β-blockade: benefits beyond blood pressure reduction?

Hypertension is a major cardiovascular (CV) risk factor, but several other common conditions, including chronic obstructive pulmonary disease (COPD), osteoporosis, and peripheral arterial disease (PAD), have been shown to independently increase the risk of CV events and death. The physiological basis for an increased CV risk in those conditions probably lies in the augmentations of oxidative stress, endothelial dysfunction, systemic inflammation, and arterial stiffness, which all are also hallmarks of hypertension. β-Blockers have been used for the treatment of hypertension for more than 40 years, but a number of meta-analyses have demonstrated that treatment with these agents may be associated with an increased risk of CV events and mortality. However, the majority of primary prevention β-blocker trials employed atenolol, an earlier-generation β(1) -selective blocker whose mechanism of action is based on a reduction of cardiac output. Available evidence suggests that vasodilatory β-blockers may be free of the deleterious effects of atenolol. The purpose of this review is to summarize pathophysiologic mechanisms thought to be responsible for the increased CV risk associated with COPD, osteoporosis, and PAD, and examine the possible benefits of vasodilatory β-blockade in those conditions. Our examination focused on nebivolol, a β(1) -selective agent with vasodilatory effects most likely mediated via β(3) activation.

Does nebivolol prevent contrast-induced nephropathy in humans?

BACKGROUND

An experimental study showed that nebivolol is an effective agent in contrast-induced nephropathy (CIN) prophylaxis.

HYPOTHESIS

We hypothesized that prophylactic nebivolol use had protective effects on renal function in human beings subjected to iodinated contrast agent since it has vasodilatory effect and antioxidant properties.

METHODS

The present study enrolled 120 patients scheduled for coronary angiography and ventriculography. All patients were hydrated with intravenous isotonic saline. The patients in group I received 600 mg N-acetylcysteine every 12 hours for 4 days. The patients in group II received 5 mg nebivolol every 24 hours for 4 days. The patients in group III were only hydrated. The primary endpoint was the occurrence of CIN. The secondary endpoint was the change in serum creatinine (Cr) levels at 2 days and 5 days after the contrast exposure.

RESULTS

Nine (22.5%) patients in group I developed CIN, as did 8 patients (20.0%) in group II and 11 patients (27.5%) in group III (P = 0.72). Changes in mean Cr level from baseline to day 2 were not statistically significant in all groups. However, we detected a statistically significant increase in mean Cr levels at day 5 compared with baseline levels in group I and group III (from 1.42 ± 0.13 to 1.52 ± 0.26, p2 = 0.02; and from 1.43 ± 0.14 to 1.55 ± 0.30, p2 = 0.01, respectively). Although an increase was detected in mean Cr level from baseline to the 5-day Cr level in group II, this did not reach statistical significance (from 1.40 ± 0.12 to 1.48 ± 0.23, P = 0.06).

CONCLUSIONS

Pretreatment with nebivolol is protective against nephrotoxic effects of contrast media.

The use of beta blocker Nebivolol in patients with chronic obstructive pulmonary disease in association with arterial hypertension

There were investigated 22 patients with chronic obstructive pulmonary disease in association with arterial hypertension initially and after 5 weeks of treatment with beta-blocker Nebivolol 5 mg/day. There were not detected any negative changes on bronchial permeability after treatment. Considerable improvement of endothelial function (from 7-12% to 17-35%, p < 0.05) in parallel with decreasing of pulmonary artery, systolic (44.5 +/- 5.5 mmHg vs. 32.8 +/- 4.1 mmHg, p < 0.05) and mean pressure (26.3 +/- 4.2 mmHg vs. 21.1 +/- 2.1 mmHg, p < 0.05)--were observed after treatment. Thus, Nebilet is well-tolerated and highly effective in patients with chronic obstructive pulmonary disease in association with arterial hypertension.

[Effect of the third generation beta-blockers on ion-regulating renal function in rats with heart failure model]

Beta-adrenoceptor blockers nebivolol and carvedilol do not affect diuresis and renal sodium excretion in intact rats, but significantly increase urinary excretion of sodium in animals with a model of heart failure caused by excessive physical exercise and injection of phenylephrine. Nebivolol, in contrast to carvedilol, causes additional increase the urinary potassium loss, which is retained in animals with experimental heart failure. It is concluded that both drugs increase renal sodium excretion in rats with heart failure model by preventing the excessive sodium delay in the body.

[Use of nebivolol in patients with idiopathic pulmonary hypertension: results of the pilot study]

AIM

To study the impact of 24-week therapy with nebivolol in a dose of 5 mg/day on the clinical and functional status of patients with idiopathic pulmonary hypertension (IPH), echocardiographic parameters, and blood levels of vasoactive mediators and nitric oxide (NO) metabolite.

SUBJECTS AND METHODS

During continuous standard therapy comprising dihydropyridine calcium antagonists, warfarin, and diuretics, 12 patients with IPH and functional class (FC) II-III received nebivolol in a dose of 5 mg/day for 24 weeks. According to the data of right heart catheterization, all the patients had a positive acute pharmacological test with a vasodilator (NO). Six-minute walk test (6'WT), estimation of the Borg dyspnea index (BDI) and FC, transthoracic echocardiography (EchoCG), and measurements of the levels of NO metabolites, endothelin-1, (ET-1), thromboxane B2 (TxB2), and 6-keto-prostaglandin F1alpha (6-ketoPG F1alpha) were done at baseline and after 12 and 24 weeks of the therapy.

RESULTS

Following 24-week nebivolol treatment, there was a statistically significant increase in 6'WT distance (from 473 +/- 47.6 to 516.7 +/- 58.4 m; p < 0.0001) and a drop in BDI (from 3.4 +/- 2.2 to 1.1 +/- 0.7; p < 0.05) and FC (from 2.9 +/- 0.4 to 1.7 +/- 0.2; p < 0.05). Doppler EchoCG showed that pulmonary artery systolic pressure statistically significantly decreased (91.6 +/- 30 to 78.3 +/- 39 mm Hg; p = 0.05) at 12 weeks and slightly increased up to 83.2 +/- 32.4 mm Hg at 24 weeks. After 24-week treatment, the anteroposterior dimensions of the right ventricle (RV) statistically significantly reduced (from 4.4 +/- 0.6 to 3.8 +/- 1.2 cm; p < 0.05). The other EchoCG parameters remained substantially unchanged. There was a statistically reduction in the level of ET-1 (from 2.99 +/- 1.1 to 2.17 +/- 0.8 micromol/l; p < 0.05). The concentrations of 6-ketoPG Fla, TxB2, and NO metabolite remained substantially unchanged at 24 weeks of treatment with nebivolol. There were no adverse reactions requiring that the dose of the drug be discontinued or reduced. Heart rate tended to be lower at a 24-week follow-up. All the patients continued taking nebivolol after completion of the study.

CONCLUSION

Therapy with nebivolol in a dose of 5 mg/day for 24 weeks led to a significant functional improvement in the patients with IPH and reductions in RV dimensions and blood ET-1 levels. The therapy did not cause adverse reactions.

[Analysis of variability of cardiac rhythm and sexual function in men with arterial hypertension during therapy with biosporolol and nebivolol]

The aim of the work was to study effect of bisoprolol and nebivolol therapy on the sexual function of men with AH. 20 men aged 35-55 (48 +/- 3.5) yr with grade I and II AH received either drug for 2 months. Cardiac rhythm variability (CRV) was estimated in the end of the 4-week placebo period and after 2-month monotherapy. Dopplerography of penile arteries and a questionnaire study (as described by Vasilchenko) were conducted. Both drugs significantly increased the tone of the parasympathetic component of the vegetative nervous system, improved systolic blood flow in cavernous and dorsal arteries. The questionnaire study failed to revel significant changes of the sexual function. It is concluded that biosporolol and nebivolol did not compromise the sexual function of men with AH; they improve spectral CRV characteristics and blood flow in cavernous arteries.

