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Circadian rhythms govern cardiac repolarization and arrhythmogenesis.
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PMID:  22367544     Owner:  NLM     Status:  MEDLINE    
Sudden cardiac death exhibits diurnal variation in both acquired and hereditary forms of heart disease, but the molecular basis of this variation is unknown. A common mechanism that underlies susceptibility to ventricular arrhythmias is abnormalities in the duration (for example, short or long QT syndromes and heart failure) or pattern (for example, Brugada's syndrome) of myocardial repolarization. Here we provide molecular evidence that links circadian rhythms to vulnerability in ventricular arrhythmias in mice. Specifically, we show that cardiac ion-channel expression and QT-interval duration (an index of myocardial repolarization) exhibit endogenous circadian rhythmicity under the control of a clock-dependent oscillator, krüppel-like factor 15 (Klf15). Klf15 transcriptionally controls rhythmic expression of Kv channel-interacting protein 2 (KChIP2), a critical subunit required for generating the transient outward potassium current. Deficiency or excess of Klf15 causes loss of rhythmic QT variation, abnormal repolarization and enhanced susceptibility to ventricular arrhythmias. These findings identify circadian transcription of ion channels as a mechanism for cardiac arrhythmogenesis.
Darwin Jeyaraj; Saptarsi M Haldar; Xiaoping Wan; Mark D McCauley; Jürgen A Ripperger; Kun Hu; Yuan Lu; Betty L Eapen; Nikunj Sharma; Eckhard Ficker; Michael J Cutler; James Gulick; Atsushi Sanbe; Jeffrey Robbins; Sophie Demolombe; Roman V Kondratov; Steven A Shea; Urs Albrecht; Xander H T Wehrens; David S Rosenbaum; Mukesh K Jain
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Publication Detail:
Type:  Journal Article; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't     Date:  2012-02-22
Journal Detail:
Title:  Nature     Volume:  483     ISSN:  1476-4687     ISO Abbreviation:  Nature     Publication Date:  2012 Mar 
Date Detail:
Created Date:  2012-03-02     Completed Date:  2012-04-18     Revised Date:  2014-09-19    
Medline Journal Info:
Nlm Unique ID:  0410462     Medline TA:  Nature     Country:  England    
Other Details:
Languages:  eng     Pagination:  96-9     Citation Subset:  IM    
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MeSH Terms
Arrhythmias, Cardiac / complications,  genetics,  physiopathology*
Cells, Cultured
Circadian Rhythm / genetics,  physiology*
DNA-Binding Proteins / deficiency,  genetics,  metabolism
Death, Sudden, Cardiac / etiology
Gene Expression Regulation
Heart Conduction System / physiology*
Heart Rate / physiology
Heart Ventricles / cytology
Kv Channel-Interacting Proteins / biosynthesis,  genetics
Mice, Inbred C57BL
Muscle Cells / cytology
Promoter Regions, Genetic / genetics
Time Factors
Transcription Factors / deficiency,  genetics,  metabolism
Grant Support
Reg. No./Substance:
0/DNA-Binding Proteins; 0/Kcnip2 protein, rat; 0/Klf15 protein, mouse; 0/Kv Channel-Interacting Proteins; 0/Transcription Factors
Comment In:
Circ Res. 2012 Jun 22;111(1):14-6   [PMID:  22723220 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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Journal Information
Journal ID (nlm-journal-id): 0410462
Journal ID (pubmed-jr-id): 6011
Journal ID (nlm-ta): Nature
ISSN: 0028-0836
ISSN: 1476-4687
Article Information
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nihms-submitted publication date: Day: 17 Month: 1 Year: 2012
Electronic publication date: Day: 22 Month: 2 Year: 2012
pmc-release publication date: Day: 1 Month: 9 Year: 2012
Volume: 483 Issue: 7387
First Page: 96 Last Page: 99
ID: 3297978
PubMed Id: 22367544
DOI: 10.1038/nature10852
ID: nihpa349931

