Inhibition of cardiac late sodium current (late I Na ) is a strategy to suppress arrhythmias and sodium-dependent calcium overload associated with myocardial ischemia and heart failure. Current inhibitors of late I Na are unselective and can be proarrhythmic. This study introduces GS967 (6-[4-(trifluoromethoxy), a potent and selective inhibitor of late I Na , and demonstrates its effectiveness to suppress ventricular arrhythmias. The effects of GS967 on rabbit ventricular myocyte ion channel currents and action potentials were determined. Anti-arrhythmic actions of GS967 were characterized in ex vivo and in vivo rabbit models of reduced repolarization reserve and ischemia. GS967 inhibited Anemonia sulcata toxin II (ATX-II)-induced late I Na in ventricular myocytes and isolated hearts with IC 50 values of 0.13 and 0.21 mM, respectively. Reduction of peak I Na by GS967 was minimal at a holding potential of 2120 mV but increased at 280 mV. GS967 did not prolong action potential duration or the QRS interval. GS967 prevented and reversed proarrhythmic effects (afterdepolarizations and torsades de pointes) of the late I Na enhancer ATX-II and the I Kr inhibitor E-4031 in isolated ventricular myocytes and hearts. GS967 significantly attenuated the proarrhythmic effects of methoxamine1clofilium and suppressed ischemiainduced arrhythmias. GS967 was more potent and effective to reduce late I Na and arrhythmias than either flecainide or ranolazine. Results of all studies and assays of binding and activity of GS967 at numerous receptors, transporters, and enzymes indicated that GS967 selectively inhibited late I Na . In summary, GS967 selectively suppressed late I Na and prevented and/or reduced the incidence of experimentally induced arrhythmias in rabbit myocytes and hearts.

Late sodium current (late I) is enhanced during ischemia by reactive oxygen species (ROS) modifying the Na 1.5 channel, resulting in incomplete inactivation. Compound 4 (GS-6615, eleclazine) a novel, potent, and selective inhibitor of late I, is currently in clinical development for treatment of long QT-3 syndrome (LQT-3), hypertrophic cardiomyopathy (HCM), and ventricular tachycardia-ventricular fibrillation (VT-VF). We will describe structure-activity relationship (SAR) leading to the discovery of 4 that is vastly improved from the first generation late I inhibitor 1 (ranolazine). Compound 4 was 42 times more potent than 1 in reducing ischemic burden in vivo (S-T segment elevation, 15 min left anteriorior descending, LAD, occlusion in rabbits) with EC values of 190 and 8000 nM, respectively. Compound 4 represents a new class of potent late I inhibitors that will be useful in delineating the role of inhibitors of this current in the treatment of patients.

The physiological role of cardiac late Na current ( I) has not been well described. In this study, we tested the hypothesis that selective inhibition of physiological late I abbreviates the normal action potential (AP) duration (APD) and counteracts the prolongation of APD and arrhythmic activities caused by inhibition of the delayed rectifier K current ( I). The effects of GS-458967 (GS967) on the physiological late I and APs in rabbit isolated ventricular myocytes and on the monophasic APs and arrhythmias in rabbit isolated perfused hearts were determined. In ventricular myocytes, GS967 and, for comparison, tetrodotoxin concentration dependently decreased the physiological late I with IC values of 0.5 and 1.9 µM, respectively, and significantly shortened the APD measured at 90% repolarization (APD). A strong correlation between inhibition of the physiological late I and shortening of APD by GS967 or tetrodotoxin ( R of 0.96 and 0.97, respectively) was observed. Pretreatment of isolated myocytes or hearts with GS967 (1 µM) significantly shortened APD and monophasic APD and prevented the prolongation and associated arrhythmias caused by the I inhibitor E4031 (1 µM). In conclusion, selective inhibition of physiological late I shortens the APD, stabilizes ventricular repolarization, and decreases the proarrhythmic potential of pharmacological agents that slow ventricular repolarization. Thus, selective inhibition of late I may constitute a generalizable approach to stabilize ventricular repolarization and suppress arrhythmogenicity associated with conditions whereby AP or QT intervals are prolonged. NEW & NOTEWORTHY The contribution of physiological late Na current in action potential duration (APD) of rabbit cardiac myocytes was estimated. The inhibition of this current prevented the prolongation of APD in rabbit cardiac myocytes, the prolongation of monophasic APD, and generation of arrhythmias in rabbit isolated hearts caused by delayed rectifier K current inhibition.