Comparison between nebivolol and ramipril in patients with hypertension and left ventricular hypertrophy: a randomized open blinded end-point (PROBE) trial

AIMS

To compare the effects of nebivolol and ramipril on left ventricular hypertrophy in hypertensive patients.

MATERIALS AND METHODS

The study was conducted with a pre-randomised blinded endpoint (PROBE) design in which 106 patients with mild-to-moderate hypertension and left ventricular hypertrophy were randomised to ramipril (n = 52) or to nebivolol (n = 54) and treated for 39 weeks. The doses of ramipril and nebivolol were 2.5 and 5 mg/day, respectively. After 4-8 weeks, in patients with not normalised diastolic blood pressure, a thiazide diuretic was added (indapamide 2.5 mg or hydrochlorothiazide 12.5 mg/day). In the ramipril group, thiazide diuretic was added in 97% of subjects and in nebivolol group in 92%. The effect of treatment on left ventricular mass was assessed by two-dimensional guided M-mode transthoracic echocardiography, at baseline and at the end of the treatment. Left ventricular mass index (LVMI) was calculated and indexed to body surface area (g/m2) and height2.7 (g/height2.7). Blood pressure (BP) was measured at baseline, after 4, 8, 12, 24 and 39 weeks with a standard mercury sphygmomanometer.

RESULTS

Both left ventricular mass (LVM) and mass index (LVMI) decreased significantly after treatment with ramipril (LVMI -14.8 g/m2, -7.3 g/height2.7; p < 0.001), and after treatment with nebivolol (LVMI -31.9 g/m2, -15.6 g/height2.7; p < 0.001). The difference between ramipril and nebivolol (-17.1 g/m2, -8.3 g/height2.7) with regards to reduction of LVMI was statistically significant (p < 0.001). No differences were observed between the two groups in terms of normalization of LVMI. Both drugs decreased BP similarly after 39 weeks of treatment

CONCLUSIONS

The present study shows that both nebivolol and ramipril decrease LVMI. Nebivolol 5 mg/daily treatment reduced LVMI significantly more than ramipril 2.5 mg/daily. Both drugs similarly decreased BP during the treatment.

Nebivolol improves insulin sensitivity in the TGR(Ren2)27 rat

Hypertension is often associated with increased oxidative stress and systemic insulin resistance. Use of β-adrenergic receptor blockers in hypertension is limited because of potential negative influence on insulin sensitivity and glucose homeostasis. We sought to determine the impact of nebivolol, a selective vasodilatory β₁-adrenergic blocker, on whole-body insulin sensitivity, skeletal muscle oxidative stress, insulin signaling, and glucose transport in the transgenic TG(mRen2)27 rat (Ren2). This rodent model manifests increased tissue renin angiotensin expression, excess oxidative stress, and whole-body insulin resistance. Young (age, 6-9 weeks) Ren2 and age-matched Sprague-Dawley control rats were treated with nebivolol 10 mg/(kg d) or placebo for 21 days. Basal measurements were obtained for glucose and insulin to calculate the homeostasis model assessment. In addition, insulin metabolic signaling, nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity, reactive oxygen species, and ultrastructural changes as evaluated by transmission electron microscopy were examined ex vivo in skeletal muscle tissue. The Ren2 rat demonstrated systemic insulin resistance as examined by the homeostasis model assessment, along with impaired insulin metabolic signaling in skeletal muscle. This was associated with increased oxidative stress and mitochondrial remodeling. Treatment with nebivolol was associated with improvement in insulin resistance and decreased NADPH oxidase activity/levels of reactive oxygen species in skeletal muscle tissue. Nebivolol treatment for 3 weeks reduces NADPH oxidase activity and improves systemic insulin resistance in concert with reduced oxidative stress in skeletal muscle in a young rodent model of hypertension, insulin resistance, and enhanced tissue RAS expression.

Results of the NESCIO Study, a randomized, double blind trial

OBJECTIVES

This study compared the efficacy of metoprolol and nebivolol in reducing the frequency of in-stent restenosis (ISR) after a percutaneous coronary intervention (PCI).

BACKGROUND

ISR results from excessive neointimal proliferation. Nebivolol inhibits proliferation of human coronary endothelial and smooth muscle cells in vitro. Its efficacy has not been studied in clinical trials.

MATERIAL AND METHODS

In a single-centre double-blind study, 79 subjects with de novo lesions were randomly assigned to receive either nebivolol (n=37) or metoprolol (n=42) 3 to 7 days before elective PCI with bare metal stents. The study medication was continued for 6 months. Nebivolol was administered at 5 mg/day for 3 weeks, then at 10 mg/day. Metoprolol was administered at 100 mg/day. The endpoints were the difference in fractional flow reserve (deltaFFR) between values immediately after PCI and those at 6 months and ISR during the 6 months following PCI The study was powered to detect a deltaFFR of 6% with 30 subjects per treatment group.

RESULTS

Among subjects who underwent angiography at 6 months, mean deltaFFR was--0.08 for the nebivolol group (n=25) and -0.12 in the metoprolol group (n=26; p = 0.367). ISR occurred in 11 subjects (26.2%) on metoprolol and in 3 (8.1%) on nebivolol during treatment, and in 7 subjects on metoprolol and in 3 on nebivolol at 6 months (p = 0.014)

CONCLUSION

There was a non-significant trend toward less decline in detaFFR at 6 months with nebivolol. Nebivolol should be investigated further in larger trials. Nebivolol significantly reduced the frequency of ISR as compared to metoprolol.

Nebivolol for the treatment of heart failure

PURPOSE. The pharmacology, pharmacokinetics, efficacy, safety, and place in therapy of nebivolol are reviewed. SUMMARY. Nebivolol, a third-generation, highly β(1)-specific β-blocker, is labeled for the treatment of hypertension in the United States. In addition to its β-blocking effects, nebivolol has been shown to increase endothelin-dependent nitric oxide, giving it a unique peripheral vasodilatory action. Nebivolol is extensively metabolized by cytochrome P-450 isoenzyme 2D6. In patients with heart failure, certain β-blockers antagonize excessive adrenergic stimulation and can slow the progression of the disease. Clinical trials have compared nebivolol at target dosages of 5 and 10 mg once daily with placebo and, in small trials, with carvedilol in the treatment of adults with chronic heart failure. Nebivolol appears to have beneficial effects in patients with heart failure, including improvements in left ventricular ejection fraction, left ventricular volumes, and exercise capacity. In addition, the Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with Heart Failure showed a reduction in morbidity and mortality after treatment with nebivolol when compared with placebo, though this effect appeared to be less than that of other β-blockers currently recommended for the treatment of heart failure. Nebivolol was well tolerated in all clinical trials, with the most frequently reported adverse events including bradycardia, hypotension, and dizziness. To date, no large clinical trials have compared nebivolol with currently recommended β-blockers in patients with heart failure. CONCLUSION. Nebivolol has beneficial effects in heart failure but cannot be considered equivalent to other currently accepted therapies.

