Current and future status of beta-blockers in the treatment of hypertension

One Molecule, Many Faces: Repositioning Cardiovascular Agents for Advanced Wound Healing

Chronic wound treatments pose a challenge for healthcare worldwide, particularly for the people in developed countries. Chronic wounds significantly impair quality of life, especially among the elderly. Current research is devoted to novel approaches to wound care by repositioning cardiovascular agents for topical wound treatment. The emerging field of medicinal products' repurposing, which involves redirecting existing pharmaceuticals to new therapeutic uses, is a promising strategy. Recent studies suggest that medicinal products such as sartans, beta-blockers, and statins have unexplored potential, exhibiting multifaceted pharmacological properties that extend beyond their primary indications. The purpose of this review is to analyze the current state of knowledge on the repositioning of cardiovascular agents' use and their molecular mechanisms in the context of wound healing.

Etiological Diagnosis and Personalized Therapy for Hypertension: A Hypothesis of the REASOH Classification

With the epidemic of risk factors such as unhealthy lifestyle, obesity and mental stress, the prevalence of hypertension continues to rise across the world. Although standardized treatment protocols simplify the selection of antihypertensive drugs and ensure therapeutic efficacy, the pathophysiological state of some patients remains, which may also lead to the development of other cardiovascular diseases. Thus, there is an urgent need to consider the pathogenesis and selection of antihypertensive drug for different type of hypertensive patients in the era of precision medicine. We proposed the REASOH classification, based on the etiology of hypertension, including renin-dependent hypertension, elderly-arteriosclerosis-based hypertension, sympathetic-active hypertension, secondary hypertension, salt-sensitive hypertension and hyperhomocysteinemia hypertension. The aim of this paper is to propose a hypothesis and provide a brief reference for the personalized treatment of hypertensive patients.

Propranolol versus Other Selected Drugs in the Treatment of Various Types of Anxiety or Stress, with Particular Reference to Stage Fright and Post-Traumatic Stress Disorder

Propranolol, a non-cardioselective β_1,2 blocker, is most commonly recognised for its application in the therapy of various cardiovascular conditions, such as hypertension, coronary artery disease, and tachyarrhythmias. However, due to its ability to cross the blood–brain barrier and affinity towards multiple macromolecules, not only adrenoreceptors, it has also found application in other fields. For example, it is one of the very few medications successfully applied in the treatment of stage fright. This review focuses on the application of propranolol in the treatment of various types of anxiety and stress, with particular reference to stage fright and post-traumatic stress disorder (PTSD). Both mechanisms of action as well as comparison with other therapies are presented. As those indications for propranolol are, in most countries, considered off-label, this review aims to gather information that can be useful while making a decision about the choice of propranolol as a drug in the treatment of those mental conditions.

Acute Myocardial Infarction and Daylight Saving Time Transitions: Is There a Risk?

Available evidence on the risk of acute myocardial infarction (AMI) in the days after the spring daylight saving time (DST) transition suggests either a modest increase or no risk increase. Partial sleep deprivation and enhanced circadian clock misalignment have been implicated as the underlying mechanisms for increased AMI risk, probably via enhanced thrombo-inflammatory processes and activation of the sympathetic nervous system. Most of the studies, as we suggest as a perspective here, have used potentially inappropriate control periods, including the two post-transitional weeks, because adjustment after the spring DST transition lasts at least four weeks for all chronotypes and probably even beyond this period for late chronotypes. The most plausible conclusions, at the moment, for the risk of AMI after the spring DST transition are: (1) the risk is increased, (2) a relatively modest risk increase could be currently underestimated or in some studies undetected, (3) late chronotypes and/or individuals with high levels of social jetlag (a proxy for circadian clock misalignment) could be more affected by the phenomenon, and (4) underlying pathophysiological mechanisms should be further explored. As a significant part of world’s population continues to be affected by the biannual clock change, the question of increased AMI risk in the post-transitional period remains an intriguing public health issue.

Nebivolol for the Treatment of Essential Systemic Arterial Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

Cardiovascular diseases are the main cause of mortality worldwide, and systemic arterial hypertension is associated with a large number of these cases. The objective of health professionals and health policies should be searching for the best therapeutics to control this disease. A recent consensus indicated that β-blockers have recently lost their place in initial indications for the treatment of systemic arterial hypertension and are now more indicated for the treatment of hypertension in association with other clinical situations such as angina, heart failure and arrhythmia; however, it is known that this approach was based on studies that evaluated older β-blockers such as atenolol.

