After a decade of the sentinel identification of ion channel mutation in LQTS, genotype-phenotype correlations have been developed along with important improvement in risk stratification and genetic guided-treatment. Genetic screening has shown that LQTS is more frequent than expected and interestingly, ethnic specific polymorphism conferring increased susceptibility to drug induced QT prolongation and torsades de pointes have been identified. A better understanding of ventricular arrhythmias as an adverse effect of ion channel binding drugs, allow the development of more safety formulas and better control of this public health problem. Progress in understanding the molecular basis of LQTS has been remarkable; eight different genes have been identified, however still 25% of patients remain genotype-negative. This article is an overview of the main LQTS knowledge developed during the last years.

Massive Boson Production at Small qT in Soft-Collinear Effective Theory

We study the differential cross sections for electroweak gauge-boson and Higgs production at small and very small transverse-momentum qT. Large logarithms are resummed using soft-collinear effective theory. The collinear anomaly generates a non-perturbative scale q⁎, which protects the processes from receiving large long-distance hadronic contributions. A numerical comparison of our predictions with data on the transverse-momentum distribution in Z-boson production at the Tevatron and LHC is given.

Electroweak gauge-boson and Higgs production at Small qT: Infrared safety from the collinear anomaly

We discuss the differential cross sections for electroweak gauge-boson and Higgs production at small and very small transverse momentum q_T. Large logarithms are resummed using soft-collinear effective theory. The collinear anomaly generates a non-perturbative scale q^∗, which protects the processes from receiving large long-distance hadronic contributions. A numerical comparison of our predictions with data on the transverse-momentum distribution in Z-boson production at the Tevatron and LHC is given.

Multiple independent genetic factors at NOS1AP modulate the QT interval in a multi-ethnic population.

Extremes of electrocardiographic QT interval are associated with increased risk for sudden cardiac death (SCD); thus, identification and characterization of genetic variants that modulate QT interval may elucidate the underlying etiology of SCD. Previous studies have revealed an association between a common genetic variant in NOS1AP and QT interval in populations of European ancestry, but this finding has not been extended to other ethnic populations. We sought to characterize the effects of NOS1AP genetic variants on QT interval in the multi-ethnic population-based Dallas Heart Study (DHS, n = 3,072). The SNP most strongly associated with QT interval in previous samples of European ancestry, rs16847548, was the most strongly associated in White (P = 0.005) and Black (P = 3.6 x 10(-5)) participants, with the same direction of effect in Hispanics (P = 0.17), and further showed a significant SNP x sex-interaction (P = 0.03). A second SNP, rs16856785, uncorrelated with rs16847548, was also associated with QT interval in Blacks (P = 0.01), with qualitatively similar results in Whites and Hispanics. In a previously genotyped cohort of 14,107 White individuals drawn from the combined Atherosclerotic Risk in Communities (ARIC) and Cardiovascular Health Study (CHS) cohorts, we validated both the second locus at rs16856785 (P = 7.63 x 10(-8)), as well as the sex-interaction with rs16847548 (P = 8.68 x 10(-6)). These data extend the association of genetic variants in NOS1AP with QT interval to a Black population, with similar trends, though not statistically significant at P<0.05, in Hispanics. In addition, we identify a strong sex-interaction and the presence of a second independent site within NOS1AP associated with the QT interval. These results highlight the consistent and complex role of NOS1AP genetic variants in modulating QT interval.

Genetic association study of QT interval highlights role for calcium signaling pathways in myocardial repolarization

The QT interval, an electrocardiographic measure reflecting myocardial repolarization, is a heritable trait. QT prolongation is a risk factor for ventricular arrhythmias and sudden cardiac death (SCD) and could indicate the presence of the potentially lethal mendelian long-QT syndrome (LQTS). Using a genome-wide association and replication study in up to 100,000 individuals, we identified 35 common variant loci associated with QT interval that collectively explain ∼8-10% of QT-interval variation and highlight the importance of calcium regulation in myocardial repolarization. Rare variant analysis of 6 new QT interval-associated loci in 298 unrelated probands with LQTS identified coding variants not found in controls but of uncertain causality and therefore requiring validation. Several newly identified loci encode proteins that physically interact with other recognized repolarization proteins. Our integration of common variant association, expression and orthogonal protein-protein interaction screens provides new insights into cardiac electrophysiology and identifies new candidate genes for ventricular arrhythmias, LQTS and SCD.

