Vascular effects of newer cardiovascular drugs: focus on nebivolol and ACE-inhibitors

Role of Gi proteins in the regulation of blood pressure and vascular remodeling

Heterotrimeric guanine nucleotide regulatory proteins (G-proteins) through the activation of several signaling mechanisms including adenylyl cyclase/cAMP and phospholipase C (PLC)/phosphatidyl inositol (PI) turnover. regulate a variety of cellular functions, including vascular reactivity, proliferation and hypertrophy of VSMC. Activity of adenylyl cyclase is regulated by two G proteins, stimulatory (Gsα) and inhibitory (Giα). Gsα stimulates adenylyl cyclase activity and increases the levels of cAMP, whereas Giα inhibits the activity of adenylyl cyclase and results in the reduction of cAMP levels. Abnormalities in Giα protein expression and associated adenylyl cyclase\cAMP levels result in the impaired cellular functions and contribute to various pathological states including hypertension. The expression of Giα proteins is enhanced in various tissues including heart, kidney, aorta and vascular smooth muscle cells (VSMC) from genetic (spontaneously hypertensive rats (SHR)) and experimentally - induced hypertensive rats and contribute to the pathogenesis of hypertension. In addition, the enhanced expression of Giα proteins exhibited by VSMC from SHR is also implicated in the hyperproliferation and hypertrophy, the two key players contributing to vascular remodelling in hypertension. The enhanced levels of endogenous vasoactive peptides including angiotensin II (Ang II), endothelin-1 (ET-1) and growth factors contribute to the overexpression of Giα proteins in VSMC from SHR. In addition, enhanced oxidative stress, activation of c-Src, growth factor receptor transactivation and MAP kinase/PI3kinase signaling also contribute to the augmented expression of Giα proteins in VSMC from SHR. This review summarizes the role of Giα proteins, and the underlying molecular mechanisms implicated in the regulation of high blood pressure and vascular remodelling.

Cerebral Vascular Control and Metabolism in Heat Stress

This review provides an in-depth update on the impact of heat stress on cerebrovascular functioning. The regulation of cerebral temperature, blood flow, and metabolism are discussed. We further provide an overview of vascular permeability, the neurocognitive changes, and the key clinical implications and pathologies known to confound cerebral functioning during hyperthermia. A reduction in cerebral blood flow (CBF), derived primarily from a respiratory-induced alkalosis, underscores the cerebrovascular changes to hyperthermia. Arterial pressures may also become compromised because of reduced peripheral resistance secondary to skin vasodilatation. Therefore, when hyperthermia is combined with conditions that increase cardiovascular strain, for example, orthostasis or dehydration, the inability to preserve cerebral perfusion pressure further reduces CBF. A reduced cerebral perfusion pressure is in turn the primary mechanism for impaired tolerance to orthostatic challenges. Any reduction in CBF attenuates the brain's convective heat loss, while the hyperthermic-induced increase in metabolic rate increases the cerebral heat gain. This paradoxical uncoupling of CBF to metabolism increases brain temperature, and potentiates a condition whereby cerebral oxygenation may be compromised. With levels of experimentally viable passive hyperthermia (up to 39.5-40.0 °C core temperature), the associated reduction in CBF (∼ 30%) and increase in cerebral metabolic demand (∼ 10%) is likely compensated by increases in cerebral oxygen extraction. However, severe increases in whole-body and brain temperature may increase blood-brain barrier permeability, potentially leading to cerebral vasogenic edema. The cerebrovascular challenges associated with hyperthermia are of paramount importance for populations with compromised thermoregulatory control--for example, spinal cord injury, elderly, and those with preexisting cardiovascular diseases.

Nebivolol ameliorates asymmetric dimethylarginine-induced vascular response in rat aorta via β3 adrenoceptor-mediated mechanism

BACKGROUND

Asymmetric dimethylarginine (ADMA), an endogenous nitric oxide synthase (NOS) inhibitor, induces endothelial dysfunction. Nebivolol, a highly selective β1-adrenergic receptor (AR) blocker, is the only beta-blocker known to induce vascular production of nitric oxide.

OBJECTIVE

The present study was designed to evaluate the effect and mechanism of nebivolol on ADMA-induced vascular response in rat aorta in vitro.