Circadian rhythms govern cardiac repolarization and arrhythmogenesis
Darwin Jeyaraj12*
Saptarsi M. Haldar1
Xiaoping Wan2
Mark D. McCauley3
Jürgen A. Ripperger4
Kun Hu5
Yuan Lu1
Betty L. Eapen1
Nikunj Sharma1
Eckhard Ficker2
Michael J. Cutler2
James Gulick6
Atsushi Sanbe6
Jeffrey Robbins6
Sophie Demolombe7
Roman V. Kondratov8
Steven A. Shea5
Urs Albrecht4
Xander H.T. Wehrens3
David S. Rosenbaum2
Mukesh K. Jain1*
1Case Cardiovascular Research Institute, Harrington-McLaughlin Heart and Vascular Institute, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
2Heart and Vascular Research Center, MetroHealth campus of Case Western Reserve University, Cleveland, OH
3Departments of Medicine and Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX
4Department of Medicine, Division of Biochemistry, University of Fribourg, Fribourg, Switzerland
5Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
6Department of Pediatrics, Division of Molecular Cardiovascular Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
7Institut de Pharmacologie Moléculaire et Cellulaire, UMR CNRS 6097, Université de Nice Sophia Antipolis, 06560 Valbonne, France
8Department of Biological, Geological and Environmental Sciences and Center for gene regulation in health and disease, Cleveland State University, Cleveland, OH
*Address correspondence to: Mukesh K. Jain, MD, Professor of Medicine, Director, Case Cardiovascular Research Institute, 2103 Cornell Road, Wolstein Research Building, Room # 4501, Cleveland, OH 44106, Tel: (216) 368 3391,; Darwin Jeyaraj, MD, Assistant Professor of Medicine, MetroHealth Campus of Case Western Reserve University, Heart and Vascular Research Center, Rammelkamp # 650, 2500 MetroHealth Drive, Cleveland, OH 44109, Tel: (216) 368 3391,

Sudden cardiac death from ventricular arrhythmias is the principal cause of mortality from heart disease worldwide, and remains a major unresolved public health problem. The incidence of sudden cardiac death exhibits diurnal variation in both acquired and hereditary forms of heart disease 1, 2. In the general population, the occurrence of sudden cardiac death increases sharply within a few hours of rising in the morning, and a second peak is evident in the evening hours 1. In specific hereditary disorders, e.g. Brugada syndrome, fatal ventricular arrhythmias often occur during sleep2. A common mechanism in both acquired and hereditary forms of heart disease that enhances susceptibility to ventricular arrhythmias is abnormal myocardial repolarization6. Clinically, three common types of alterations in myocardial repolarization are evident on the surface electrocardiogram (ECG). First, prolongation of repolarization is seen in acquired (e.g., heart failure) 5 and congenital disorders (e.g., long QT syndrome) 3. Second, shortening of repolarization is observed in the short QT syndrome 4. Third, early repolarization is the hallmark ECG finding in Brugada syndrome 8. Interestingly, all three modifications of repolarization increase vulnerability to ventricular arrhythmias 6. Despite rigorous investigation of the biophysical and structural characteristics of ion channels that control myocardial repolarization, the molecular basis for the diurnal variation in occurrence of ventricular arrhythmias remains unknown.

Biological processes in living organisms that oscillate with a periodicity of 24-hours are ascribed to be circadian. This cell-autonomous rhythm is coordinated by an endless negative transcriptional-translational feedback loop, commonly referred to as the biological clock 9. Several physiological parameters in the cardiovascular system such as heart rate, blood pressure, vascular tone, QT interval and ventricular effective refractory period exhibit diurnal variation 10-13. Recent studies have also identified a direct role for the biological clock in regulating cardiac metabolism, growth and response to injury 14. Previous studies have also reported that expression of repolarizing ion channels and ionic currents (Ito) exhibit diurnal changes 15. However, a potential link between circadian rhythms and arrhythmogenesis remains unknown. We made the serendipitous observation that the Krüppel-like factor 15 (Klf15) exhibits endogenous circadian rhythmicity in the heart (Fig. 1a). Gene expression microarrays in hearts of mice deficient in Klf15 led us to identify KChIP2, the regulatory β-subunit for the repolarizing transient outward potassium current (Ito) as a putative target for this factor in the heart. These observations led us to posit whether the circadian clock through Klf15 may regulate rhythmic variation in repolarization and alter susceptibility to arrhythmias.