The effect of nebivolol versus metoprolol succinate extended release on asymmetric dimethylarginine in hypertension

This study sought to determine if metoprolol succinate ER (MET), and nebivolol (NEB), a β1-AR with increased bioavailability of nitric oxide (NO), would have differing effects on plasma asymmetric dimethylarginine concentration in hypertensives. It was hypothesized that NEB, a β1-AR antagonist and β3-AR agonist with NO-releasing properties, and MET, only a β1-AR antagonist, would have different effects on plasma asymmetric dimethylarginine (ADMA) concentration. Forty-one hypertensive subjects randomly received either 50 mg of MET (n = 19) or 5 mg of NEB (n = 22) for 4 weeks followed by 100 mg MET and 10 mg NEB for 4 weeks. ADMA and insulin-like growth factor-1 (IGF-1) were measured by enzyme-linked immunosorbent assay kit; endothelial progenitor cells were estimated using fluorescein-labeled monoclonal antibody to KDR and CD133 receptors; arterial augmentation index was measured by radial tonometry. Baseline systolic/diastolic blood pressure was 155.1 ± 18.7/85.3 ± 12.5 mm Hg for MET subjects and 157.6 ± 20.7/87.1 ± 14.0 mm Hg for NEB subjects. Baseline ADMA was 0.32 ± 0.123 μmol/L in the MET group and 0.4035 ± 0.1378 in the NEB group. ADMA increased 44.78% and 72% in the MET group at weeks 4 and 8 (P < .05 for both), respectively, without increase in the NEB group. At week 8, augmentation index was increased in the MET group (P < .05). IGF-1 and endothelial progenitor cells were unchanged by treatment. Plasma ADMA and augmentation index are increased in a dose-dependent fashion by MET but not with NEB.

Nebivolol attenuates redox-sensitive glomerular and tubular mediated proteinuria in obese rats

Obesity and insulin resistance-related proteinuria is associated with oxidative stress and impaired tissue bioavailable nitric oxide. Recent data suggest that nicotinamide adenine dinucleotide phosphate oxidase-mediated oxidative injury to the proximal tubule, like that seen in the glomerulus, contributes to proteinuria in insulin-resistant states. The vasodilator β-blocker nebivolol reduces nicotinamide adenine dinucleotide phosphate oxidase activity, increases bioavailable nitric oxide, and improves insulin sensitivity. To test the hypothesis that a treatment strategy that reduces oxidative stress and attenuates obesity-associated increases in glomerular and proximal tubule derived protein, we treated young Zucker obese (ZO) and age-matched Zucker lean male rats with nebivolol (10 mg · kg(-1) · d(-1)) for 21 d. Compared with Zucker lean, ZO controls exhibited increased proteinuria and γ-glutamyl transpeptidase, reductions in systemic insulin sensitivity in association with increased renal renin, (pro)renin receptor, angiotensin II type 1 receptor, and mineralocorticoid receptor immunostaining, oxidative stress, and glomerular tubular structural abnormalities that were substantially improved with in vivo nebivolol treatment. Nebivolol treatment also led to improvements in glomerular podocyte foot-process effacement and improvement in podocyte-specific proteins (nephrin and synaptopodin) as well as proximal tubule-specific proteins (megalin and lysosomal-associated membrane protein-2) and proximal tubule ultrastructural remodeling in the ZO kidney. Our findings support the notion that obesity and insulin resistance lead to increased glomerulotubular oxidative stress and resultant glomerular and tubular sources of excess urine protein. Furthermore, the results of this study suggest the beneficial effect of nebivolol on proteinuria was derived from improvements in weight and insulin sensitivity and reductions in renal oxidative stress in a state of obesity and insulin resistance.

[Efficacy of nebivolol in patients with coronary heart disease and concomitant chronic obstructive pulmonary disease]

The study was designed to assess clinical efficiency and safety of nebivolol in patients with cardiovascular problems and chronic obstructive pulmonary disease. It included 50 patients of whom 25 were given daily 5 and 25 mg of nebivolol and 80-100 mg of verapamil. Nebivolol was shown to significantly reduce arterial pressure, heart rate, and the number of ventricular extrasystoles. The drug was well tolerated by the patients and had no adverse effect on bronchial patiency.

[Comparative analysis of antioxidant activity of nebivolol in patients with chronic heart failure with and without concomitant type 2 diabetes]

Consistent neurohormonal activation of sympatho-adrenal system in patients with chronic heart failure (CHF) and hyperglycemia contributes to development of oxidative stress--one of the most important pathogenetic mechanisms of endothelial dysfunction.

PURPOSE

To study the impact of nebivolol concerning modification of clinical and hemodynamic indicators and parameters of oxidative stress in patients with CHF and with or without concomitant diabetes mellitus type 2 (DM2).

MATERIAL

Nebivolol was used in complex therapy of CHF in 82 patients, suffering from NYHA class I - III CHF (EF < 50%) of ischemic genesis with or without comorbid DM2, average age 63.2 +/- 8.2 years.

RESULTS

After 8 months of therapy significant improvement of clinical status was observed in both groups, tolerance to physical activity increased (significant reduction of average class of CHF in the group with DM2 from 2.5 +/- 0.58 to 2.125 +/- 0.71, p = 0.001, and in the second group from 2.3 +/- 0.5 to 1.9 +/- 0.4, p = 0.01). We also noted in both groups increase of plasma oxidative resistance (reduction of intensity of fast flash in lipid peroxidation h from 7 to 6 mm, p = 0.016, and from 8 to 6 mm, p = 0.03, respectively) and increase of antioxidant plasma protection (increase of SH-groups from 154.19 to 182.4 mmol/1, p = 0.00035, and from 176 to 205, p = 0.004, respectively).

CONCLUSION

Nebivolol is a modern neurohormonal modulator, which contributes to reverse evolution of oxidative changes in patients with CHF and hyperglycemia.

Quantification of nebivolol hydrochloride in human plasma by liquid chromatography using fluorescence detection: Use in pharmacokinetic study

A simple, rapid, and sensitive method of reversed-phase high-performance liquid chromatography with fluorescence detection has been developed and validated for use in determining levels of nebivolol•HCl in human plasma. Sample preparation involves a simple single-step protein precipitation procedure and extraction of nebivolol in acetonitrile. The separation was performed on a Kromasil® RP-C18 column (Ф 4.6 mm × 250 mm, 5 μm) with a mobile phase consisting of 0.05 M potassium dihydrogen phosphate buffer/acetonitrile (40:60, v/v) adjusted to pH 3 using orthophosphoric acid. Analysis was carried out under isocratic conditions at a flow rate of 1.5 mL/min and at room temperature using a fluorescence detector with excitation at 288 nm and emission at 310 nm. The chromatographic run was 4 min. The calibration curve was linear over the concentration range 0.2-20 ng/mL. The method was validated in terms of its accuracy, precision, and specificity. The assay enabled the measurement of nebivolol with a minimum quantification limit of 0.16 ng/mL. The average recovery of nebivolol from spiked human plasma was 98.4 ± 3.3%. This method was successfully used in a pharmacokinetic study of oral administration of 5-mg tablets to healthy human volunteers.

Salt-induced renal injury in spontaneously hypertensive rats: effects of nebivolol

BACKGROUND

we investigated renal effects of nebivolol, a selective β(1)-receptor blocker with additional antioxidative ability, in spontaneously hypertensive rats (SHR) where increased salt intake induces oxidative stress and worsens renal function as a result of further activation of the renin-angiotensin and sympathetic nervous systems.

METHODS

male SHR were given an 8% salt diet (HS; n = 22) for 5 weeks; their age-matched controls (n = 9) received standard chow. Nebivolol was given at a dose of 10 mg/kg/day for 5 weeks in 11 HS rats.

RESULTS

HS increased blood pressure, plasma renin concentration, urinary protein excretion, and renal nitroxidative stress while decreasing renal blood flow and angiotensin 1-7 receptor (mas) protein expression. There was no change in angiotensin II type 1 receptor expression among the experimental groups. Nebivolol did not alter the salt-induced increase in blood pressure but reduced urinary protein excretion, plasma renin concentration, and nitroxidative stress. Nebivolol also increased neuronal NOS expression while preventing the salt-induced decrease in renal blood flow and mas protein expression.