METHODS

In vitro, the effects of nebivolol and ADMA on resting tone or contraction induced by phenylephrine (PE, 10(-6 )mol/L) and relaxation induced by acetylcholine (Ach, 10(-10)-10(-5 )mol/L) were evaluated.

RESULTS

ADMA in a concentration-dependent manner increased the resting and PE-induced tone and reduced Ach-induced relaxation. Nebivolol inhibited the ADMA-induced enhancements in tone and reversed the effects of ADMA on Ach-induced relaxation. These effects of nebivolol were blocked by selective β3 receptor blocker cyanopindolol (1 μM), but not by selective β2 receptor blocker butoxamine (50 μM).

CONCLUSIONS

Nebivolol ameliorates the ADMA-induced vascular responses in rat aorta, at least in part, by mechanisms involving β3 adrenoceptor.

Nitric oxide in hypertension

Hypertension is a major risk factor for cardiovascular disease, and reduction of elevated blood pressure significantly reduces the risk of cardiovascular events. Endothelial dysfunction, which is characterized by impairment of nitric oxide (NO) bioavailability, is an important risk factor for both hypertension and cardiovascular disease and may represent a major link between the conditions. Evidence suggests that NO plays a major role in regulating blood pressure and that impaired NO bioactivity is an important component of hypertension. Mice with disruption of the gene for endothelial NO synthase have elevated blood pressure levels compared with control animals, suggesting a genetic component to the link between impaired NO bioactivity and hypertension. Clinical studies have shown that patients with hypertension have a blunted arterial vasodilatory response to infusion of endothelium-dependent vasodilators and that inhibition of NO raises blood pressure. Impaired NO bioactivity is also implicated in arterial stiffness, a major mechanism of systolic hypertension. Clarification of the mechanisms of impaired NO bioactivity in hypertension could have important implications for the treatment of hypertension.

Targeting Nitric Oxide With Drug Therapy

Increasing knowledge of the role of nitric oxide (NO) in physiology and disease has stimulated efforts to target the NO pathway pharmacologically. These therapeutic strategies include NO donors that directly or indirectly release NO and agents that increase NO bioactivity. Traditional organic nitrates such as nitroglycerin, which indirectly release NO, were believed to have limited long-term efficacy and tolerability, chiefly because of nitrate tolerance. Recent studies, however, suggest more effective ways of using these agents and new applications for them. Nicorandil, a hybrid organic nitrate that also activates potassium channels, has demonstrated significant benefits in acute coronary syndromes. Other nitrates are being investigated for use in neurodegenerative diseases. Direct NO donors include NO gas, which is useful in respiratory disorders, and the more recent classes of diazeniumdiolates, sydnonimines, and S-nitrosothiols. Preliminary data suggest that these agents may be effective as antiatherosclerotic agents as well as in other disease states. In addition, hybrid agents that consist of an NO donor coupled with a parent anti-inflammatory drug, including nonsteroidal anti-inflammatory drugs, have demonstrated enhanced efficacy and tolerability compared with the anti-inflammatory parent drug alone in diverse experimental models. Established drugs that enhance NO bioactivity include antihypertensive agents, particularly angiotensin-converting enzyme inhibitors, calcium channel blockers, and newer vasodilating beta-blockers. In addition, 3-methylglutaryl coenzyme A reductase inhibitors (statins) promote NO bioactivity, both through and independent of lipid lowering. The NO-promoting actions of these established drugs provide some insight into their known benefits and suggest possible therapeutic potential.

Pharmacological Mechanisms of Clinically Favorable Properties of a Selective β1-Adrenoceptor Antagonist, Nebivolol