First, we explored mechanisms through which the circadian clock regulated rhythmic expression of Klf15 in the heart. Examination of the −5kb promoter region of Klf15 revealed four canonical “E-box,” regions, i.e., consensus binding sites for CLOCK and its heterodimer BMAL1, which are essential transcription factors involved in the circadian clock (Supplemental Fig. 1a inset). Consistent with this finding, Klf15-luciferase (−5kb) was activated in a dose-dependent manner by the CLOCK/BMAL1 heterodimer (Supplemental Fig. 1a). To confirm this interaction, we performed chromatin immunoprecipitation (ChIP) and identified rhythmic variation in BMAL1 binding to the Klf15 promoter in WT hearts, but not in BMAL1-null hearts (Fig. 1b). In accordance with above observations, the expression of Klf15 was disrupted in BMAL1-null and Per2/Cry1-null hearts (Supplemental Fig. 1b). Thus, our data strongly suggests that the circadian clock directly regulates the oscillation of Klf15 in the heart.

Next, to determine whether myocardial repolarization and ion channel expression exhibit “true” (endogenous) circadian rhythms i.e., oscillate in the absence of external cues such as light, wildtype (WT) mice were placed in constant darkness for 36 hours (DD) and telemetry-based ECG intervals were measured every 2 hours for 24 hours thereafter. Under these conditions, the heart rate and QT interval corrected to heart rate (QTc) were both rhythmic and exhibited true endogenous circadian rhythmicity (Fig. 1c, d). Next, to examine whether expression of repolarizing ion channels had endogenous circadian rhythms, mice were placed in constant darkness for 36 hours, and hearts harvested every four hours over a 24-hour period. The expression of the alpha-subunit for the transient outward potassium current (Ito), i.e., Kv4.2 (Fig. 1e) and the regulatory beta-subunit, i.e., KChIP2 (Fig. 1f) exhibit endogenous circadian rhythmicity, as did components of the circadian clock in the heart (Supplemental Fig. 2). In contrast, the expression of two other major repolarizing currents in the murine ventricle, Kv1.5 (the alpha subunit for the ultra-rapid delayed rectifier potassium current) and Kir2.1 (the alpha subunit for the inward rectifier potassium current) did not reveal significant rhythmic variation (Supplemental Fig. 3). In addition, we observed a 24-hour rhythm in oscillation of Bmal1, Klf15 and KChIP2 following serum shock in cultured neonatal rat ventricular myocytes (Supplemental Fig. 4). In sum, these data indicate that myocardial repolarization and the expression of some repolarizing ion channels exhibit an endogenous circadian rhythm.