CONCLUSION

nebivolol prevented salt-induced kidney injury and associated proteinuria in SHR through a blood pressure-independent mechanism. Its protective effects may be related to reduction in oxidative stress, increases in neuronal NOS and restoration of angiotensin II type 1/mas receptor balance.

[Clinical-hemodynamic and anti-ischemic effects ivabradine and nebivolol ischemic heart disease with left ventricular dysfunction]

The aim of this study was to examine the effectiveness of Ivabradine (available under the brandnames of Procoralan, Coralan, Corlentor, Coraxan, "Servier", France) and Nebivolol (Nebilet, "Berlin-Chemie", Germany) with combination of standard therapy in patients with coronary artery disease and left ventricular dysfunction. A total of 72 patients (mean age 57.3±4,5 years) have been observed during 6 months. Patients were divided into 3 groups (standard therapy; standard therapy and Nebilet; standard therapy and Coraxan). The results showed that Coraxan with combination therapy compared optimally reduced heart rate and ensure a proper anti-ischemic effect, expressed as reduced left ventricular dysfunction, improved the degree of congestive heart failure than the group Nebilet.

Efficacy, tolerability and safety of nebivolol in patients with hypertension and diabetes: a post-marketing surveillance study

BACKGROUND AND OBJECTIVES

Hypertension is a widely prevalent condition of elevated blood pressure (BP) and is the leading risk factor for the development of cardiovascular disease (CVD). Many patients have additional risk factors such as diabetes mellitus (DM) or previous history of CVD. Nebivolol is a third-generation beta (beta)-blockers which has been shown not to influence metabolic parameters in patients with DM. This postmarketing surveillance study aimed to collect information on the efficacy, safety and tolerability of nebivolol in hypertensive patients with concomitant DM.

PATIENTS AND METHODS

Hypertensive patients with DM followed by 52 cardiologists, internal medicine specialists and general practitioners, between 24 August 2003 and 9 January 2007 in The Netherlands were included in this study. Physicians were asked to survey nebivolol treatment for 6 months.

RESULTS

A total of 510 patients were enrolled. Overall, 93.3% of patients were diagnosed with essential hypertension and 6.7% with secondary hypertension. All patients were co-diagnosed with DM. Nebivolol therapy was associated with a significant reduction in both systolic blood pressure (BP) and diastolic BP versus baseline (p < 0.001 for both). These reductions were seen regardless of reason for initiation of nebivolol (i.e. first diagnosis of hypertension, resistance or intolerance to previous antihypertensive medication, or other reasons). A significant improvement in blood glucose was seen at 4 months (-0.6 mmol/L; p = 0.021). Significant reductions in total cholesterol (-1.45 mmol/L; p = 0.006), low density lipoprotein (LDL) cholesterol (-1.32 mmol/L; p = 0.003) and LDL/high density lipoprotein (HDL) cholesterol ratio (-0.77; p = 0.011) were observed at 2 months. No significant changes were seen in HDL cholesterol and triglycerides.

CONCLUSION

Nebivolol treatment was associated with a significantly reduced BP, improved blood glucose and LDL cholesterol levels and was well tolerated in hypertensive patients with concomitant DM.

Comparison of the effects of nebivolol and valsartan on BP reduction and sleep apnoea activity in patients with essential hypertension and OSA

OBJECTIVES

To investigate the effect of nebivolol, a third generation beta-blocker, on blood pressure (BP) reduction and polysomnographic parameters in hypertensive patients with mild-to-moderate obstructive sleep apnoea (OSA).

METHODS

In this double-blind, parallel group study, patients were randomized to nebivolol 5 mg or valsartan 80 mg once daily following a 14-day, placebo run-in period during which any antihypertensive medication were discontinued. BP and heart rate measurements and overnight polysomnography were performed at baseline and after 6 weeks of treatment. Safety and tolerability were assessed.

RESULTS

Thirty-one patients were randomized to nebivolol (n = 16) or valsartan (n = 15). After six weeks both systolic and diastolic BP were effectively reduced by both treatments. Reductions in BP were not statistically significant different between agents, but mean heart rate was significantly decreased with nebivolol (compared with valsartan (p < 0.001). There was no statistically significant difference between both treatments for the change from baseline to treatment end for mean (+/-SD) Apnoea Hypopnoea Index (AHI) (nebivolol: 23.0 +/- 9.2 to 27.9 +/- 21.2 events/h; valsartan: 23.8 +/- 6.6 to 22.5 +/- 18.0 events/h; p = 0.48) or for any other sleep-related parameters. Both agents were well tolerated.

CONCLUSION

Nebivolol has a significant BP reduction effect in patients with OSA that is similar to valsartan and reduces heart rate to a greater extent which may prove beneficial in selected patients.

Influence of diabetes mellitus and hyperglycemia on prognosis in patients > or =70 years old with heart failure and effects of nebivolol (data from the Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors with heart failure [SENIORS])

The beneficial effects of beta blockers in younger patients with heart failure (HF) due to systolic dysfunction are well established. However, data from patients > or =70 years old with diabetes mellitus and HF are lacking. The Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors with heart failure [SENIORS] tested the efficacy of the vasodilator beta blocker nebivolol in patients > or =70 years old with HF and impaired or preserved left ventricular ejection fraction. In the present analysis, we evaluated the association between diabetes mellitus and baseline glucose levels on the primary outcome (all-cause mortality and cardiovascular hospitalization) and secondary end points, including all-cause mortality, cardiovascular hospitalizations, and cardiovascular mortality. Of 2,128 patients, 555 (26.1%) had diabetes mellitus. Of the 555 patients with diabetes mellitus, 223 (40.2%) experienced the primary end point compared to 484 (30.8%) of the 1,573 nondiabetic patients (p <0.001). For the nondiabetic patients, the rate of the primary outcome for placebo compared to nebivolol was 33.7% for the placebo group and 27.8% for the nebivolol group (hazard ratio 0.78, 95% confidence interval 0.65 to 0.93; p = 0.006). In the diabetic subset, the rate was 40.3% for the placebo group and 40.1% for the nebivolol group (hazard ratio 1.04, 95% confidence interval 0.80 to 1.35, p = 0.773). The subgroup interaction p value was 0.073. The baseline glucose levels in the nondiabetic patients did not significantly affect the outcomes. The effect of diabetes mellitus on outcome was independent of the left ventricular ejection fraction and was most pronounced in those with HF due to a nonischemic etiology. In conclusion, in patients > or =70 years old with HF, diabetes mellitus was associated with a worse prognosis. Nebivolol was less effective in the patients with diabetes and HF than in those with HF but without diabetes who were > or =70 years old.

Antihypertensive treatment with beta-blockers in the metabolic syndrome: a review

Metabolic syndrome, a "cluster" of metabolic disorders including hypertension, increases the cardiovascular risk, and insulin resistance plays a key role in its pathogenesis. In this syndrome antihypertensive treatment with beta-blockers is underused because of their adverse metabolic effects. The aim was to review the evidences supporting the reasons for underusing beta-blockers in hypertensive patients with metabolic syndrome. A review of Literature has been carried out via PubMed from 1998 to 2008: most of beta-blockers have adverse effects on insulin sensitivity, carbohydrate and lipid metabolism, and are not recommended in metabolic syndrome. However, some recent large studies have shown a better metabolic profile with newer third generation vasodilating beta-blockers, such as Carvedilol and Nebivolol. Vasodilating action of Carvedilol and Nebivolol, due respectively to alpha1-blocking effect and release of nitric oxide, explains the lack of adverse metabolic effects of these beta-blockers that could also be used in hypertensive patients with metabolic syndrome.

