A subset share characteristics that make them effective as antiarrhythmic drugs, ie, they exhibit high affinity, use-dependent block of Na current (I Na ) at high heart rates. Despite extensive study, there remains uncertainty regarding how observed block relates to specific drug-channel conformations. Several vocabularies have emerged to describe block, which in general, have their basis in kinetic models of Na channel gating and assume preferential binding to one or more states that produce no 1 or altered 2 gating. Recent availability of crystal structures in combination with mutagenesis data now allow for linking electrophysiological data, kinetic states, and drug block to specific channel conformations.It is generally accepted that lidocaine and lidocaine-like drugs bind in the inner pore of voltage-gated Na channels. Scanning mutagenesis studies with various Na channel isoforms and multiple lidocaine-like drugs have identified only one amino acid residue, a phenylalanine (Phe) in domain IV, S6 (DIVS6), which, when mutated, alters use-dependent drug affinity by more than ten-fold. When this Phe (1759 in Na V 1.5) is mutated to nonaromatic residues 3-8 or to unnatural amino acids with different electron withdrawing capabilities 9 the mutated channel shows a marked decrease in high-affinity LA block. Homology modeling with K channels predicts that this Phe faces the pore just below the selectivity filter. 10,11 This orientation of Phe is supported by the finding that its cysteine mutant is accessible to MTS reagents applied from inside the pore when the channel is maintained in an open state. 12 Furthermore, it has been shown by us 13 and others 14 that use-dependent block is intimately associated with altered movements of the structurally distant S4 segments in domains III and IV.Block assayed from negative holding potentials at low rates of stimulation is affected very little by channel mutations in contract to their effects on use-dependent block. This lower affinity block is usually called tonic block, although it has also been called rested-state block (or closed-state block)