Alterations by norepinephrine of cardiac sympathetic nerve terminal function and myocardial beta-adrenergic receptor sensitivity in the ferret: normalization by antioxidant vitamins

Modulation of beta-adrenergic receptor subtype activities in perioperative medicine: mechanisms and sites of action

This review focuses on the mechanisms and sites of action underlying beta-adrenergic antagonism in perioperative medicine. A large body of knowledge has recently emerged from basic and clinical research concerning the mechanisms of the life-saving effects of beta-adrenergic antagonists (beta-AAs) in high-risk cardiac patients. This article re-emphasizes the mechanisms underlying beta-adrenergic antagonism and also illuminates novel rationales behind the use of perioperative beta-AAs from a biological point of view. Particularly, it delineates new concepts of beta-adrenergic signal transduction emerging from transgenic animal models. The role of the different characteristics of various beta-AAs is discussed, and evidence will be presented for the selection of one specific agent over another on the basis of individual drug profiles in defined clinical situations. The salutary effects of beta-AAs on the cardiovascular system will be described at the cellular and molecular levels. Beta-AAs exhibit many effects beyond a reduction in heart rate, which are less known by perioperative physicians but equally desirable in the perioperative care of high-risk cardiac patients. These include effects on core components of an anaesthetic regimen, such as analgesia, hypnosis, and memory function. Despite overwhelming evidence of benefit, beta-AAs are currently under-utilized in the perioperative period because of concerns of potential adverse effects and toxicity. The effects of acute administration of beta-AAs on cardiac function in the compromised patient and strategies to counteract potential adverse effects will be discussed in detail. This may help to overcome barriers to the initiation of perioperative treatment with beta-AAs in a larger number of high-risk cardiac patients undergoing surgery.

Long-term effects of carvedilol on left ventricular function, remodeling, and expression of cardiac cytokines after large myocardial infarction in the rat

Carvedilol (20 mg/kg, bid) or vehicle was given to rats surviving a myocardial infarction (MI) 24 h (n = 409). In rats with large MI, carvedilol partially preserved left ventricular (LV) function and intrinsic myocardial contractility and reactivity to beta-adrenergic stimulation. Carvedilol led to scar thickening, increased LV hypertrophy, and decreased cardiac fibrosis but did not prevent LV dilatation. Carvedilol reduced cardiac expression of interleukin-1beta but did not prevent cardiac fetal gene re-expression or modify cardiac oxidative stress. Despite these beneficial effects, carvedilol decreased survival (38.8%, versus vehicle, 50.6%) due to excessive early mortality. Thus, post-MI carvedilol has many beneficial effects, however, in this study it increased post-MI mortality, perhaps due to excessive hypotension.

Antioxidant vitamins attenuate oxidative stress and cardiac dysfunction in tachycardia-induced cardiomyopathy

OBJECTIVES

We administered antioxidant vitamins to rabbits with pacing-induced cardiomyopathy to assess whether antioxidant therapy retards the progression of congestive heart failure (CHF).

BACKGROUND

Although oxidative stress is increased in CHF, whether progression of heart failure could be prevented or reduced by antioxidants is not known.

METHODS

Rabbits with chronic cardiac pacing and sham operation were randomized to receive a combination of beta-carotene, ascorbic acid and alpha-tocopherol, alpha-tocopherol alone or placebo over eight weeks. Echocardiography was used to measure cardiac function weekly. Resting hemodynamics and in vivo myocardial beta-adrenergic responsiveness were studied at week 8. Animals were then sacrificed for measuring myocardial beta-receptor density, norepinephrine (NE) uptake-1 site density, sympathetic neuronal marker profiles, tissue-reduced glutathione/oxidized glutathione (GSH/GSSG) ratio and oxidative damage of mitochondrial DNA (mtDNA).

RESULTS

Rapid cardiac pacing increased myocardial oxidative stress as evidenced by reduced myocardial GSH/GSSG ratio and increased oxidized mtDNA and produced cardiac dysfunction, beta-adrenergic subsensitivity, beta-receptor downregulation, diminished sympathetic neurotransmitter profiles and reduced NE uptake-1 carrier density. A combination of antioxidant vitamins reduced the myocardial oxidative stress, attenuated cardiac dysfunction and prevented myocardial beta-receptor downregulation and sympathetic nerve terminal dysfunction. Administration of alpha-tocopherol alone produced similar effects, but the effects were less marked than those produced by the three vitamins together. Vitamins produced no effects in sham-operated animals.