[Nebivolol: the first vasodilatory beta-blocker with a beta3-adrenergic agonist activity]

Several studies suggest that the beta(3)-adrenergic stimulation could be a new therapeutic target for the treatment of cardiovascular diseases. The vascular effects induced by beta(3)-adrenergic stimulation are able to decrease the left ventricular strain allowing to reduce after-load. In addition, the increased coronary blood flow due to vasorelaxation increases the myocardial oxygene delivery. The hypothesis about the beneficial role of beta(3)-adrenoceptors is supported by recent data about a beta-blocker of third generation, nebivolol, currently used in the treatment of heart failure and hypertension. The present review presents the beta(3)-adrenoceptors characteristics as well as its involvement in the cardiovascular effects of nebivolol.

Beneficial effects of nebivolol treatment on oxidative stress parameters in patients with slow coronary flow

OBJECTIVES

Imbalance between oxidative stress and antioxidant defense has been demonstrated in patients with slow coronary flow (SCF). The aim of this study was to investigate the effect of nebivolol treatment on oxidative stress parameters in SCF patients.

STUDY DESIGN

The study included 32 patients (10 females, 22 males; mean age 53.3 ± 5.2 years) with SCF and 32 control subjects (14 females, 18 males; mean age 50.6 ± 5.2 years) with normal coronary arteries on angiography. Coronary slow flow was determined by the TIMI frame count method. Patients with SCF received nebivolol treatment (5 mg/day) for six months. Blood samples were analyzed for malondialdehyde (MDA) and serum nitric oxide (NO) levels, and erythrocyte catalase (CAT) and erythrocyte superoxide dismutase (SOD) activities in the control group and, in SCF patients, at baseline and after six months of nebivolol treatment.

RESULTS

The two groups were similar with respect to age, body mass index, blood pressure, heart rate, and lipid profile. Smoking was more frequent in the SCF group compared to the controls. TIMI frame counts measured from the left anterior descending, circumflex, and right coronary arteries were significantly higher in the SCF group (p < 0.0001). Baseline MDA and NO levels, and SOD and CAT activities were significantly different between the two groups, with significantly increased MDA (p < 0.0001), and significantly decreased SOD (p < 0.0001), CAT (p < 0.001), and NO (p < 0.001) in the SCF group. After six months of nebivolol treatment, all oxidative stress parameters showed significant improvements compared to the baseline values (p < 0.0001 for MDA, SOD, CAT, and NO) and approximated to the values of the control group.

CONCLUSION

Our results show that nebivolol treatment may be beneficial to improve oxidative stress parameters in patients with SCF, which are considered to be an early stage of atherosclerosis.

Nebivolol/hydrochlorothiazide (HCTZ) combination in patients with essential hypertension: a pooled analysis from five non-interventional studies with a focus on diabetic and elderly patients

BACKGROUND AND OBJECTIVES

Nebivolol is a third-generation beta-blocker, characterized by unique pharmacological properties. The combination of nebivolol and hydrochlorothiazide (HCTZ) has been evaluated in large-scale clinical trials. This post-marketing surveillance analysis evaluated the effectiveness of the nebivolol/HCTZ combination in a "real-life" setting that included diabetic and elderly patients.

PATIENTS AND METHODS

The analysis was based on data from five non-interventional studies conducted in Germany, which lasted up to 12 weeks. Data from patients treated with nebivolol/HCTZ 5/12.5 mg/day in combination were pooled. The following parameters were calculated at the final visit, in the whole population and in elderly (>70 years) and diabetic subgroups: (1) difference from baseline in diastolic blood pressure (DBP) and in systolic blood pressure (SBP); (2) percentage of responder patients (reduction in DBP or SBP of 10 or 20 mmHg, respectively). Alterations in laboratory parameters were also monitored.

RESULTS

In total, 86 patients (mean age 58.9 +/- 10.8 years) were included in the analysis. Nebivolol/HCTZ significantly reduced both DBP (-11.8 +/- 7.9 mmHg; p<0.0001 vs baseline) and SBP (-22.5 +/- 13.5 mmHg; p<0.0001 vs baseline). In total, 81.4% of patients were responders (75% and 83.3% in elderly and diabetic patients, respectively). No clinically significant alterations in laboratory parameters were observed.

DISCUSSION

This study confirms that nebivolol/HCTZ is an effective and well tolerated therapeutic strategy in a real-life setting as well as in clinical trials. Therefore, this combination may represent a first-choice therapy in the management of hypertension.

Nebivolol prevents remodeling in a rat myocardial infarction model: an echocardiographic study

OBJECTIVE

Ventricular remodeling (VR) which develops after myocardial infarction (MI) plays an important role in progressive left ventricular dysfunction. We aimed to investigate the role of nebivolol treatment on VR after a MI in a rat ischemia-reperfusion model.

METHODS

Rats were divided into 3 groups of 12 each: sham operated (sham-control), MI-induced (MI-control) and nebivolol treated (MI-nebivolol). Left ventricular (LV) diameters, volumes, and diastolic filling parameters were evaluated by echocardiography. On the 28th day, after recording the systemic and LV pressures and determining the plasma nitric oxide (NO) and peroxynitrite (ONOO-) levels , animals were sacrificed and heart, body and LV weights (HW, BW, LVW) were measured and infarct sizes were determined. Results were evaluated statistically by ANOVA for repeated measurements 3x3 factorial design with post-hoc Bonferroni test.

RESULTS

After MI, while VR (an increase in LV diameters and volumes associated with a decrease in EF, FS and posterior wall thickness change (LWPc) was significant in MI-control rats (p<0.05 for; all comparisons) these changes were significantly less in MI-nebivolol group (p=0.08 and p=0.06 for EF and FS respectively). LV end diastolic pressure (LVEDP) was lower (p<0.005) and Delta+/- dp/dt's (p<0.05) were higher in MI-nebivolol group compared to MI-control animals. Although infarct sizes were similar in MI-induced groups (p=0.79); LVW/HW and HW/BW's were significantly greater in the MI-control group compared to sham-control (p<0.01 for all comparisons), these changes were not statistically significant in MI-nebivolol group. The increase in plasma NO and ONOO- levels were also prevented with nebivolol.

CONCLUSION

Nebivolol therapy reduced the effects of VR in rats after MI. These beneficial effects were not related to its heart rate and blood pressure reducing effects. Nitric oxide regulatory action of this compound may contribute these beneficial effects on VR developed after MI.

Nebivolol attenuates maladaptive proximal tubule remodeling in transgenic rats

BACKGROUND/AIMS

The impact of nebivolol therapy on the renal proximal tubular cell (PTC) structure and function was investigated in a transgenic (TG) rodent model of hypertension and the cardiometabolic syndrome. The TG Ren2 rat develops nephropathy with proteinuria, increased renal angiotensin II levels and oxidative stress, and PTC remodeling. Nebivolol, a beta(1)-antagonist, has recently been shown to reduce albuminuria, in part, through reductions in renal oxidative stress. Accordingly, we hypothesized that nebivolol therapy would attenuate PTC damage and tubulointerstitial fibrosis.

METHODS

Young Ren2 (R2-N) and SD (SD-N) rats were treated with nebivolol (10 mg/kg/day) or vehicle (R2-C; SD-C) for 3 weeks. PTC structure and function were tested using transmission electron microscopy and functional measurements.

RESULTS

Nebivolol treatment decreased urinary N-acetyl-beta-D-glucosaminidase, tubulointerstitial ultrastructural remodeling and fibrosis, NADPH oxidase activity, 3-nitrotyrosine levels, and increased megalin and lysosomal-associated membrane protein-2 immunostaining in PTCs. Ultrastructural abnormalities that were improved with therapy included altered canalicular structure, reduced endosomes/lysosomes and PTC vacuoles, basement membrane thickening, and mitochondrial remodeling/fragmentation.