Del orden del cosmos al "yo" disperso : distancias, espacios y experiencias en una perspectiva diacrónica de las escrituras del viaje

El presente trabajo constituye una propuesta para abordar textos referidos al viaje que se basa en analizar la mayor o menor relevancia dada a la distancia recorrida, al exotismo o extrañeza de los espacios visitados y a las experiencias en cuanto modificadoras de la persona del viajero. Las concepciones de diversas épocas sobre el mundo exterior y sobre el interior del "yo" han ejercido una influencia fundamental en la gran variabilidad de estas valoraciones. Pero no se trata de un proceso desarrollado de forma lineal y por lo tanto, en los ejemplos presentados se subrayan las interrelaciones entre pormenores de dicho proceso histórico y los desfases y matices propios de cada texto.

Emergencia y convergencia de las corrientes urbanísticas alternativas al desarrollo disperso. Europa y los EE.UU. 1980/2010

La presente tesis doctoral identifica el reciente fenómeno de la emergenciai de corrientes urbanísticas que actúan en la periferia urbana a partir de una concepción del diseño urbano que propugna modelos más compactos, a escala humana, de carácter integral y sostenible, como alternativa al desarrollo disperso y difusoii que caracteriza en gran medida a la ciudad contemporánea. Se develan las diferencias de origen y las coincidencias entre las distintas líneas de pensamiento que definen a estas emergentes corrientes alternativas, situándolas dentro de determinados enfoques planteados en la presente tesis, y demostrando con ello, las progresivas áreas de convergencia que permiten su ordenamiento como fenómeno histórico común. Estas distintas líneas de pensamiento, que derivan en las corrientes urbanísticas alternativas, se manifiestan primeramente como reacción a las operaciones modernistas de la posguerra, pero crecientemente expresan una visión contestataria a la expansión urbana descontrolada iii, de bajas densidades, zonificación excluyente y dependiente del automóvil; modelo asociado a las autopistas urbanas, los llamados nuevos artefactos urbanos y las grandes parcelas destinadas a proyectos habitacionales. Una realidad expresada en variados contextos en el ámbito de la globalización económica y cultural que, en gran medida, se singulariza como responsable de las profundas transformaciones urbanas, de la consecuente gradual pérdida de habitabilidad en las ciudades y del impacto sobre el medio natural; cuestión a tratar en el “Marco conceptual” referido al contexto y problema de la tesis. Se estudian los planteamientos fundamentales que postulan estas corrientes alternativas en el contexto de la expansión urbana horizontal, con el fin de identificar las distintas vertientes o líneas existentes, de establecer sus orígenes, enfoques, vínculos y alcances, permitiendo con ello caracterizar el fenómeno en sí desde una visión original e integradora. Estas corrientes a tratar han surgido en diversos momentos y con diversas particularidades, pero con mayor intensidad, articulación y visibilidad a partir de los años ochenta y especialmente en los noventa del siglo recién pasado, fundamentalmente en Europa y en los Estados Unidos de América, representando el “Cuerpo teórico” de esta tesis. Emergen en un escenario de creciente empoderamiento ciudadano, en tiempos de una mayor conciencia ambiental y social, y desde la convicción extendida de las limitaciones de un desarrollismo que, en términos del territorio físico, se manifiesta en el crecimiento urbano por extensión, incremental y desarticulado; tienen distintos idearios de origen, algunos en aparente contradicción o manifiesta oposición entre sí; se articulan desde diversos énfasis y surgen a partir de distintas aproximaciones. Para poder comprender el fenómeno de manera integral, se identifican y observan las tendencias contemporáneas y las correspondientes corrientes principales del diseño urbano; se indaga en sus discursos críticos y se ordenan en función de tres enfoques, los cuales reúnen los fundamentos esenciales de las distintas miradas críticas al modelo disperso y difuso: el enfoque neotradicional, el enfoque de la movilidad, y el enfoque ecológicoiv. Reconociendo la importancia de las operaciones de renovación urbana en la “ciudad intramuros” y siendo partícipes de estas intervenciones, las diferentes corrientes observadas desde los tres enfoques planteados, tienen un común denominador disciplinar en cuanto a su preocupación por generar actuaciones urbanas viables y practicables que causen un menor impacto sobre el territorio y que ofrezcan las condiciones para mejorar la habitabilidad en la ciudad, asumiendo el crecimiento hacia las periferias desde una aproximación alternativa a los modelos hoy predominantes. Las distintas corrientes, desde los particulares enfoques señalados, pretenden en síntesis, un desarrollo que refuerce el rol del diseño urbano, que promueva modelos más compactosv, de usos mixtos compatibles con la residencia y con espacios públicos de calidad, a una escala apropiada para la movilidad peatonal, favoreciendo de esta manera el uso del transporte público y velando consecuentemente por aquellos aspectos que mejoren las condiciones de sostenibilidad. En definitiva, el ideario de las corrientes caracterizadas en esta tesis como alternativas, se origina y se sostiene a partir de la convicción de situar a la disciplina del diseño urbano en su justa medida en el desarrollo contemporáneo, en el convencimiento de la relevancia del proyecto urbano en el ordenamiento del territorio y el crecimiento de las ciudades actuales. Una convergencia implícita a tratarse en la “Discusión de resultados”. La preocupación que reflejan las distintas corrientes estudiadas por el hábitat construido, en cuanto a su condición de acoger y estimular la dimensión humana de las ciudades, puede