Nebivolol is a racemic mixture of d- and l-enantiomers. The drug is characterized by beta(1)-adrenoceptor selectivity and long-acting beta-blockade exerted predominantly by d-enantiomer. Nebivolol is devoid of intrinsic sympathomimetic activity and has no relevant membrane stabilizing action. Antiproliferative properties of nebivolol were demonstrated in endothelial and smooth muscle cell cultures. Infusion of nebivolol causes a vasodilation in all vascular beds by endothelial-dependent mechanism involving stimulation of beta(3)-adrenoceptors as well as by endothelial-independent mechanism. Nebivolol possesses not only direct vasodilator properties but also augments the action of endothelium-dependent vasodilators. The antioxidant property of nebivolol can at least in part explain why treatment with this drug enhances eNOS activity and minimizes the reperfusion-induced myocardial injury. The systemic effects of nebivolol in humans have an unusual hemodynamic profile. In contrast to traditional beta-adrenoceptor antagonists, nebivolol reduces preload and afterload due to systemic vasodilation and improves arterial distensibility. At 5 mg daily nebivolol effectively reduces systolic and diastolic blood pressure over a 24-h period. During treatment with nebivolol arterial pressure follows the natural circadian rhythm. Trough-to-peak ratio for nebivolol is 0.9. It has been demonstrated in numerous placebo-controlled studies that exercise tolerance is not reduced during nebivolol therapy. By chronic administration to patients with left ventricular dysfunction nebivolol increases myocardial contractility. Nebivolol produced no significant changes in lipid levels, insulin sensitivity or glucose tolerance. These findings make nebivolol a promising therapeutic tool for the treatment of arterial hypertension and chronic heart failure.

Short-term improvement in submaximal exercise capacity by optimized therapy with ACE inhibitors and beta blockers in heart failure patients is associated with restoration of peripheral endothelial function

BACKGROUND

Improved exercise capacity in chronic heart failure (CHF) has been attributed to restoration of endothelial function. ACE inhibitors as well as beta blockers have previously been shown to enhance endothelial function and exercise capacity. The aim of this study was to determine whether short-term improvement in submaximal exercise capacity induced by optimized therapy with ACE inhibitors in combination with beta blockers is associated with restoration of endothelial function in CHF patients.

METHODS

Thirty-three patients with CHF were evaluated: six-minute walk test, NYHA class, brain natriuretic peptide (BNP), big Endothelin-1 (bigET-1) and flow-mediated vasodilation (FMD) of the brachial artery were assessed at baseline and after a 3-month period of optimized neurohormonal therapy. Two groups were formed retrospectively based on the changes in submaximal exercise capacity (responders and non-responders).

RESULTS

Optimization of neurohormonal therapy was comparable between groups. Responders (n=17) revealed a significant increase in walking distance (304+/-109 to 441+/-75 m; p<0.01), which was paralleled by a decrease in NYHA class (2.7+/-0.6 to 2.0+/-0.4; p<0.01), BNP (484+/-454 to 243+/-197 pg/ml; p<0.01), and bigET-1 (2.0+/-0.9 vs. 1.5+/-0.6 fmol/ml; p=0.04). By contrast, the latter variables did not change in non-responders. Improvement in functional capacity in responders was associated with an increase in FMD (8.2+/-3.9% to 11.0+/-5.6%; p<0.05). Increments in FMD were directly correlated with increases in walking distance (r=0.34; p<0.05).

CONCLUSION

Short-term improvement of submaximal exercise capacity in CHF patients following optimized therapy with ACE inhibitors and beta blockers is associated with restoration of endothelial function in conduit arteries.

The cellular mechanisms involved in the vasodilator effect of nebivolol on the renal artery

Nebivolol is known as a highly selective beta1-adrenoceptor antagonist. Based on the reported vasodilator effect of nebivolol, we examined the cellular mechanisms by which the drug induces renal artery vasodilation, an issue of potential relevance for condition associated with high blood pressure. To this purpose, myograph and patch-clamp techniques were used. Small mouse renal arteries were placed in the myograph chamber, and after the optimal concentration for the vasodilator effect of nebivolol was established (50 microM), the arteries were further investigated to assess the potential contribution of nitric oxide (NO) and of Ca2+ ions to the nebivolol-induced effect, by exposing the arteries to the specific inhibitors such as N(G)-nitro-L-arginine methylester (L-NAME, 100 microM), ethylenglycol-bis-(beta-amino-ethylen ester) N,N'-tetraacetic acid (EGTA, 4 microM) and thapsigargin (1 microM). The expression of NO synthase was evaluated by the Western-blot technique. Using myograph and patch-clamp techniques applied on intact renal artery, we investigated the role of beta2-adrenoceptors, of myoendothelial junctions and of Ca(2+)-activated K+ channels in the vasodilatory effects of nebivolol, using 100 microM butoxamine, 40 microM 18 beta-glycyrrhetinic acid, 1 mM tetraethylammonium, and 100 nM iberiotoxin, respectively. The results showed that the cellular mechanisms of the vasodilator effect of nebivolol on the renal artery entail (i) activation of the endothelial beta2-adrenoceptor, (ii) participation of [Ca2+]i, (iii) increase in NO and eNOS, and (iv) activation of Ca(2+)-activated K+ channels. The cellular mechanisms underlying vasodilator effect of nebivolol on the artery explain the favorable effect of this drug in hypertension.

