Beta-adrenoceptor Antagonist Research Articles

CL 316,243, a selective β3-adrenergic agonist, inhibits protein breakdown in rat skeletal muscle

The in vitro effect of CL 316,243 (CL), a selective beta3-adrenoceptor agonist in the rate of overall proteolysis, the activity of proteolytic systems (lysosomal, Ca2+-dependent, ATP-dependent, and ATP-independent) and in the process of protein synthesis was investigated in rat skeletal muscles. The rate of overall proteolysis in soleus muscle from rats incubated with CL (10(-4) and 10(-5) M) or epinephrine (10(-5) M) was significantly decreased. In vitro rates of maximal activity of Ca2+-dependent proteolysis in soleus muscles were decreased by about 41% in the presence of 10(-5) M CL. No change was observed in the activities of the lysosomal, ATP-dependent or ATP-independent proteolytic systems. The anti-proteolytic effect of CL or epinephrine was partially prevented by 10(-5) M SR 59230A, a selective beta3-adrenoceptor antagonist. The increase of proteolysis induced by food deprivation in soleus was abolished by in vitro addition of 10(-5) M CL. No change in proteolysis was observed in extensor digitorum longus (EDL) muscles incubated with any concentration of the beta3-adrenoceptor agonist tested. Rates of protein synthesis were not affected by 10(-4) M CL neither in soleus nor EDL. The data suggest that a beta3-adrenoceptor-mediated inhibition of Ca2+-dependent proteolysis participates of the antiproteolytic effect of catecholamines in oxidative muscles.

COMPARISON OF LOW and HIGH DOSES OF CARVEDILOL ON RESTORATION OF CARDIAC FUNCTION and CALCIUM‐HANDLING PROTEINS IN RAT FAILING HEART

1. The beta-adrenoceptor antagonist carvedilol reverses cardiac dysfunction in the failing heart. A recent study showed that beta-adrenoceptor antagonists indirectly normalize Ca(2+)-regulatory proteins. The relationship between these two phenomena and the suitable dosage of carvedilol remains unclear. 2. We investigated the change in left ventricular (LV) remodelling and function in a rat model of heart failure due to myocardial infarction (MI) with or without carvedilol (30 or 2 mg/kg per day) treatment for 6 weeks. The expression of mRNA and proteins of sarcoplasmic reticulum Ca(2+)-ATPase (SERCA) and phospholamban (PLB) in cardiomyocytes was also measured. 3. There was significant LV remodelling and cardiac contractile dysfunction in MI rats. The expression of SERCA mRNA and protein were downregulated (P < 0.01), but the expression of PLB mRNA and protein were upregulated (P < 0.01) in MI rats compared with sham-operated rats. After treatment with carvedilol, LV remodelling and cardiac contractile dysfunction were clearly improved. Low-dose carvedilol was better at improving some parameters of LV remodelling and function than the high dose. Carvedilol partially restored the low expression of SERCA (P < 0.05), but had no effect on PLB expression (P > 0.05). Moreover, low-dose carvedilol induced a more significant improvement in SERCA expression than did the high dose (P < 0.05). 4. The results of the present study suggest that carvedilol is effective in improving LV remodelling and cardiac contractile dysfunction after MI. This may be related to the normalization of SERCA expression.

Central and peripheral components of the pressor effect of anandamide in urethane‐anaesthetized rats

1. We wanted to search for the mechanism(s) responsible for the brief pressor response induced by anandamide in urethane-anaesthetized rats. 2. The anandamide-induced pressor effect was not modified by the antagonists of cannabinoid CB(1) and vanilloid TRPV(1) receptors, SR 141716A (3 micromol kg(-1)) and capsazepine (1 micromol kg(-1)), respectively, by bilateral vagotomy and by pithing. Replacement of urethane by pentobarbitone virtually abolished the pressor effect of anandamide, both in pithed and vagotomized and in 'intact' rats (i.e. not treated in this manner). 3. The pressor effect of anandamide was reduced by the nonselective TRPV family inhibitor ruthenium red (3 micromol kg(-1)) and by the blocker of L-type calcium channels nifedipine (1 micromol kg(-1)), both in pithed urethane-anaesthetized rats and in 'intact' urethane-anaesthetized rats. The nonselective beta-adrenoceptor antagonist propranolol (0.1 or 0.3 micromol kg(-1)) and the nonselective NMDA receptor antagonist MK-801 (1 micromol kg(-1)) diminished the anandamide-induced vasopressor response in 'intact' but not in pithed rats. The inhibitory effect of propranolol in 'intact' rats was mimicked by the beta(2)-adrenoceptor antagonist ICI 118551 (1 micromol kg(-1)), but not by the beta(1)-adrenoceptor antagonist CGP 20712 (1 micromol kg(-1)). 4. The present study revealed that two mechanisms may be responsible for the anandamide-induced pressor response in urethane-anaesthetized rats. The first involves the central nervous system (probably the medulla oblongata) and is sensitive to propranolol and MK-801. The second, which is located peripherally (most probably in blood vessels), is sensitive to nifedipine, ruthenium red and pentobarbitone and, hence, probably represents a Ca(2+)-dependent mode of action.