CONCLUSION

These observations support the notion that nebivolol may improve PTC reabsorption of albumin and other glomerular filtered small molecular weight proteins in association with the attenuation of oxidative stress, tubulointerstitial injury and fibrosis in this rat model of metabolic kidney disease.

The effect of nebivolol on atherogenesis in apoE-knockout mice

Nebivolol is a novel beta1-blocker with a nitric oxide (NO)--potentiating, vasodilatory effect that is unique among beta-blockers. It was already shown that nebivolol ameliorates atherosclerosis in cholesterol-fed rabbits. We, therefore, wanted to investigate whether this is the case in the fine experimental model of atherosclerosis: apolipoprotein E (apoE)-knockout mice. Nebivolol attenuated atherogenesis, measured both by "en face" method (9.23+/-1.8% vs. 14.6+/-2.1%) and "cross-section" method (63125+/-8455 microm(2) vs. 91416+/-8357 m(2)). This is the first report showing the effect of nebivolol on atherogenesis in gene-targeted mice.

the QoLaN study

BACKGROUND

Nebivolol is a highly selective beta-adrenoreceptor antagonist with vasodilating properties. This study investigated its effect on quality of life (QoL) and blood pressure (BP) in real life conditions. In total, 1468 patients were enrolled, 12% diabetics. Nebivolol was prescribed as monotherapy, add-on or switch medication.

METHODS

In this open-label, prospective study, the JNC-VII BP target values were used: < 140/90 and < 130/80 mmHg for diabetics. The responder rate and the QoL was determined at baseline and after 4 and 8 weeks.

RESULTS

After 4 weeks, 27% of subjects reached target BP, 45% after 8 weeks. The responder rates were 92, 90 and 83% for the monotherapy, add-on and switch groups. Compared with baseline, all showed statistical significance at 8 weeks. Similarly to results for the QoL after 8 weeks, the mean improvement in QoL for all three groups was 9-10 points (total range: 0-88).

CONCLUSIONS

The study demonstrates that nebivolol in mild to moderate hypertension is associated with overall improvements in QoL, with a marked BP-lowering effect, in monotherapy, add-on or switch, irrespective of the glucose tolerance status. It may be hypothesized that its dual mode of action explains its BP-lowering effect as well as the tolerability.

Nebivolol therapy improves endothelial function and increases exercise tolerance in patients with cardiac syndrome X

OBJECTIVE

We sought to determine whether nebivolol affects coronary endothelial function and exercise induced ischemia in patients with cardiac syndrome X (CSX).

METHODS

The study protocol undertaken was based on a single-blind randomized controlled prospective study. After a 2-week washout period, 38 patients with cardiac syndrome X were randomized to receive either nebivolol 5 mg daily (n=19) or metoprolol 50 mg daily (n=19) in a single- blind design for 12 weeks. The control group under study was consisted of 16 age- and gender-matched subjects with negative treadmill exercise tests. Plasma endothelial nitric oxide (NOx), L-arginine, and asymmetric dimethylarginine (ADMA) were measured in all patients at baseline and after 12 weeks of treatment. Statistical differences among groups were tested by one-way analysis of variance and unpaired samples t test for parametric; Kruskal-Wallis and Mann-Whitney U tests for non-parametric variables, respectively. A paired samples t test was used to compare continuous variables before and after drug therapy.

RESULTS

At baseline, plasma level of NOx, L-arginine, and L-arginine/ADMA ratio were lower (p<0.001 for all) in patients with CSX than in the control patients. Whereas, the plasma ADMA levels were increased in the patient group (p<0.001). After 12 weeks of drug therapy, the patients taking nebivolol had increased levels of plasma NOx , plasma L-arginine, the L-arginine/ADMA ratio and decreased levels of plasma ADMA compared to those of the patients taking metoprolol (p<0.001). In addition, exercise duration to 1-mm ST depression and total exercise duration significantly increased after treatment in the nebivolol group compared to the metoprolol group (p<0.01). In the nebivolol group, Canadian Cardiovascular Society (CCS) angina classification improved by one or more categories in 12 (70%) patients, whereas it deteriorated or remained in the same category in 5 (30%) patients. Meanwhile, in the metoprolol group, the CCS angina classification improved by one or more categories in 7 (41%), whereas it deteriorated or remained in the same category in 10 (59%) patients.

CONCLUSION

Circulating endothelial function parameters (plasma ADMA, L-arginine, NOx levels) were impaired in patients with CSX. Nebivolol treatment was associated with better improvements in both circulating endothelial function and exercise stress test parameters than metoprolol. We believe that further studies are needed to evaluate the effects of nebivolol treatment on long-term clinical outcomes in patients with CSX.

Validation and application of high-performance liquid chromatographic and spectrophotometric methods for simultaneous estimation of nebivolol and hydrochlorothiazide: a novel approach to multivariate calibrations by R-Software Environment

A fast, simple reversed-phase HPLC method and two spectrophotometric methods based on principal component regression and partial least squares calibrations were developed for determination of nebivolol (NEB) and hydrochlorothiazide (HCTZ) in formulations without prior separation or masking. The HPLC assay utilized a Phenomenex-Luna RP-18(2) 250 x 4.6 mm, 5 microm column with acetonitrile--0.03% aqueous formic acid, pH 3.3 (65 + 35, v/v), mobile phase at a flow rate of 1.0 mL/min, and UV detection at 277 nm. The retention times of NEB and HCTZ were 2.133 and 2.877 min, respectively. The total run time was < 4 min. Chemometric calibrations were constructed by using an absorption data matrix corresponding to a concentration data matrix, with measurements in the range of 231-310 nm (Delta lambda = 1 nm) in their zero-order spectra using 16 samples in a training set. The chemometric numerical computations were obtained by using R-Software Environment (Version 2.1.1). The proposed methods were validated for various International Conference on Harmonization regulatory parameters like linearity, range, accuracy, precision, robustness, LOD, LOQ, and HPLC system suitability. Laboratory-prepared mixtures and commercial tablet formulations were successfully analyzed using the developed methods. All results were acceptable and confirmed that the method is suitable for its intended use.

The effects of nebivolol on P wave duration and dispersion in patients with coronary slow flow

OBJECTIVE

Coronary slow flow (CSF) is characterized by delayed opacification of coronary arteries in the absence epicardial occlusive disease. P wave duration and dispersion have been reported to be longer in patients with CSF. Nebivolol, besides its selective beta1-blocking activity, causes an endothelium dependent vasodilatation through nitric oxide release. In this study, we searched for the association between left ventricular diastolic functions and atrial conduction dispersion, the effects of nebivolol on P wave duration and dispersion in patients with CSF.

METHODS

This prospective case-controlled study included 30 patients having CSF and 30 subjects having normal coronary arteries in coronary angiography. The patients were evaluated with 12-leads electrocardiography and echocardiography before and three months after treatment with nebivolol. The difference between maximum and minimum P wave durations was defined as P-wave dispersion (PWD). Early diastolic flow (E), atrial contraction wave (A) and E deceleration time (DT) and isovolumetric relaxation time (IVRT) were measured. Unpaired and paired t-tests, Chi-square test, Mann-Whitney's U-test and Pearson correlation analysis were used in statistical analysis.