CONCLUSIONS

Antioxidant vitamins reduced tissue oxidative stress in CHF and attenuated the associated cardiac dysfunction, beta-receptor downregulation and sympathetic nerve terminal abnormalities. The findings suggest that antioxidant therapy may be efficacious in human CHF.

Do most antihypertensive agents have a sympatholytic action?

The sympathetic nervous system is a major modulator of cardiovascular functions. Over the past three decades, numerous studies, using various methodologies, have reported the existence of a variety of pre- and postsynaptic sympathetic dysfunctions in essential hypertension. Most of those abnormalities facilitate sympathetic neurotransmission, resulting in a chronic increase in the sympathetic tone and reactivity in an important proportion of hypertensive patients. The chronic sympathetic activation is also associated with major alterations in the balance between postsynaptic adrenergic receptors in cardiovascular tissues. Indeed, an attenuation of beta-adrenergic functions and a potentiation of alpha1-adrenergic functions have been demonstrated in human cardiovascular tissues, suggesting the development of a sympathetic postsynaptic alpha1 dominance during the development and evolution of hypertension. The chronic activation of the sympathetic system is deleterious and could contribute to the development of most cardiovascular complications associated with hypertension. One of the major aims of antihypertensive therapy should be to attenuate pre- or postsynaptic sympathetic tone. Most antihypertensive drugs have been found to improve either pre- or postsynaptic sympathetic functions in hypertensive patients. At the presynaptic level, the effects of antihypertensive drugs have been found to be more variable. At the postsynaptic level, all currently used antihypertensive drugs have been found to attenuate alpha1-adrenergic functions either by interfering directly with intracellular mechanisms underlying alpha1-adrenergic functions or indirectly by decreasing the release of norepinephrine from peripheral sympathetic nerves.

Antiretroviral therapy-associated hyperlipidaemia in HIV disease

Widespread utilization of highly active antiretroviral therapy (HAART) for HIV-infection, primarily protease inhibitors in combination with nucleoside analogue reverse transcriptase inhibitors, has recently led to a sustained reduction in the morbidity and mortality of this disease. However, administration of HAART is frequently associated with the development of lipid disorders. The severity and prevalence of dyslipidaemia vary, depending on the type of HAART, nutritional status, HIV disease stage, and concomitant presence of lipodystrophy and insulin resistance (two additional adverse effects of HAART). The mechanism that is responsible for HAART-associated dyslipidaemia remains incompletely understood. Recent data indicate that this effect may be, at least in part, accounted for by protease inhibitor-mediated inhibition of the proteasome activity and accumulation of the active portion of sterol regulatory element-binding protein-1c in liver cells and adipocytes. Whether lipid disorders in HIV-infected patients receiving HAART translate into an increased cardiovascular risk, and the indications for lipid-lowering interventions in this population, remain to be established.

Renin-angiotensin system inhibition on noradrenergic nerve terminal function in pacing-induced heart failure

Chronic angiotensin-converting enzyme (ACE) inhibition has been shown to improve cardiac sympathetic nerve terminal function in heart failure. To determine whether similar effects could be produced by angiotensin II AT(1) receptor blockade, we administered the ACE inhibitor quinapril, angiotensin II AT(1) receptor blocker losartan, or both agents together, to rabbits with pacing-induced heart failure. Chronic rapid pacing produced left ventricular dilation and decline of fractional shortening, increased plasma norepinephrine (NE), and caused reductions of myocardial NE uptake activity, NE histofluorescence profile, and tyrosine hydroxylase immunostained profile. Administration of quinapril or losartan retarded the progression of left ventricular dysfunction and attenuated cardiac sympathetic nerve terminal abnormalities in heart failure. Quinapril and losartan together produced greater effects than either agent alone. The effect of renin-angiotensin system inhibition on improvement of left ventricular function and remodeling, however, was not sustained. Our results suggest that the effects of ACE inhibitors are mediated via the reduction of angiotensin II and that angiotensin II plays a pivotal role in modulating cardiac sympathetic nerve terminal function during development of heart failure. The combined effect of ACE inhibition and angiotensin II AT(1) receptor blockade on cardiac sympathetic nerve terminal dysfunction may contribute to the beneficial effects on cardiac function in heart failure.