The functional significance of genetic variation within the β1‐adrenoceptor

The beta-1 adrenoceptor is an archetypal G-coupled protein receptor that controls sympathetic responses in the heart, kidney and adipocytes. It has been widely exploited as a drug target with the development of antagonists to treat cardiovascular diseases such as hypertension, angina and heart failure. Signalling through the receptor is modulated by desensitization and beta1- adrenoceptor down-regulation. It is also affected by in vitro substitution of specific amino acid residues within the beta-1 adrenoceptor. Amino acid substitutions also occur naturally due to polymorphic variation within the human beta-1 adrenoceptor gene itself. Since these variants are common (typically being present in > 5% of the population), the pharmacogenetic implications are enormous. A number of these variants have been identified, although two have been the particular focus of recent publications: a serine to glycine substitution at position 49 (49S > G) and an arginine to glycine at position 389 (389R > G). The data on the in vitro behaviour of these two receptor variants is reviewed here, along with the evidence that they may affect both the risk of cardiovascular disease and the therapeutic response to beta-1 adrenoceptor antagonists.

Ketamine Preconditions Isolated Human Right Atrial Myocardium

The authors examined the effect of ketamine and its S(+) isomer on isolated human myocardium submitted to hypoxia-reoxygenation in vitro. The authors studied isometric contraction of human right atrial trabeculae suspended in an oxygenated Tyrode's modified solution at 34 degrees C. Ten minutes before a 30-min hypoxic period followed by a 60-min reoxygenation, muscles were exposed for 15 min to racemic ketamine and its S(+) isomer at 10, 10, and 10 m alone or in the presence of 8.10 m 5-hydroxydecanoate, 10 m HMR 1098 (sarcolemmal adenosine triphosphate-sensitive potassium channel antagonist), 10 m phentolamine (alpha-adrenoceptor antagonist), and 10 m propranolol (beta-adrenoceptor antagonist). Force of contraction at the end of the 60-min reoxygenation period was compared between groups (mean +/- SD). Ketamine (10 m: 85 +/- 4%; 10 m: 95 +/- 10%; 10 m: 94 +/- 14% of baseline) and S(+)-ketamine (10-6 m: 85 +/- 4%; 10 m: 91 +/- 16%; 10 m: 93 +/- 14% of baseline) enhanced recovery of force of contraction at the end of the reoxygenation period as compared with the control group (47 +/- 10% of baseline; P < 0.001). Ketamine-induced preconditioning at 10 m was inhibited by 5-hydroxydecanoate (60 +/- 16%; P < 0.001), HMR 1098 (60 +/- 14%; P < 0.001), phentolamine (56 +/- 12%; P < 0.001), and propranolol (60 +/- 7%; P < 0.001). In vitro, ketamine preconditions isolated human myocardium, at least in part, via activation of adenosine triphosphate-sensitive potassium channels and stimulation of alpha- and beta-adrenergic receptors.

CAMP and Extracellular Signal-Regulated Kinase Signaling in Response to d-Amphetamine and Methylphenidate in the Prefrontal Cortex in Vivo: Role of β1-Adrenoceptors