RESULTS

Compared to control group maximum P wave duration (Pmax) (104.3+/-12.2 vs. 93.4+/-9.8 msec, p<0.001) and PWD (35.0+/-8.6 vs. 24.8+/-5.4 msec, p<0.001), DT (245.4+/-54.9 vs. 198.0+/-41.7 msec, p<0.001) and IVRT (112.9+/-20.8 vs. 89.5+/-18.2 msec, p<0.001) were significantly longer and E/A ratio (0.89+/-0.27 vs. 1.27+/-0.27, p<0.001) was lower in patients with CSF as compared with control subjects. There were no significant correlations of Pmax and PWD with clinical and echocardiographic variables. Systolic and diastolic blood pressures (130.5+/-15.5 mmHg to 117.8+/-12.3 mmHg and 84.5+/-9.8 mmHg to 75.0+/-6.2 mmHg, p<0.001), Pmax (to 98.7+/-11.7 msec, p=0.038), PWD (to 21.3+/-5.1 msec, p<0.001) and DT (to 217.3+/-41.4 msec, p<0.001) and IVRT (to 101.2+/-17.4 msec, p<0.001) significantly decreased and E/A ratio (to 1.1+/-0.23, p<0.001) significantly increased after treatment with nebivolol. Correlation analysis revealed that the change in PWD was not significantly correlated with any of the clinical and echocardiographic variables including decrease in blood pressures.

CONCLUSION

Coronary slow flow is associated with prolonged P wave duration and dispersion and impaired diastolic filling. Nebivolol may be helpful in restoration of these findings. P wave duration and dispersion may not be associated with left ventricular function parameters in patients with CSF.

Nebivolol reduces proteinuria and renal NADPH oxidase-generated reactive oxygen species in the transgenic Ren2 rat

BACKGROUND/AIMS

Renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system activation are crucial in the pathogenesis of hypertension, cardiovascular and renal disease. NADPH oxidase-mediated increases in reactive oxygen species (ROS) are an important mediator for RAAS-induced cardiovascular and renal injury. Increased levels of ROS can diminish the bioactivity of nitric oxide (NO), a critical modulator of RAAS effects on the kidney. Thereby, we hypothesized that in vivo nebivolol therapy in a rodent model of activated RAAS would attenuate glomerular damage and proteinuria through its actions to reduce NADPH oxidase activity/ROS and increase bioavailable NO.

METHODS

We utilized the transgenic Ren2 rat which displays heightened tissue RAAS, hypertension, and proteinuria. Ren2 rats (6-9 weeks of age) and age-matched Sprague-Dawley littermates were treated with nebivolol 10 mg/kg/day (osmotic mini-pump) for 21 days.

RESULTS

Ren2 rats exhibited increases in systolic blood pressure, proteinuria, kidney cortical tissue total NADPH oxidase activity and subunits (Rac1, p67(phox), and p47(phox)), ROS and 3-nitrotyrosine, as well as reductions in podocyte protein markers; each of these parameters improved with nebivolol treatment along with increases in renal endothelial NO synthase expression.

CONCLUSIONS

Our data suggest that nebivolol improves proteinuria through reductions in renal RAAS-mediated increases in NADPH oxidase/ROS and increases in bioavailable NO.

Clinical pharmacodynamics of nebivolol: new evidence of nitric oxide‐mediated vasodilating activity and peculiar haemodynamic properties in hypertensive patients

New evidence from recently completed clinical studies performed with nebivolol, a highly selective beta-1 beta-blocker, endowed with additional vasodilating activity mediated by nitric oxide (NO) endothelial release, confirm previous findings that nebivolol differs from other beta-blocking agents and that the combination of beta-1 blockade and NO-mediated vasodilation not only potentiates the blood pressure lowering activity, but leads to a broader favourable haemodynamic profile, which is clinically relevant to the treatment of hypertensive patients. In particular, six new studies focusing on the vasodilation properties of nebivolol demonstrated that: (i) its blood pressure lowering effect is accompanied by a vasodilating action that is seen after single and chronic administration of the usual antihypertensive oral dose of 5 mg once daily; (ii) the vasodilation can be documented systemically, at various regional vascular beds and skin microcirculation, and is accompanied by increased small arterial distensibility; (iii) the NO-endothelium-dependency of its vasodilating action is shown by the model of forearm or cutaneous vasodilating response to acetylcholine and by the blockade of the nebivolol-induced local vasodilation by a blocker of the arginine-NO cascade, L-NMMA. Two more studies demonstrated the ability of nebivolol to increase NO concentrations through preservation of NO from oxidative degradation, and not only by stimulation of its synthesis. Finally, two studies confirmed the favourable haemodynamic action of nebivolol on both systolic and diastolic function and, in particular, an increase in stroke volume, associated with reduction in vascular resistance, resulting in a maintained cardiac output despite reduced heart rate. These properties consistently differentiate nebivolol from non-vasodilating beta-blockers, such as those used for the active comparative studies, i.e. atenolol, metoprolol or bisoprolol. The observation that nebivolol enhances or restores NO-mediated vasodilation in hypertensive patients has important therapeutic implications in view of the well-established protective role of NO against cardiovascular risk factors, and particularly the development of atherosclerosis. Similarly, the favourable haemodynamic profile of nebivolol, as described by the new investigations (preservation of cardiac output, reduction of peripheral resistance and improved diastolic function) appear to have clinically relevant benefits on the impairment in systolic and/or diastolic function often complicating the hypertension.

Radical scavenging and NO-releasing properties of selected β-adrenoreceptor antagonists

It is claimed that novel beta-adrenolytic drugs possess superior antioxidant properties as compared to classical selective or non-selective beta-adrenoceptor antagonists. Here we tested this notion by analyzing radical scavenging properties of selected beta-adrenolytic drugs and their ability to release nitric oxide in biological preparations. Selective beta1-adrenolytics such as nebivolol, atenolol, metoprolol and non-selective beta-adrenolytics with alpha1-receptor blocking properties such as carvedilol and labetalol were chosen for analysis. NO-releasing properties of nebivolol and carvedilol distinguished third generation beta-adrenolytics from their older counterparts while the reactivity towards hydroxyl and peroxyl radicals discerns only carvedilol but not nebivolol. Thus, superior clinical efficacy of third generation beta-adrenolytics may be related to their ability to release NO rather then to their direct antioxidant properties.

Gender Dependency of Circadian Blood Pressure and Heart Rate Profiles in Spontaneously Hypertensive Rats: Effects of Beta‐Blockers

This study investigated (i) blood pressure (BP), heart rate (HR), and their relation to urinary NOx and eNOS protein expression in male and female spontaneously hypertensive rats (SHR), as well as (ii) gender-dependent cardiovascular effects of nebivolol (NEB) in comparison to metoprolol (MET) in SHR. BP and HR were measured telemetrically after a single intraperitoneal application of NEB or MET at 07.00 and 19.00 h in male rats and at 19.00 h in proestrus female rats. The two beta-blockers varied in time of decreasing BP and HR and also in duration. In males, MET decreased BP and HR for few hours exclusively when applied at the onset of the activity phase (i.e., at 19.00 h), while after its application at 07.00 h, BP and HR were unchanged. In females, MET also caused a short-lasting BP and HR reduction, with the effect being more pronounced than in males. In males, NEB at either dosing time decreased HR and BP to a greater extent than did MET. This effect was evident both during the activity and rest periods and persisted for at least five days. In females, NEB provoked a similar, but more pronounced, effect on BP and HR in comparison to males. These findings demonstrate that significant gender-dependent differences in the circadian profile of BP and HR exist. BP and urinary NOx as well as eNOS expression are inversely correlated, and the cardiovascular effects of NEB and MET vary, depending on the time of application as well as gender.

New drug update: 2008

Only 16 new therapeutic agents were marketed in the United States in 2008, the lowest number in many years. Four new drugs have been selected for consideration in this review. The uses and most important properties of each agent are considered, and a rating for each new drug is provided using the New Drug Comparison Rating (NDCR) system developed by the author.

