Increased L-type calcium current causes action potential prolongation in Jervell and Lange-Nielsen syndrome and is a drug target

BackgroundKCNQ1 loss of function variants are thought to cause type 1 long QT syndrome by reducing IKs. However, we have recently reported that pharmacologic block of IKs in human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) produced minimal increases in action potential duration at 90% repolarization (APD90), while genetic loss of KCNQ1 markedly prolonged APD90. We sought here to define mechanisms underlying APD prolongation by genetic loss of KCNQ1. MethodsWe studied iPSC-CMs from population controls, an isogenic KCNQ1 knock out (KO) line created by a homozygous edit for the R518X loss of function variant, and 2 unrelated patients with the Jervell and Lange-Nielsen syndrome (JLN) due to compound heterozygosity for loss of function KCNQ1 variants. ResultsIn both JLN and the KCNQ1-KO lines, IKs was absent, APD90 was markedly prolonged, and L-type Ca channel (LTCC) current (ICa-L) was significantly increased, 2-3-fold, compared to the control cells with no change in kinetics or gating. RNA-sequencing identified 298 and 584 genes that were up- and down-regulated, respectively, by KCNQ1-KO compared to the isogenic control cells. Gene ontology analysis identified down-regulation of 6 Ca2+ channel negative regulatory genes (p=0.0002, FDR=0.02), and in knockdown experiments in wild-type iPSC-CMs, three of these, CBARP, FKBP1B, and RRAD, increased ICa-L, and RRAD increased APD90. A therapeutic low concentration (1 M) of the Ca channel antagonist diltiazem significantly shortened APD90 in the two JLN cell lines and in KCNQ1-KO cells. A single low dose of intravenous diltiazem in one of the JLN patients shortened QTc. ConclusionsThese data further support the concept that delayed repolarization in JLN cannot be explained solely by loss of IKs. Our findings demonstrate that KCNQ1 mutations lead to down-regulation of Ca2+ channel inhibitory genes, with resultant increased ICa-L that underlies delayed repolarization in JLN. We further propose that diltiazem can be repurposed for treatment of patients with JLN.