d-Amphetamine and methylphenidate are widely used in the treatment of attention-deficit/hyperactivity disorder. Both drugs increase extracellular norepinephrine and dopamine in the prefrontal cortex, where they are believed to exert their therapeutic effects. However, the molecular mechanisms underlying their action are poorly understood. To investigate the intracellular signaling pathways activated by d-amphetamine and methylphenidate in the prefrontal cortex in vivo in mice, we measured the cAMP-dependent Ser845 phosphorylation of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor GluR1 subunit and the active form of extracellular signal-regulated kinase (ERK). Administration of d-amphetamine (5-10 mg/kg) or methylphenidate (10-20 mg/kg) increased phosphorylation of GluR1. Basal and d-amphetamine-induced GluR1 phosphorylation was reduced by propranolol, a general beta-adrenoceptor antagonist, and betaxolol, a beta1-antagonist, but not by (+/-)-1-[2,3-(dihydro-7-methyl-1H-inden-4-yl)oxy]-3-[(1-methylethyl)amino]-2-butanol (ICI-118,515), a beta2-antagonist. The effect of methylphenidate was also blocked by propranolol and betaxolol. The d-amphetamine effect was slightly potentiated by prazosin, an alpha1-adrenoceptor antagonist, and mimicked by yohimbine, an alpha2 antagonist. Blockade of dopamine or N-methyl-d-aspartate (NMDA) receptors or serotonin depletion had no effect on d-amphetamine-induced GluR1 phosphorylation. d-amphetamine but not methylphenidate increased ERK phosphorylation. This effect required multiple signaling pathways because it was blocked by beta1- and alpha1-adrenoceptor antagonists, by dizocilpine maleate (MK801), an NMDA antagonist, and by serotonin depletion. In contrast, blockade of dopamine receptors had no effect on d-amphetamine-induced ERK phosphorylation. Propranolol and betaxolol increased the hyperlocomotion produced by d-amphetamine and methylphenidate. Thus, both d-amphetamine and methylphenidate potently activate the cAMP pathway in the prefrontal cortex through beta1-adrenergic receptors. This activation could have behavioral consequences and contribute to the treatment of attention-deficit/hyperactivity disorder.

Pressor and tachycardic responses evoked by microinjections ofl‐glutamate into the medial prefrontal cortex of unanaesthetized rats

The ventral medial prefrontal cortex (vMPFC) is involved in central cardiovascular control. In the present study, we studied the cardiovascular effects of injections of L-glutamate into the vMPFC of unanaesthetized rats and the mechanisms of these effects. Male Wistar rats were used and L-glutamate was microinjected in the vMPFC in a final volume of 200 nL. Microinjections of L-glutamate (9, 27, 81, 150 or 300 nmol) caused long-lasting, dose-related pressor and tachycardic responses in unanaesthetized rats. No differences were observed among cardiovascular responses when L-glutamate was injected into the three sub-areas that comprise the vMPFC, namely the prelimbic, the infralimbic and the dorsal peduncular cortices. No responses were observed when the dose of 81 nmol of L-glutamate was microinjected into surrounding structures such as the cingulate cortex area 1, the corpus callosum and the tenia tecta, indicating a predominant action on the vMPFC. The cardiovascular response to L-glutamate into the vMPFC was blocked by intravenous pretreatment with the ganglion blocker pentolinium (10 mg/kg, i.v.) or the beta1-adrenoceptor antagonist atenolol (1.5 mg/kg, i.v.), supporting the involvement of the cardiac sympathetic nervous system in the response to L-glutamate. Pretreatment with the muscarinic antagonist homatropine methyl bromide (1 mg/kg, i.v.) reduced the latency to the onset of the pressor and tachycardic responses to L-glutamate injected into the vMPFC without significant effects on response duration or maximum effect. We conclude that stimulation of the vMPFC with L-glutamate caused pressor and tachycardic responses in unanaesthetized rats, responses which were dependent on cardiac sympathetic nerve activation and were potentiated by blockade of peripheral muscarinic receptors.

β2‐Adrenoceptor regulation of the K+channel iKCa1 in human mast cells

Human mast cells express the intermediate conductance Ca2+-activated K+ channel iKCa1, which opens following IgE-dependent activation. This results in cell membrane hyperpolarization and potentiation of both Ca2+ influx and degranulation. Mast cell activation is attenuated following exposure to beta2-adrenoceptor agonists such as salbutamol, an effect postulated to operate via intracellular cyclic AMP. In this study, we show that salbutamol closes iKCa1 in mast cells derived from human lung and peripheral blood. Salbutamol (1-10 microM) inhibited iKCa1 currents following activation with both anti-IgE and the iKCa1 opener 1-EBIO, and was reversed by removing salbutamol or by the addition of the selective beta2-adrenoceptor antagonist and inverse agonist ICI 118551. Interestingly, ICI 118551 consistently opened iKCa1 in quiescent cells, suggesting that constitutive beta2-receptor signaling suppresses channel activity. Manipulation of intracellular cAMP, Galphai, and Galphas demonstrates that the beta2-adrenergic effects are consistent with a membrane-delimited mechanism involving Galphas. This is the first demonstration that gating of the iKCa1 channel is regulated by a G protein-coupled receptor and provides a clearly defined mechanism for the mast cell "stabilizing" effect of beta2-agonists. Furthermore, the degree of constitutive beta2-receptor "tone" may control the threshold for human mast cell activation through the regulation of iKCa1.