Nitric oxide-releasing drugs

Pharmacological compounds that release nitric oxide (NO) have been useful tools for evaluating the broad role of NO in physiology and therapeutics. NO deficiency has been implicated in the genesis and evolution of several disease states. Both medical needs and commercial opportunities have fostered attempts to modulate NO in the human body for therapeutic gain. Strategies for NO modulation encompass antiinflammatory, sexual dysfunction, and cardiovascular indications. Apart from newly developed drugs, several commonly used cardiovascular drugs exert their beneficial action, at least in part, by modulating the NO pathway. This review discusses the fundamental pharmacological properties and mechanisms of action of NO-releasing drugs. Some of these compounds may enter in the clinical arena providing important therapeutic benefits in human diseases.

Effects of antihypertensive agents, alpha receptor blockers, beta blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and calcium channel blockers, on oxidative stress

BACKGROUND

Free oxygen radicals and insufficiency of antioxidant enzymes have been implicated in the pathogenesis of hypertension disease (HD). Trace elements function as a co-factor in antioxidant enzymes. The antioxidant system and trace elements have been investigated in many different studies including HD, but these subjects have not been investigated as a whole in these patients.

OBJECTIVE

The aim of the present study was to investigate the antioxidative system and trace elements in hypertensive patients given different antihypertensive therapy.

METHODS

We examined malondialdehyde and superoxide dismutase activities together with copper and zinc levels in plasma of 102 patients with HD and in 51 healthy controls.

RESULTS

It was found that in patients with HD, plasma malondialdehyde was significantly higher than those of controls, while plasma superoxide dismutase activities were significantly lower in patients with HD. Plasma zinc levels were significantly higher than those of controls and plasma copper levels were significantly lower in patients with HD. Plasma lipid levels and oxidative state were analyzed in five different treatment groups given antihypertensive drug therapy before and after a 3-month treatment period.

CONCLUSIONS

In conclusion, our clinical study shows that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have notable effects on oxidative stress, and are an essential step in managing essential hypertension by the way of improvement of endothelial dysfunction. Although it has been shown that calcium channel blockers, beta blockers and alpha receptor blockers have antioxidant effects in in vitro conditions, we did not demonstrate these effects in our clinical study.

Effects of nebivolol on ischemia-induced metabolic changes in dog hearts

dl-Nebivolol has a beta(1)-adrenergic blocking property and l-nebivolol has an endothelial-dependent vasodilating property, sp that a racemic mixture, deltal-nebivolol, shows both properties. This study examined the effect of dl-nebivolol on ischemic myocardium in anesthetized open chest dogs. Ischemia was induced for 3 min by ligating the left anterior descending coronary artery 10 min after IV injection of vehicle, dl-nebivolol (0.03, 0.1, and 0.3 mg/kg), or d- or l-nebivolol (0.15 mg/kg). Ischemia significantly decreased the levels of ATP, creatine phosphate, and fructose-1,6-diphosphate and increased those of ADP, AMP, hexose monophosphates, and ratio of [lactate]/[pyruvate]. dl-Nebivolol at higher doses significantly attenuated some metabolic changes caused by ischemia. Although neither enantiomers significantly affected these ischemia-induced metabolic changes, d-nebivolol appeared to attenuate adenine nucleotide reduction due to ischemia. Pretreatment with Nw-nitro-l-arginine methyl ester did not abolish the restoration of ischemia-induced myocardial metabolic changes by dl-nebivolol. In conclusion, dl-nebivolol lessens ischemic derangement of myocardial metabolism, and the effects may be due mainly to its beta-adrenergic blocking property but not to endothelium-dependent vasorelaxing property.