OBJECTIVE

The main objective of this study was to perform a systematic review with subsequent meta-analysis on the use of nebivolol for hypertensive disease treatment, comparing it with drugs of the main antihypertensive classes.

METHODS

This systematic review was based on a search of the MEDLINE (via Pubmed), Scopus, Cochrane, International Pharmaceuticals Abstracts (IPA), and Lilacs databases for randomized and double-blind clinical trials. In addition, we also searched for gray literature studies, to 31 July 2015. Next, a cumulative meta-analysis was performed, with studies being added in a sequential manner, evaluating their impact on the combined effect. For this project, we only meta-analyzed direct comparisons of random effect.

RESULTS

Overall, 981 clinical trials were included in this systematic review. After careful analysis, 34 randomized and double-blind clinical trials were included to investigate the efficacy of nebivolol on systolic (SBP) and diastolic blood pressure (DBP) control and adverse effects. The study population comprised 12,465 patients with systemic arterial hypertension (SAH) aged between 18 and 85 years; 17% of subjects were of Black ethnicity, approximately 55% were men, and almost 10% had diabetes. In SBP management, nebivolol was superior to other β-blockers and diuretics and showed no difference in efficacy when compared with angiotensin receptor blockers or calcium channel blockers. There were insufficient studies on angiotensin-converting enzyme inhibitors for adequate comparison of both SBP and DBP control. For DBP control, nebivolol was more efficient than other β-blockers, angiotensin receptor blockers, diuretics, and calcium channel blockers.

DISCUSSION

Nebivolol is a third-generation β-blocker with additional capabilities to improve blood pressure levels in patients with arterial hypertension, because it acts by additional mechanisms such as endothelium-dependent vasodilation associated with L-arginine and oxide nitric acid, nitric oxide activity on smooth muscle cells, decreasing platelet aggregation, and leukocyte adhesion in the endothelium, decreasing oxidative stress. Although nebivolol has shown good results in controlling hypertension in this study (with few adverse events when compared with placebo treatment) and has an unquestionable benefit in individuals with heart failure (mainly with reduced ejection fraction), there is a lack of studies proving the benefit of this drug for controlling hypertension and reducing clinical outcomes such as cardiovascular (or general) mortality, acute myocardial infarction, or stroke.

CONCLUSIONS

Nebivolol demonstrated at least similar control of blood pressure levels in hypertensive individuals when compared with drugs of the most used classes. In addition, in relation to the control of arterial hypertension, studies with clinical outcomes should be performed to ensure the use of this drug in detriment to others with these well-established results.

Dispersive Solid Phase Extraction Using Magnetic Nanoparticles Performed in a Narrow-Bored Tube for Extraction of Atorvastatin, Losartan, and Valsartan in Plasma

Purpose: In this investigation, a new version of magnetic solid phase extraction (MSPE) performed in a narrow–bore tube has been proposed. In this study, hydrophobic octyl (C₈) functionalized Fe₃O₄ magnetic nanoparticles (MNPs) stabilized by SiOH groups (Fe₃O₄@SiO₂@C₈) are used as magnetic nano–sorbents for the extraction of cardiovascular drugs from human plasma prior to their determination by high performance liquid chromatography–photodiode array detection.

Methods: After precipitation of the plasma proteins, the supernatant is diluted with deionized water and filled into the narrow–bore tube. Then mg–level of the sorbent is added into the tube. The sorbent is dispersed and moved down through the solution instead of passing the solution from the cartridge. Using an external magnet, the collected nano–sorbents at the bottom of the tube are transferred on top of the solution and released to move down through the solution for three times to increase the extraction efficiency.

Results: The linearity of the assay was ranging from 0.4–500 mg mL^-1. The limits of detection and quantification of the method were obtained in the ranges of 0.05–0.07 and 0.16–0.24 mg L^-1, respectively. The extraction recoveries were obtained in the range of 31–49%. Intra– and inter–day precisions were calculated and obtained in the ranges of 5–8 and 7%–9% for 0.5 mg L^-1 of each analyte, and 5–6 and 6%–8% for 2 mg L^-1 of each analyte, respectively.