Mapping of the cardiac sympathetic nervous system by single photon emission tomography with technetium-99m-labelled fluorobenzylpiperidine derivative (99mTc-FBPBAT): result of a feasibility study in a porcine model and an initial dosimetric estimation in humans

Positron emission tomography (PET) and single photon emission tomography (SPET) offer the most promising tools for the in-vivo assessment of the cardiac autonomic nervous system in humans. However, the clinical application of PET and SPET on a routine basis is severely limited by the lack of widely available selective radiotracers. Technetium-99m-labelled 4-fluorobenzyl-4-(2-mercapto-2-methyl-4-aza-pentyl)-4-(2-mercapto-2-methyl-propylamino)-piperidine (99mTc-FBPBAT) is a recently developed radiotracer which exhibited marked adrenergic affinity in previous investigations in vascular smooth muscle cells and cardiac myocytes, and in rats. In this study, we have verified these findings in a porcine model, and evaluated the potential of SPET with 99mTc-FBPBAT to assess the adrenergic nervous system of the heart. Using a SPET camera, scintigraphic evaluations were carried out in pigs following intravenous injection of 99mTc-FBPBAT. The specificity of the cardiac uptake was determined by pharmacological intervention, using alpha- and beta-adrenoceptor antagonists and adrenergic re-uptake blocker. Whole-body kinetic and radiation absorbed doses were estimated from whole-body scintigraphies in two healthy volunteers. 99mTc-FBPBAT-SPET demonstrated a homogeneous distribution of radioactivity in myocardium of pigs and in humans. The cardiac uptake was specifically suppressed by previous treatment of the animals with metoprolol and prazosin, and was displaceable by norepinephrine. In contrast, the inhibition of radioactivity uptake into the heart was less pronounced after pretreatment with desipramine. The peak radioactivity in blood was determined after 1.5-2 min, followed by a plateau of nearly constant radioactivity from 25-30 min onwards. Within 6 h, more than 35% of the injected activity was excreted in the urine. The effective dose according to International Commission on Radiological Protection Publication 60 (ICRP 60) was 0.0064 mSv.MBq-1 for adults. In view of these findings, we conclude that the myocardial uptake of 99mTc-FBPBAT reflects the sympathetic adrenergic nervous system of the heart. The effective dose estimated indicates that the clinical use of 99mTc-FBPBAT results in an acceptable radiation dose in humans. Despite the relatively high radioactivity uptake into the lung and liver, 99mTc-FBPBAT appears to be the first promising Tc-based radiotracer for scintigraphic assessment of the cardiac adrenergic system. This result encourages further development of Tc-based agents for routine SPET studies in humans.

Galanin modulates cholinergic neurotransmission in the heart

The role of galanin (Gal) in the modulation of cholinergic neurotransmission in the heart in wild-type (129 SvJ), and GALR1 knockout mice has been studied. The mice were anaesthetised and ventilated. Blood pressure (BP) and the increase in pulse interval evoked by stimulation of the vagus nerve (deltaPI) were recorded. Resting BP and PI were not different in control and GALR1-KO mice. In control mice an intravenous, bolus injection of Gal (0.8-13 nmol/kg; n = 4-6) attenuated the deltaPI, dose dependently from 33 +/- 7% to 78 +/- 9.5%. In GALR1-KO mice, Gal (0.8-13 nmol/kg) did not attenuate deltaPI at any dose (n = 3-4). In control mice intravenous, bolus injection of neuropeptide Y (NPY; 0.5-10 nmol/kg, n = 5-7) attenuated the deltaPI by 13 +/- 10% to 67 +/- 7% with a half time to recovery of 0.5-5 +/- 1 min. In control mice, following activation of the cardiac sympathetic nerve (10 Hz for 2 min; n = 3) the deltaPI was attenuated by 92 +/- 2% with a half time to recovery of 7 +/- 1 min. In control mice in the presence of the beta-adrenoceptor antagonist propranolol (1 mg/kg), and 1 micromol/kg BIIE0426 (an NPY Y2 receptor antagonist) the deltaPI was 57+/-3% with a half time to recovery of 2.5+/-0.5 min. In GALR1-KO mice, in the presence of propranolol and BIIE0426 there was no inhibition of deltaPI. In mice, it is proposed that both Gal and NPY contribute to the prolonged attenuation of parasympathetic slowing of the heart following activation of the cardiac sympathetic nerve.

