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Sildenafil (Viagra) is a vasodilator mainly used in the treatment of erectile dysfunction. Atrial or ventricular fibrillation may rarely occur as a side effect during sildenafil therapy. Although changes in inward rectifier potassium currents including  I  K1  are known to contribute to the pathogenesis of fibrillation, the effect of sildenafil on  I  K1  has not been studied. In experiments, Ba 2+  is used as a specific inhibitor of  I  K1  at high concentrations (usually 100 µM). Being an environmental contaminant, it is also present in the human body; Ba 2+  plasmatic concentrations up to 1.5 µM are usually reported in the general population. This study was primarily aimed to investigate changes of  I  K1  induced by sildenafil in a wide range of concentrations (0.1–100 µM). Additionally, the effect of combination of sildenafil and Ba 2+  at selected clinically-relevant concentrations was tested, at 0.1 µM both on  I  K1  and on the action potential duration (APD). Experiments were performed by the whole-cell patch-clamp technique on enzymatically isolated rat ventricular cardiomyocytes, mostly at 23°C with the exception of APD measurements which were performed at 37°C as well. Sildenafil caused a significant, reversible, and concentration-dependent inhibition of  I  K1  that did not differ at −50 and −110 mV. Simultaneous application of sildenafil and Ba 2+  at 0.1 µM revealed a massive inhibition of both inward and outward components of  I  K1  (this synergy was missing at other tested combinations). The combined effect at 0.1 µM (45.7 ± 5.7 and 43.0 ± 6.9% inhibition at −50 and −110 mV, respectively) was significantly higher than a simple sum of almost negligible effects of the individual substances and it led to a significant prolongation of APD at both 23 and 37°C. To our knowledge, similar potentiation of the drug-channel interaction has not been described. The observed massive inhibition of  I  K1  induced by a combined action of the vasodilator sildenafil and environmental contaminant Ba 2+  at a low concentration and resulting in a significant APD prolongation may contribute to the genesis of arrhythmias observed in some patients treated with sildenafil.

frontiers in pharmacology

Combination of Sildenafil and Ba2+ at a Low Concentration Show a Significant Synergistic Inhibition of Inward Rectifier Potassium Current Resulting in Action Potential Prolongation