Next, to elucidate the role of Klf15 in regulating rhythmic changes in repolarization, we used complementary in vivo loss and gain-of-function approaches in mice. For loss-of-function, a previously described systemic Klf15-null mouse was utilized 16; for gain-of-function, a cardiac-specific Klf15 transgenic (Klf15-Tg) mouse driven by an attenuated α-myosin heavy chain (α-MHC) promoter was developed (Supplemental Fig. 5). First, we examined if rhythmic expression of Kv4.2 or KChIP2 was altered in the Klf15-deficient state. Kv4.2 expression exhibited altered rhythmic variation in Klf15-null mice with reduced expression at ZT6, and increased expression at ZT22 when compared to WT controls (Fig. 2a). KChIP2 expression was devoid of any discernable rhythm in the Klf15-null mice along with sustained reduction at all time points (Fig. 2b,c & Supplemental Fig. 6a). Next, we examined if either Kv4.2 or KChIP2 serve as transcriptional targets for Klf15 in the heart. Adenoviral overexpression of Klf15 in neonatal rat ventricular myocytes robustly induced KChIP2, but had no effect on Kv4.2 expression (Supplemental Fig. 6b). Importantly, in Klf15-Tg hearts, a two-fold greater expression of KChIP2 with no effect on Kv4.2 expression was observed (Fig. 2d, e). Examination of the KChIP2 promoter region revealed numerous consensus Krüppel binding sites, i.e., C(A/T)CCC (Supplemental Fig. 7a). The activity of KChIP2-luciferase was induced by full-length KLF15, but not by a mutant that lacked the zinc-finger DNA binding domain (Supplemental Fig. 7b). To identify the specific Klf15 binding site, deletion constructs of the KChIP2 promoter were generated, and transcriptional activity mapped to the proximal 555 bases (Supplemental Fig. 7a). Mutation of one Krüppel-binding site within this region (Δ1) was sufficient to cause complete loss of activity in the full-length KChIP2 promoter (Supplemental Fig. 7c). Chromatin immunoprecipitation of Flag-KLF15 from Klf15-Tg hearts confirmed enrichment of KLF15 on the endogenous KChIP2 promoter (Fig. 2f). Importantly, the oscillation of several components of the core clock machinery was minimally affected in the Klf15-deficient state (Supplemental Fig. 8). In addition, the expression levels of clock genes in Klf15-Tg hearts were similar to their controls at ZT6 (Supplemental Fig. 8). This suggested that the endogenous clock is dependent on Klf15 in orchestrating rhythmic changes in KChIP2 expression. Consistent with this observation, the expression of Klf15 (Supplemental Fig. 1b) and KChIP2 (supplemental Fig. 9) were altered in a similar fashion in Bmal1-null and Per2/Cry1-null mice. These data support the notion that KChIP2 is a direct transcriptional target for Klf15 in the heart.

We next examined if Klf15-dependent regulation of KChIP2 could be responsible for rhythmic day/night variation in myocardial repolarization. Interestingly, analysis of telemetry based ECG’s revealed that rhythmic QTc interval variation was indeed abrogated in both Klf15-null and Klf15-Tg mice (Fig. 3 a-d). In the Klf15 deficient state, the ECG QTc interval was prolonged in the dark phase and failed to oscillate (Fig. 3a, c). This occurred despite similar heart rates to their WT counterparts (Supplemental Fig. 11). In contrast, the Klf15-Tg mice had persistently short QT interval with no rhythmic day/night variation (Fig. 3b, d). Again, this occurred despite minimal difference in heart rates when compared to WT (Non-Tg) controls (Supplemental Fig. 11). Next, we examined in isolated myocytes if transient outward current (Ito fast) dependent changes in repolarization were responsible for the aforementioned ECG changes in Klf15-null and Klf15-Tg mice. In Klf15-null mice, there was a marked reduction in Ito fast density (Fig. 3e) and prolongation of action potential duration (APD) (Fig. 3g). In contrast, Klf15-Tg mice exhibited significant increase in Ito fast density (Fig. 3f) with dramatic shortening of APD (Fig. 3h). In the Klf15-Tg mice, in addition to short QT intervals, we observed ST-segment changes suggestive of early-repolarization that are similar to ECG findings in Brugada syndrome 8 (Fig. 3b, arrows). In sum, our data suggests that Klf15-dependent transcriptional regulation of rhythmic KChIP2 expression in murine hearts plays a central role in rhythmic variation in ventricular repolarization.

Next, we examined if excessive prolongation or shortening of repolarization could alter arrhythmia susceptibility and survival. Klf15-null mice exhibit no spontaneous arrhythmias on ECG telemetry, hence we utilized intra-cardiac programmed electrical stimulation to examine for arrhythmia susceptibility. In contrast to WT mice, a marked increase in occurrence of ventricular arrhythmias was observed in Klf15-null mice (Fig 4a). Importantly, Klf15-Tg mice exhibit spontaneous ventricular arrhythmias on ECG telemetry (Fig. 4b), and succumb to ~ 35% mortality by 4 months of age (3/8 deaths in Klf15-Tg vs. 0/8 deaths in WT Non-Tg controls, data not shown). As the Klf15-null mice exhibit no evidence of overt ventricular dysfunction, apoptosis or fibrosis 16, 17 in the basal state, the enhanced susceptibility to arrhythmias is likely primarily driven by abnormalities in repolarization. In sum, our studies demonstrate that both deficiency and excess of Klf15 impair temporal variation in cardiac repolarization and greatly increase susceptibility to arrhythmias.