Paradoxal effect of salbutamol in an in vitro model of bronchoprotection

Salbutamol-induced hyperresponsiveness to acetylcholine was investigated in human and guinea-pig isolated airways and cultured human airway smooth muscle cells. Salbutamol (10(-7)-10(-5) m) inhibited contractions induced by low concentrations of acetylcholine (10(-8)-10(-7) m) but potentiated contractions induced by higher concentrations of acetylcholine (10(-5)-10(-3) m). Pretreatment with the calcium channel antagonist nicardipine suppressed salbutamol-induced hyperresponse. Stimulation of cultured human airway smooth muscle cells with salbutamol (10(-6) m) amplified intracellular calcium concentration rise induced by acetylcholine (10(-5) m). Propranolol (10(-7) m), a beta1- and beta2-adrenoceptor antagonist, and ICI 118551 (10(-7)-10(-6) m), a beta2-adrenoceptor antagonist, suppressed the inhibitory effect of salbutamol but did not inhibit the hyperresponse on high concentrations of acetylcholine. In contrast, higher concentration of propranolol (10(-6) m) inhibited salbutamol-induced hyperreactivity. Effects of salbutamol were not affected by atenolol, a beta1-adrenoceptor blocker. Salbutamol-induced hyperresponsiveness is mediated through a mechanism involving calcium channel activation.

Optimising the Use of ??-Adrenoceptor Antagonists in Coronary Artery Disease

beta-Adrenoceptor antagonists (beta-blockers) provide multiple benefits to patients with coronary artery disease. The 2001 American Heart Association and American College of Cardiology (AHA/ACC) guidelines for secondary prevention of myocardial infarction (MI) recommend initiating beta-adrenoceptor blockade in all post-MI patients and continuing therapy indefinitely. Atenolol and metoprolol have been shown to decrease vascular mortality in the acute-MI period. In the post-MI period timolol provided a 39% reduction in mortality in the Norwegian Multicenter Study group and propranolol was associated with a 26% reduction in mortality in BHAT (Beta-blocker Heart Attack Trial). beta-Adrenoceptor antagonist therapy results in reduction of myocardial oxygen demand and is therefore also effective for the treatment of angina pectoris. In CAST (Cardiac Arrhythmia Suppression Trial) beta-adrenoceptor antagonist therapy was associated with a significant reduction in arrhythmic death or cardiac arrest. In the post-MI amiodarone trials EMIAT (European Myocardial Infarct Amiodarone Trial) and CAMIAT (Canadian Amiodarone Myocardial Infarction Trial) there was a mortality benefit and decreased arrhythmic death in patients who received both amiodarone and beta-adrenoceptor antagonist therapy, compared with patients receiving amiodarone therapy alone. In the post-MI defibrillator (implantable cardioverter defibrillator [ICD]) trials, AVID (Antiarrhythmic Versus Implantable Defibrillator) and MUSTT (Multicenter Unsustained Tachycardia Trial), beta-adrenoceptor antagonist therapy was independently associated with improved overall survival. The exception was the ICD patients in MUSTT, and the benefit was attenuated in the amiodarone and ICD patients in AVID.AHA/ACC guidelines recommend the use of beta-adrenoceptor antagonists in all patients with symptomatic left ventricular dysfunction, based on several large, controlled heart failure trials. Extended-release metoprolol succinate reduced all-cause mortality by 34% in MERIT-HF (Metoprolol Controlled-Release/Extended-Release Randomized Intervention Trial in Heart Failure). Bisoprolol was associated with a 34% mortality benefit in CIBIS-II (Cardiac Insufficiency Bisoprolol Study II) and carvedilol was associated with a 35% mortality reduction in the COPERNICUS (Carvedilol Prospective Randomized Cumulative Survival) trial. beta-Adrenoceptor antagonists reduce perioperative mortality in patients undergoing cardiac as well as non-cardiac surgery; however, they remain underutilised. Contraindications to beta-adrenoceptor antagonist therapy include severe bradycardia, high-grade atrioventricular block, marked sinus node dysfunction and acute exacerbations of heart failure. Many of the perceived adverse effects of beta-adrenoceptor antagonists have not been substantiated by large clinical trials.beta-Adrenoceptor antagonists differ with regard to receptor selectivity, receptor affinity, lipophilicity and intrinsic sympathomimetic activity. Beneficial properties of beta-adrenoceptor antagonists may not always be extrapolated as a class effect, and patient selection and drug preparations should follow trial guidelines. The beneficial effects of beta-adrenoceptor antagonists are clearly proven in cardiac patients and those at risk for cardiac disease. They are indicated for heart failure and proven beneficial in patients undergoing cardiac and non-cardiac surgery. These benefits appear to be consistent across most patient subgroups. beta-Adrenoceptor antagonists are generally well tolerated, yet significant morbidity and mortality result from their continued underutilisation.

