The couplonopathies: A comparative approach to a class of diseases of skeletal and cardiac muscle

ConclusionsWe define a novel category of diseases of striated muscle, the couplonopathies, as those that have in common a substantial disruption of the functional unit of Ca²⁺ release for EC coupling, the couplon. Consideration of similarities and differences between the couplons of skeletal and cardiac muscle affords insights into the pathogenesis of several couplonopathies, including MH and CPVT. Specifically, we argue that the allosteric connection among couplon proteins Ca_V1.1 and RyR1 is required for the MH phenotype usually linked to mutations in the RyR channel to also associate with mutations in Ca_V1.1. As an extension of this idea, we propose that the same allosteric interaction underpins the beneficial effects of dantrolene. The absence of a corresponding mechanical connection in cardiac muscle explains the absence of CPVT diseases caused by mutations in Ca_V1.2. Based on mechanistic considerations applicable to both couplons, we identify the plasmalemma as a site of alterations in transport properties, typically consisting of an increase in store-operated calcium entry, secondary to couplon mutations that promote Ca²⁺ release. These secondary changes constitute significant factors in the pathogenesis of MH. Mutations in triadin and calsequestrin have tissue-specific consequences: in the heart they cause couplonopathies associated with either loss of the allosteric control putatively exerted by these proteins on the Ca²⁺ release channel or loss of Ca²⁺ buffer capacity in the SR. In skeletal muscle, the phenotypes are milder or nonexistent because of the narrower range of physiological [Ca²⁺]_SR visited during function, as well as the much greater functional reserve of Ca storage that is present in this tissue. Finally, the effects of variants or ablation of JP-45 demonstrate a control of the DHPR that is unique to skeletal muscle and may be prescribed by the separate channel and sensor functions of the skeletal muscle DHPR.