Conclusion: The proposed method was successfully used in determination of the studied drugs in patient’s plasmas.

Influence of Peroxide Impurities in Povidone on the Stability of Selected β-Blockers with the Help of HPLC

A present study was conducted to investigate compatibility of β-blocker drugs( like atenolol, labetalol hydrochloride, bisoprolol fumarate, metoprolol succinate, carvedilol and propranolol hydrochloride) with the pharmaceutical excipient povidone. To check the influence of peroxide impurity present in povidone on the stability of β-blockers, a binary mixture technique has been adopted. The binary mixtures (1:1) of β-blockers with povidone excipient were stored for the duration of 6 months at accelerated conditions (40°C and 75% RH) and analyzed with the technique of high-performance liquid chromatography (HPLC). On analysis, HPLC results shows that, the percentage of total impurity for atenolol-2.15%, bisoprolol fumarate-3.55%, carvedilol-2.19%, and labetalol hydrochloride-1.89%, with respect to povidone. To verify the interaction of H₂O₂ present in povidone as an impurity, oxidative degradation of selected active pharmaceutical ingredients were performed and degradation profile were compared with that of degradation impurities generated in drug-excipient mixture at accelerated conditions. The relative retention time (RRT) of impurities generated in accelerated stability study samples resembles the RRT of degradation products generated by oxidative degradation of pure drugs. Thus, it confirms that degradation of β-blockers with povidone was mediated by organic peroxides present as an impurity in povidone.

Predictors for glucose change in hypertensive participants following short-term treatment with atenolol or hydrochlorothiazide

STUDY OBJECTIVE

To develop and validate a predictive model for glucose change and risk for new-onset impaired fasting glucose in hypertensive participants following treatment with atenolol or hydrochlorothiazide (HCTZ).

DESIGN

Randomized multicenter clinical trial.

PATIENTS

A total of 735 white or African-American men and women with uncomplicated hypertension.

MEASUREMENTS AND MAIN RESULTS

Pharmacogenomic Evaluation of Antihypertensive Responses (PEAR) is a randomized clinical trial to assess the genetic and nongenetic predictors of blood pressure response and adverse metabolic effects following treatment with atenolol or HCTZ. To develop and validate predictive models for glucose change, PEAR participants were randomly divided into a derivation cohort of 367 and a validation cohort of 368. Linear and logistic regression modeling were used to build models of drug-associated glucose change and impaired fasting glucose (IFG), respectively, in the derivation cohorts. These models were then evaluated in the validation cohorts. For glucose change after atenolol or HCTZ treatment, baseline glucose was a significant (p<0.0001) predictor, explaining 13% of the variability in glucose change after atenolol and 12% of the variability in glucose change after HCTZ. Baseline glucose was also the strongest and most consistent predictor (p<0.0001) for development of IFG after atenolol or HCTZ monotherapy. The area under the receiver operating curve was 0.77 for IFG after atenolol and 0.71 after HCTZ treatment, respectively.

CONCLUSION

Baseline glucose is the primary predictor of atenolol or HCTZ-associated glucose increase and development of IFG after treatment with either drug.

Salt-assisted LLE combined with field-amplified sample stacking in CE for improved determination of beta blocker drugs in human urine

Background: A simple and sensitive CE method was developed and validated for the analysis of some beta blockers in human urine. Methods: In this study, salting-out assisted LLE combined with field-amplified sample stacking method was employed for biological sample clean-up and sensitivity enhancement in CE. Results: Under the optimal conditions good linearity (r2 ≥0.998) was obtained, within 0.025–1 µg/ml for propranolol and metoprolol, and within 0.05–1 µg/ml for carvedilol in urine samples. LODs and LLOQs ranged from 0.005 to 0.015 µg/ml, and from 0.025 to 0.05 µg/ml, respectively. The RSDs of intra- and inter-day analysis of examined compounds were less than 4.0%. The recoveries were in the range of 98–119%. Conclusion: The validated method is successfully applied to determine propranolol, metoprolol and carvedilol in human urine samples obtained from the patients who received these drugs.