Is the Effect of Antihypertensive Drugs on Platelet Aggregability and Fibrinolysis Clinically Relevant?

Hypertension is associated with decreased fibrinolytic potential, mainly expressed as elevated plasma plasminogen activator inhibitor type 1 (PAI-1) levels, and increased platelet aggregability, which may account in part for the increased risk of atherosclerosis and its clinical complications in hypertensive patients. The effects of antihypertensive drugs on this prothrombotic state have been investigated and controversial findings have been reported, possibly because of differences in study designs, patients selected, and methodology used. Scarce and conflicting data exist about the effects of diuretics and beta-adrenoceptor antagonists on the fibrinolytic system, whereas ACE inhibitors have generally been reported to improve the fibrinolytic balance by decreasing plasma PAI-1 levels, calcium channel antagonists have been shown to increase tissue plasminogen activator (tPA) activity, and angiotensin II type 1 (AT(1)) receptor antagonists seem to exert neutral effects. beta-Adrenoceptor antagonists, calcium channel antagonists, and AT(1)-receptor antagonists have been reported to exert anti-aggregatory effects on platelets, while contrasting data exist about the influence of ACE inhibitors. Clinical implications of the changes induced by antihypertensive drugs on the fibrinolytic balance and platelet function are still debated. In particular, the question of whether these changes may translate into different degrees of cardiovascular protection in hypertensive patients remains unanswered. While awaiting more information from clinical trials, the choice of antihypertensive drugs, particularly in high-risk patients, should take into account effects beyond their BP-lowering efficacy. Selected agents should have a favorable, or at least neutral, impact on fibrinolytic function and platelet activity.

Underutilization of ??-Adrenoceptor Antagonists Post-Myocardial Infarction

Coronary artery disease continues to be the leading cause of death in the US. Several classes of drugs available today have shown benefit in decreasing the progression of coronary artery disease and its associated symptoms. When a patient experiences an acute coronary syndrome, beta-adrenoceptor antagonists are considered one of the cornerstones of medical therapy. Over the past 25 years, trials have demonstrated morbidity and mortality benefit when this class of drugs was given early in the post-myocardial infarction period. Subsequent substantial data have confirmed their beneficial effect on outcomes in other high-risk populations such as the elderly, those with left ventricular dysfunction, peripheral vascular disease, diabetic patients, and selected patients with reactive airway disease. Several reviews of hospital discharge data revealed that beta-adrenoceptor antagonists remain significantly underutilized in patients with acute, as well as chronic coronary artery disease. Misconceptions about the adverse effects and who would benefit probably account for physician reluctance to prescribe these medications. With rare exception, the overwhelming evidence currently supports the practice of prescribing beta-adrenoceptor antagonists to all patients immediately post-myocardial infarction and therapy to be continued indefinitely.

Management of Glaucoma: Focus on Pharmacological Therapy

Glaucoma represents a major cause of vision loss throughout the world. Primary open-angle glaucoma, the most common form of glaucoma, is a chronic, progressive disease often, though not always, accompanied by elevated intraocular pressure (IOP). In this disorder, retinal ganglion cell loss and excavation of the optic nerve head produce characteristic peripheral visual field deficits. Patients with normal-tension glaucoma present with typical visual field and optic nerve head changes, without a documented history of elevated IOP. A variety of secondary causes, such as pigment dispersion syndrome and ocular trauma, can result in glaucoma as well. Treatment of all forms of glaucoma consists of reducing IOP. With proper treatment, progression of this disease can often be delayed or prevented. Treatment options for glaucoma include medications, laser therapy and incisional surgery. Laser techniques for the reduction of IOP include argon laser trabeculoplasty and selective laser trabeculoplasty. Both techniques work by increasing outflow of aqueous humour through the trabecular meshwork. Surgical options for glaucoma treatment include trabeculectomy, glaucoma drainage tube implantation and ciliary body cyclodestruction. While each of these types of procedures is effective at lowering IOP, therapy usually begins with medications. Medications lower IOP either by reducing the production or by increasing the rate of outflow of aqueous humour within the eye. Currently, there are five major classes of drugs used for the treatment of glaucoma: (i) cholinergics (acetylcholine receptor agonists); (ii) adrenoceptor agonists; (iii) carbonic anhydrase inhibitors (CAIs); (iv) beta-adrenoceptor antagonists; and (v) prostaglandin analogues (PGAs). Treatment typically begins with the selection of an agent for IOP reduction. Although beta-adrenoceptor antagonists are still commonly used by many clinicians, the PGAs are playing an increasingly important role in the first-line therapy of glaucoma. Adjunctive agents, such as alpha-adrenoceptor agonists and CAIs are often effective at providing additional reduction in IOP for patients not controlled on monotherapy. As with any chronic disease, effective treatment depends on minimising the adverse effects of therapy and maximising patient compliance. The introduction of a variety of well tolerated and potent medications over the past few years now allows the clinician to choose a treatment regimen on an individual patient basis and thereby treat this disorder more effectively.