resumirse en una cita del arquitecto danés Jan Gehl, que interpreta a muchas de las líneas de pensamiento que se abordan en esta tesis, en cuanto al deseo de crear mejores ciudades: “Aspiramos generar ciudades animadas, saludables, atractivas, sostenibles y seguras, con el propósito de mejorar la calidad de vida de la gente”. ABSTRACT This Ph.D thesis identifies the recent phenomenon of the emergence of alternative urban design currents in the city edge, that focus on a more compact, human-scale oriented, comprehensive and sustainable urban design as an alternative to the overwhelming advance of sprawl that largely characterizes the contemporary city. It singles out the differences in origin, as well as the similarities drawn from the different lines of thought that define these emergent alternative currents, placing them within certain approaches proposed in this thesis, and thereby demonstrating the progressive areas of convergence that allow to arrange them as a common historical phenomenon. Indeed, the different lines of thought that drift towards these alternative urbanistic currents, first appear as a reaction to the post- World War II Modernist housing projects, and increasingly more so as a response to urban sprawl; an ever expanding phenomemnon expressed in different contexts within the economic and cultural globalization, largely singled out as being responsible for the deep urban transformations, the consequent gradual loss of livability and the impact on natural environment, setting the “Conceptual framework” of this thesis. Within the context of urban sprawl, the fundamental principles of these alternative currents are studied to establish their origins, approaches, linkages and scope, in order to zero in on the various aspects or existing lines and thereby allowing the identification of the phenomenon from an original and inclusive vision. The alternative currents to be dealt with, emerged at different times and with diverse characteristics, nonetheless it is in the eighties and especially during the nineties, mainly in Europe and the United States, where they appear with greater intensity, coordination and visibility, representing the “Theoretical body” of this thesis. The above mentioned currents arise in a scenario of increasing citizen empowerment in times of growing environmental and social awareness, along with the widespread conviction of the limitations of a quantitative development expressed as a physical manifestation in urban sprawl. These alternative currents have a different philosophy in origin, some are in apparent contradiction or in definite opposition, being organized from different approaches and emphases. To comprehend this phenomenon, it is necessary to identify and analize the contemporary trends and the main currents of urban design, inquiring and arranging their critical discourses according to three approaches that meet the essential foundations of the various critical perspectives of urban sprawl: the neo-traditional approach, the mobility approach, the ecological approach. Acknowledging the importance of urban renovation in the “Inner City”, and being partakers of these interventions, the different currents identified from these three approaches, concur in their concern for the development of viable and workable alternatives to urban sprawl; models that cause a lower impact on the territory, whilst improving livability in the city. The different currents recognized within the above mentioned approaches, advocate in brief, for a development that strengthens the role of urban design, that encourages more compact models, mixed-uses, and quality public spaces, considering the human scale and walkability; thereby increasing public transport and promoting consequently, the conditions for sustainable development. Ultimately, the philosophy of the so called alternative currents, is based on the belief of placing urban design as a fundamental discipline in contemporary urban development. The concern for the built habitat reflected by the various currents studied, as of their condition to accept and stimulate the human dimension of the city, can be summed up in a quote from Danish architect Jan Gehl, who represents many of the lines of thought addressed, in the belief of creating better cities: “We aspire to create cities that are lively, healthy, attractive, sustainable and safe-and thereby improve people’s quality of life”.

Characterization of human cardiac Na+ channel mutations in the congenital long QT syndrome

The congenital long QT syndrome (LQTS) is an inherited disorder characterized by a prolonged cardiac action potential. This delay in cellular repolarization can lead to potentially fatal arrhythmias. One form of LQTS (LQT3) has been linked to the human cardiac voltage-gated sodium channel gene (SCN5A). Three distinct mutations have been identified in the sodium channel gene. The biophysical and functional characteristics of each of these mutant channels were determined by heterologous expression of a recombinant human heart sodium channel in a mammalian cell line. Each mutation caused a sustained, non-inactivating sodium current amounting to a few percent of the peak inward sodium current, observable during long (>50 msec) depolarizations. The voltage dependence and rate of inactivation were altered, and the rate of recovery from inactivation was changed compared with wild-type channels. These mutations in diverse regions of the ion channel protein, all produced a common defect in channel gating that can cause the long QT phenotype. The sustained inward current caused by these mutations will prolong the action potential. Furthermore, they may create conditions that promote arrhythmias due to prolonged depolarization and the altered recovery from inactivation. These results provide insights for successful intervention in the disease.