Classification models distinguish functional and trafficking effects of KCNQ1 variants to enhance variant interpretation.

Missense mutations compromise protein fitness by altering stability and function, which can lead to various clinical disease states. The potassium ion channel KCNQ1 underlies the majority of congenital long QT syndrome (LQTS) cases, one of the most common genetic arrhythmia syndromes. During genetic testing for LQTS, variants of uncertain significance (VUS) confound diagnosis and clinical management. KCNQ1 protein fitness metrics enable mechanistic classification of variants, directly informing the molecular basis for dysfunction and providing clinical interpretation of variants linked to LQTS and other channelopathies. We developed structure-aware random forest classifier models to predict seven metrics of KCNQ1 fitness, four functional electrophysiology measurements (peak current density, voltage-dependence, gating kinetics), and three trafficking values measured by flow cytometry. Our trained models outperformed AlphaMissense in predicting protein fitness, enhancing interpretation of ClinVar VUS and variants classified as ambiguous by AlphaMissense. We demonstrate the classifiers distinguish benign and pathogenic variants from ClinVar and gnomAD and identify systematic patterns of dysfunction and mistrafficking along the functionally critical S4 helix. Our method advances variant effect prediction with a mechanistic classifier that reliably links missense mutations in KCNQ1 to their specific disease-causing mechanisms. As a resource for precision medicine approaches for LQTS or other KCNQ1 channelopathies, we provide the predictions and scores for all KCNQ1 missense variants across the structured region of the protein.