Different Effects on Inhibition of Cardiac Hypertrophy in Spontaneously Hypertensive Rats by Monotherapy and Combination Therapy of Adrenergic Receptor Antagonists and/or the Angiotensin II Type 1 Receptor Blocker under Comparable Blood Pressure Reduction

To confirm that alpha1, beta adrenoceptor antagonists and angiotensin II type 1 receptor blockers (ARBs) have different abilities to attenuate progressive cardiac hypertrophy despite their comparable lowering of blood pressure, we compared the effect of these agents alone or in combination on hypertensive cardiac hypertrophy. Eight-week-old spontaneously hypertensive rats (SHR) were divided into 7 groups. Single administration of doxazosin, atenolol, or losartan, or half-dose combinations of these drugs were given orally for 6 weeks. The control group did not receive any drugs. The heart weight-to-body weight ratio (HW/BW), left ventricular mass index (LVMI), plasma brain natriuretic peptide (BNP) and left ventricular BNP mRNA expression were measured after 6-week administration. Blood pressure did not differ among the drug-treated groups, all of which showed lower blood pressure than the control group. The HW/BW and LVMI of the drug-treated groups, except the doxazosin group, were lower than in the control group. Moreover, the LVMI values of the groups receiving losartan were significantly lower than those in the groups without losartan (p < 0.05). Plasma BNP of the drug-treated groups was lower than that in the control group (p < 0.05). The left ventricular BNP mRNA expression of the drug-treated groups, except the doxazosin group, was lower than that in the control group. The atenolol group showed a higher level of BNP mRNA than the groups receiving losartan monotherapy or combination therapies (p < 0.05). In conclusion, the ARB had the strongest attenuating effect on the development of hypertensive cardiac hypertrophy, and the alpha1 and beta adrenergic receptor blockers were more effective in combination than as monotherapies in SHR.

Postural Blood Pressure Changes and Orthostatic Hypotension in the Elderly Patient

With age our ability to maintain haemodynamic homeostasis during position changes becomes less effective. This predisposes elderly patients to significant changes in blood pressure upon standing and orthostatic hypotension (OH). The prevalence of OH varies according to the population being studied. A range of between 5% and 60% has been reported with the lower rate in elderly individuals living in the community and higher rates in those living in an institution or in the acute-care setting. Multiple factors have been linked to OH including age, bed rest, low body mass index and medications. Although antihypertensive medications can theoretically, as a group, worsen OH, the majority of cross-sectional studies have found no association. In addition, prospective randomised trials have demonstrated an improvement in postural blood pressure (PBP) changes with antihypertensive medications. When considering the individual classes, peripheral vasodilators, specifically alpha-adrenoceptor antagonists and nondihydropyridine calcium channel antagonists, can exacerbate PBP changes and lead to OH. ACE inhibitors, angiotensin-receptor antagonists and beta-adrenoceptor antagonists with intrinsic sympathomimetic activity are less likely to worsen OH. Careful management of electrolyte disturbance can decrease the risk of developing OH with diuretic use. With the aging population, this problem will be encountered by the clinicians at a much higher rate. A detailed patient history, an accurate orthostatic blood pressure measurement and careful evaluation of the autonomic nervous system can provide clinical guidance for management of OH. In hypertensive individuals with no pre-treatment OH, the use of antihypertensive medication can be safe and lead to a low risk of developing OH. In individuals with pre-treatment OH or who develop OH while on antihypertensive medications avoidance of the classes that may exacerbate OH and a judicious use of antihypertensive classes that may improve PBP changes may be safe and adequate treatment.