While our finding of circadian control of KChIP2 by Klf15 establishes the principle that circadian rhythms may contribute to arrhythmogenesis, we note that Klf15 minimally affects Kv4.2 expression that also exhibits circadian rhythm (Fig. 1f). However, Kv4.2 expression was disrupted in Bmal1-null and Per2/Cry1-null hearts suggestive of a direct regulation by the circadian clock (Supplemental Fig. 12). Consistent with this observation, cardiomyocytes from Bmal1-null mice exhibit marked action potential prolongation due to near complete elimination of the fast component of the transient outward potassium current (Supplemental Fig. 13). This raises the possibility that additional factors – perhaps components of the circadian clock or as yet unidentified transcriptional regulators – may also impact on temporal variation in electrophysiological parameters and arrhythmogenesis. Future studies in cardiac specific deletion of clock components would be necessary to confirm if the ion channel rhythms are cell autonomous, and their role in regulating cardiac electrophysiology.

In summary, our study provides the first mechanistic link between endogenous circadian rhythms and cardiac electrical instability most often associated with sudden cardiac death in humans (Supplemental Fig. 14). Specifically, we demonstrate that Klf15-dependent rhythmic transcription of KChIP2 regulates the duration and pattern of repolarization and susceptibility to arrhythmias in mice. Since the occurrence of sudden cardiac death in acquired and hereditary forms of human heart disease follows a distinct diurnal pattern 1, 2, these observations offer novel insights into heretofore unrecognized triggers of electrical instability in the heart. However, in contrast to murine repolarization which is largely dependent on Ito, human repolarization occurs through a complex interplay of multiple repolarizing ionic currents. Thus, additional studies will be needed to develop a comprehensive understanding of the link between the circadian clock and electrophysiological properties of the human heart. Nonetheless, these data may provide a mechanistic foundation for future efforts to prevent or treat cardiac arrhythmias by modulating the circadian clock through behavioral or pharmacological means.

Supplementary Material 02 1


FN1METHODS SUMMARY (detailed methods in supplemental section):

Mice used in the present study, mRNA quantification using Real-Time PCR, promoter reporter analysis, Western immunoblotting, chromatin immunoprecipitation, telemetry ECG and interval analysis, isolated myocyte studies for action potential/Ito measurements, in vivo electrophysiological studies for arrhythmia susceptibility, cosinor analysis for rhythm assessment, and statistical methods are detailed in the supplemental methods section.


D.J and M.K.J designed the research; D.J, S.M.H, X.W, M.D.M, J.A.R, Y.L, B.L.E and M.J.C acquired the data; J.G, A.S, J.R and R.V.K contributed critical reagents; D.J, N.S, S.D, R.V.K, S.A.S, U.A, X.H.T.W, D.S.R and M.K.J supervised the research; D.J, S.M.H, X.W, M.D.M, J.A.R, K.H, B.L.E, E.F, S.A.S, U.A, X.H.T.W, D.S.R and M.K.J analyzed and interpreted the data; D.J and M.K.J wrote the manuscript.


We are grateful to Dr. Alfred F. Connors Jr., for support, Mike Mustar for artistic illustrations, Yingjie Cui for experimental assistance, and to members of the Jain laboratory for helpful discussions. Funding sources: Heart Rhythm Society Fellowship (D.J), NIH grants HL094660 (D.J.), HL066991 (M.D.M), HL086614 (S.M.H.), AHA post-doctoral grant (N.S), HL089598, HL091947 (X.H.W), HL76446 (S.A.S.), HL102241 (K.H), HL054807 (D.S.R) and HL075427, HL076754, HL084154, HL086548, HL097595 (M.K.J.), SNF grant 31003A/131086 (U.A.), M01-RR02635 (BWH), Leducq Foundation grants ENAFRA Network 07CVD03 (S.D.) and CNRS (S.D.).

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