Control of hypertension in the critically ill: a pathophysiological approach

Severe acute arterial hypertension can be associated with significant morbidity and mortality. After excluding a reversible etiology, choice of therapeutic intervention should be based on evaluation of a number of factors, such as age, comorbidities, and other ongoing therapies. A rational pathophysiological approach should then be applied that integrates the effects of the drug on blood volume, vascular tone, and other determinants of cardiac output. Vasodilators, calcium channel blockers, and beta-blocking agents can all decrease arterial pressure but by totally different modes of action, which may be appropriate or contraindicated in individual patients. There is no preferred agent for all situations, although some drugs may have a more attractive profile than others, with rapid onset action, short half-life, and fewer adverse reactions. In this review, we focus on the main mechanisms underlying severe hypertension in the critically ill and how using a pathophysiological approach can help the intensivist decide on treatment options.

β-Adrenergic blockade in cardiovascular disease

The development and subsequent clinical application of the β-adrenergic receptor blocking drugs represent one of the major advances in human pharmacotherapeutics. No other class of synthetic drugs has demonstrated such widespread therapeutic utility for the treatment and prevention of so many cardiovascular diseases. In addition, these drugs have proven to be molecular probes that have contributed to our understanding of the disease, and on the molecular level, both the structure and function of the 7 transmembrane G protein receptors that mediate the actions of many different hormones, neurotransmitters, and drugs. The evolution of β-blocker drug development has led to refinements in their pharmacodynamic actions that include agents with relative β1-selectivity, partial agonist activity, concomitant α-adrenergic blockers activity, and direct vasodilator activity. In addition, long-acting and ultra-short-acting formulations of β-blockers have also demonstrated a remarkable record of clinical safety in patients of all ages.

Mapping genetic variants associated with beta-adrenergic responses in inbred mice

β-blockers and β-agonists are primarily used to treat cardiovascular diseases. Inter-individual variability in response to both drug classes is well recognized, yet the identity and relative contribution of the genetic players involved are poorly understood. This work is the first genome-wide association study (GWAS) addressing the values and susceptibility of cardiovascular-related traits to a selective β₁-blocker, Atenolol (ate), and a β-agonist, Isoproterenol (iso). The phenotypic dataset consisted of 27 highly heritable traits, each measured across 22 inbred mouse strains and four pharmacological conditions. The genotypic panel comprised 79922 informative SNPs of the mouse HapMap resource. Associations were mapped by Efficient Mixed Model Association (EMMA), a method that corrects for the population structure and genetic relatedness of the various strains. A total of 205 separate genome-wide scans were analyzed. The most significant hits include three candidate loci related to cardiac and body weight, three loci for electrocardiographic (ECG) values, two loci for the susceptibility of atrial weight index to iso, four loci for the susceptibility of systolic blood pressure (SBP) to perturbations of the β-adrenergic system, and one locus for the responsiveness of QTc (p<10⁻⁸). An additional 60 loci were suggestive for one or the other of the 27 traits, while 46 others were suggestive for one or the other drug effects (p<10⁻⁶). Most hits tagged unexpected regions, yet at least two loci for the susceptibility of SBP to β-adrenergic drugs pointed at members of the hypothalamic-pituitary-thyroid axis. Loci for cardiac-related traits were preferentially enriched in genes expressed in the heart, while 23% of the testable loci were replicated with datasets of the Mouse Phenome Database (MPD). Altogether these data and validation tests indicate that the mapped loci are relevant to the traits and responses studied.

Design, synthesis, and antiviral evaluation of purine-β-lactam and purine-aminopropanol hybrids

Purine-β-lactam chimera were prepared as a novel class of hybrid systems through N-alkylation of 6-benzylamino- or 6-benzyloxypurine with (ω-haloalkyl)-β-lactams, followed by reductive ring opening of the β-lactam ring by LiEt(3)BH to provide an entry into the class of purine-aminopropanol hybrids. Both new types of hybrid systems were assessed for their antiviral activity and cytotoxicity, resulting in the identification of eight purine-β-lactam hybrids and two purine-aminopropanol hybrids as promising lead structures.