[Correction of portal hypertension and renal dysfunction with help of nebivolol and lizinopril in patients with hepatic cirrhosis]

The effect of nebevolol, beta-blocker on the portal hypertension and renal blood flow and the safety of its use versus lisinopril, an angiotensin-converting enzyme inhibitor were examined in the patients with cirrhosis. 72 patients were examined (39 patients with cirrhosis of the liver without ascites - the 1st group and 32 patients with cirrhosis of the liver with ascites - the 2nd group. Trustworthy decrease of portal hypertension parameters (the decrease of portovenosis gradient of pressure (PPG) by 19,3% (p = 0,048) in the patients with liver cirrhosis of class A on Child-Pugh without ascites with nebevolol was revealed. The trust worthy changes of portal blood flow was not revealed in all examined patients with lisinopril. But these patients without ascites have demonstrated the improvement of the renal hemodynamic (renal functional reserve (RFR) by 56%, effective renal plasma flow (ERPF) by 17,3%). The lisinopril intake 5 mg a day declines PPG by 18,1%. The tendency of the reduction of the functional index due to the expressed hypotensive effect of nebevolol and lisinopril was revealed in all examined patients with liver cirrhosis. So it was demonstrated that for the management of the portal hypertension in the patients with liver cirrhosis is necessary to examine of functional renal condition to prevent the development of hepatorenal syndrome.

Reduced intimal hyperplasia in rabbits via medical therapy after carotid venous bypass

Intimal hyperplasia is a major cause of restenosis after the interventional or surgical treatment of occlusive arterial disease. We investigated the effects of clopidogrel, calcium dobesilate, nebivolol, and atorvastatin on the development of intimal hyperplasia in rabbits after carotid venous bypass surgery. We divided 40 male New Zealand rabbits into 4 study groups and 1 control group. After occluding the carotid arteries of the rabbits, we constructed jugular venous grafts between the proximal and the distal segments of the occluded artery. Thereafter, group 1 (control) received no medication. We administered daily oral doses of clopidogrel to group 2, calcium dobesilate to group 3, nebivolol to group 4, and atorvastatin to group 5. The rabbits were killed 28 days postoperatively. The arterialized jugular venous grafts were extracted for histopathologic examination. Intimal thicknesses were 42.87 +/- 6.95 microm (group 2), 46.5 +/- 9.02 microm (group 3), 34.12 +/- 5.64 microm (group 4), and 48.37 +/- 6.16 microm (group 5), all significantly less than the 95.12 +/- 9.93 microm in group 1 (all P < 0.001). Medial thicknesses were 94 +/- 6 microm (group 2), 101.5 +/- 13.52 microm (group 3), 90.5 +/- 9.69 microm (group 4), and 101.37 +/- 7.99 microm (group 5), all significantly thinner than the 126.62 +/- 13.53 microm in group 1 (all P < 0.001). In our experimental model of carotid venous bypass grafting in rabbits, clopidogrel, calcium dobesilate, nebivolol, and atorvastatin each effectively reduced the development of intimal hyperplasia. Herein, we discuss our findings and review the medical literature.

[Optimization of use of beta-adrenoblockers in the treatment of chronic heart failure in the outpatient setting]

AIM

to evaluate of the effectiveness of switching from beta-adrenoblockers (BAB) non-included into the guidelines for the management of chronic heart failure (CHF) to nebivolol and bisoprolol for outpatients.

SUBJECTS AND METHODS

The study included 67 patients with stable Functional Classes (FC) II and II CHF who received the standard therapy and BAB non-included into the guidelines for the management of CHF. The patients were randomized to the groups taking bisoprolol (n = 35) or nebivolol (n = 32) in doses of 1.25 to 10 mg/day. Before and 6 months after therapy, the investigators assessed the patient's clinical status and quality of life (QL), performed a six-minute walk test and echography, and determined the blood level of the N-terminal fragment of brain natriuretic peptide prohormone (NT-proBNP).

RESULTS

The switching to bisoprolol and nebivolol was followed by a significant clinical improvement, a larger covered distance, and better QL. Left ventricular ejection fraction was increased along with a reduction in mean FC CHF. There were no significant changes in NT-proBNP in the total patient group, but it was significantly decreased in the subgroup of those with the baseline high level of the peptide.

CONCLUSION

The switching of patients with stable CHF from therapy with BAB not included into the guidelines for the management of CHF to nebivolol or bisoprolol yields positive results and improves left ventricular systolic function (which is attended by the reduction in NT-proBNP levels) and may be recommended for treatment in the outpatient setting.

Determination of nebivolol hydrochloride and hydrochlorothiazide in tablets by first-order derivative spectrophotometry and liquid chromatography

Two simple and accurate methods for analysis of nebivolol hydrochloride (NEB) and hydrochlorothiazide (HCTZ) in their combined dosage forms were developed using first-order derivative spectrophotometry and reversed-phase liquid chromatography (LC). NEB and HCTZ in their combined dosage forms (tablets) were quantified using first-derivative responses at 294.6 and 334.6 nm in the spectra of their solutions in methanol. The calibration curves were linear in the concentration range of 8-40 microg/mL for NEB and 10-60 microg/mL for HCTZ. LC analysis was performed on a Phenomenex Gemini C18 column (250 x 4.6 mm id, 5 microm particle size) in the isocratic mode with 0.05 M potassium dihydrogen phosphate-acetonitrile-methanol (30 + 20 + 50, v/v/v; pH 4) mobile phase at a flow rate of 1 mL/min. Detection was made at 220 nm. Both of the drugs and the internal standard (ezetimibe) were well resolved with retention times of 5.1 min for NEB, 2.9 min for HCTZ, and 8.2 min for ezetimibe. The calibration curves were linear in the concentration range of 1-14 microg/mL for NEB and 0.3-28 microg/mL for HCTZ. Both methods were validated and found to be accurate, precise, and specific, and results were compared statistically. Developed methods were successfully applied for the estimation of NEB and HCTZ in their combined dosage forms.

Protective effects of nebivolol on oxygen free radical-induced vasoconstrictions in vitro

BACKGROUND

Disturbed ocular hemodynamics and vasospasms might be involved in the pathogenesis of glaucoma. On a clinical level there are indications for an optimization of ocular perfusion parameters in hypertensive glaucoma patients by switching a beta-adrenoceptor-antagonist therapy to nebivolol. Aim of the present study is to investigate vasoactive properties of nebivolol on ocular vasculature in vitro. Besides vasorelaxing effects, the impact of nebivolol on oxygen free radical-induced vasoconstrictions is studied.

MATERIAL/METHODS

The experiments were carried out with ring preparations from porcine ciliary arteries. The preparations were placed in a myograph system and were kept under physiological conditions (pH 7.4, 37 degrees C, Krebs-Henseleit-Buffer, 1.75 mM Ca2+) and were stimulated by K+ depolarizations. The experiments were performed at a Nernst potential of -41 mV, which reflects half-maximal activation. For radical exposure, the preparations were superfused for 20 s in a specifically designed set-up with hydroxyl radicals generated by the Fenton reaction from H2O2 and Fe3+. NO synthase activity was modulated by adding L-arginine to the buffer.

RESULTS

At a concentration of 10-5 M nebivolol leads to a reduction of vascular tone by -8.5+/-3.4% (n=11; P=0.016) vs. +2.6+/-1.9% (n=11; n.s.) in presence of its solvent DMSO. Nebivolol (10-5 M) reduces hydroxyl radical-induced vasoconstrictions by 53+/-10% (n=11; P<0.001). Stimulation of the NO synthase by L-arginine saturation potentiates this effect.

CONCLUSIONS

Nebivolol combines vasorelaxing properties with protection against oxidative stress-induced vasoconstrictions. Both effects may be attributed to NO-releasing properties of nebivolol independently of its beta-adrenoceptor-blocking effect.