A Meta-Analytical Approach to the Efficacy of Antihypertensive Drugs in Reducing Blood Pressure

Hypertension constitutes a veritable public health issue. Several classes of drugs are available for the treatment of hypertension. The objective of this meta-analytical approach was to assess the efficacy of antihypertensive drugs most commonly used in France in reducing clinical SBP and DBP. The antihypertensive drugs selected were hydrochlorothiazide, indapamide sustained release (SR), furosemide and spironolactone for diuretics; amlodipine and lercanidipine for calcium channel antagonists; atenolol for beta-adrenoceptor antagonists (beta-blockers); enalapril and ramipril for ACE inhibitors; and candesartan cilexetil, irbesartan, losartan, and valsartan for angiotensin II receptor antagonists. The trials selected were published between 1973 and 2004, evaluated monotherapy with trial drugs as fixed-dosage or with dosage increase, and assessed blood pressure reduction between 2 and 3 months. The analysis method used was based on the calculation of the sum weighted for the trial size. A total of 72 trials (comprising 9094 patients) were selected and analyzed. No trial evaluating furosemide or spironolactone satisfied the inclusion criteria for this analysis. For SBP, the reduction was more marked with diuretics, calcium channel antagonists, and ACE inhibitors. Of all the drugs studied, indapamide SR gave the greatest SBP reduction (-22.2 mm Hg). Evaluated therapeutic classes had a similar magnitude of effect on DBP, i.e. reduction between -11.4 mm Hg with beta-adrenoceptor antagonists and -10.3 mm Hg with angiotensin II type 1 receptor antagonists. Indapamide SR 1.5 mg appeared to be the most effective drug for a significant reduction in SBP within 2-3 months, which is an essential element in optimizing cardiovascular prevention among hypertensive patients. The clinical application of these results should take into consideration all the limitations discussed in this analysis.

Aortic Insufficiency

Major advances in the diagnostic, evaluation, and particularly surgical treatment of aortic regurgitation (AR) have redefined the role of medical treatment. In acute AR, aortic valve replacement (AVR) is the only life-saving treatment. Medical treatment may improve the hemodynamic state temporarily before surgery. Rationale of medical treatment in chronic AR is based on the natural history and pathophysiology of the disease. The primary goal is to optimize the time of the AVR. If there is any symptom and/or left ventricular (LV) dysfunction, early AVR is required. Vasodilators should only be considered as a short-term treatment before surgery if there is evidence of severe heart failure or as a long-term treatment if AVR is contraindicated because of cardiac or noncardiac factors. In asymptomatic patients with severe chronic AR and normal LV function (even if the left ventricle is moderately dilated), vasodilators may prolong the compensated phase of chronic AR, although proof of their efficacy in delaying AVR is limited. Nifedipine is the best evidence-based treatment in this indication. ACE inhibitors are particularly useful for hypertensive patients with AR. beta-Adrenoceptor antagonists (beta-blockers) may be indicated to slow the rate of aortic dilatation and delay the need for surgery in patients with AR associated with aortic root disease. Furthermore, they may improve cardiac performance by reducing cardiac volume and LV mass in patients with impaired LV function after AVR for AR.

Novel Approaches to the Treatment of Cocaine Addiction

Cocaine addiction continues to be an important public health problem with over 1.7 million users in the US alone. Although there are no approved pharmacotherapies for cocaine addiction, a number of medications have been tested with some promising results. In this review, we summarise some of the emerging targets for cocaine pharmacotherapy including dopaminergic and GABA medications, adrenoceptor antagonists, vasodilators and immunotherapies. The brain dopamine system plays a significant role in mediating the rewarding effects of cocaine. Among dopaminergic agents tested for cocaine pharmacotherapy, disulfiram has decreased cocaine use in a number of studies. Amantadine, another medication with dopaminergic effects, may also be effective in cocaine users with high withdrawal severity. GABA is the main inhibitory neurotransmitter in the brain, and accumulating evidence suggests that the GABA system modulates the dopaminergic system and cocaine effects. Two anticonvulsant medications with GABAergic effects, tiagabine and topiramate, have yielded positive findings in clinical trials. Baclofen, a GABA(B) receptor agonist, is also promising, especially in those with more severe cocaine use. Some of the physiological and behavioural effects of cocaine are mediated by activation of the adrenergic system. In cocaine users, propranolol, a beta-adrenoceptor antagonist, had promising effects in individuals with more severe cocaine withdrawal symptoms. Cerebral vasodilators are another potential target for cocaine pharmacotherapy. Cocaine users have reduced cerebral blood flow and cortical perfusion deficits. Treatment with the vasodilators amiloride or isradipine has reduced perfusion abnormalities found in cocaine users. The functional significance of these improvements needs to be further investigated. All these proposed pharmacotherapies for cocaine addiction act on neural pathways. In contrast, immunotherapies for cocaine addiction are based on the blockade of cocaine effects peripherally, and as a result, prevent or at least slow the entry of cocaine into the brain. A cocaine vaccine is another promising treatment for cocaine addiction. The efficacy of this vaccine for relapse prevention is under investigation. Many initial promising findings need to be replicated in larger, controlled clinical trials.