Effects of β-adrenoceptor antagonists on alcohol drinking by alcohol-dependent rats

RATIONALE

Alcohol-dependent animals display enhanced stress responsivity, reward thresholds, and alcohol self-administration during alcohol withdrawal, and some of these aspects of alcohol dependence may be mediated by activation of brain norepinephrine (NE) systems.

OBJECTIVES

This study examined the effects of propranolol, a β-adrenoceptor antagonist, on operant alcohol-reinforced responding by alcohol-dependent and non-dependent rats.

METHODS

Adult male Wistar rats were trained to respond for alcohol in an operant conditioning paradigm on fixed-ratio-1 (FR-1) and progressive ratio (PR) reinforcement schedules. Rats were either made dependent on alcohol via chronic intermittent (14 h ON/10 h OFF) alcohol vapor inhalation or were not exposed to alcohol vapor. Rats were tested for the effects of propranolol (0-10 mg/kg) or nadolol (0-20 mg/kg) on operant alcohol-reinforced responding at the time point corresponding to 6-8 h withdrawal in dependent animals.

RESULTS

All doses of propranolol suppressed FR-1 operant alcohol-reinforced responding in alcohol-dependent rats, but only the highest dose suppressed FR-1 responding by controls. No dose of propranolol affected water responding. Nadolol did not affect operant behavior. Propranolol suppressed PR operant alcohol-reinforced responding across groups, an effect attributable to significant suppression of alcohol responding at the highest dose.

CONCLUSIONS

Following development of alcohol dependence, rats exhibit hypersensitivity to the suppressive effects of propranolol on operant alcohol-reinforced responding. This effect is mediated by central actions of the drug, is not attributable to motor effects, and may reflect activation of brain NE systems that contributes to withdrawal-induced negative emotional states and drives alcohol drinking in the dependent organism.

Vasorelaxant and antihypertensive effects of methanolic extract from roots of Laelia anceps are mediated by calcium-channel antagonism

RMELanc-induced relaxation in aortic rings precontracted with NE, 5-HT and KCl. It also reduced NE-induced transient contraction in Ca(2+)-free solution and inhibited contraction induced by increasing external calcium. Nevertheless, the vasorelaxant effect of RMELanc was not reduced by ODQ, 1-alprenolol, TEA, glibenclamide, and 2-AP. Oral administration of 100 mg/kg of RMELanc exhibited a significant decrease in systolic and diastolic blood pressures in SHR rats. HPLC analysis allowed us to detect the presence of 2,7-dihydroxy-3,4,9-trimethoxyphenantrene (1), which induced a significant relaxation effect. Therefore, our results suggest that RMELanc induces vasorelaxant and antihypertensive effects by blockade of Ca(2+) channels.

Change in mRNA Expression after Atenolol, a Beta-adrenergic Receptor Antagonist and Association with Pharmacological Response

AIMS: Genetic determinants of variability in response to beta-blockers are poorly characterized. We defined changes in mRNA expression after a beta-blocker to identify novel genes that could affect response and correlated these with inhibition of exercise-induced tachycardia, a measure of beta-blocker sensitivity. METHODS: Nine subjects exercised before and after a single oral dose of 25mg atenolol and mRNA gene expression was measured using an Affymetrix GeneChip Human Gene 1.0 ST Array. The area under the heart rate-exercise intensity curve (AUC) was calculated for each subject; the difference between post- and pre-atenolol AUCs (Delta AUC), a measure of beta-blocker response, was correlated with the fold-change in mRNA expression of the genes that changed more than 1.3-fold. RESULTS: Fifty genes showed more than 1.3-fold increase in expression; 9 of these reached statistical significance (P < 0.05). Thirty-six genes had more than 1.3-fold decrease in expression after atenolol; 6 of these reached statistical significance (P < 0.05). Change in mRNA expression of FGFBP2 and Probeset ID 8118979 was significantly correlated with atenolol response (P = 0.03 and 0.02, respectively). CONCLUSION: The expression of several genes not previously identified as part of the adrenergic signaling pathway changed in response to a single oral dose of atenolol. Variation in these genes could contribute to unexplained differences in response to beta-blockers.

Antihypertensive medications: benefits of blood pressure lowering and hazards of metabolic effects

Blood pressure reduction is associated with significant reduction in adverse cardiovascular outcomes. Certain blood pressure-lowering drugs have adverse effects on glucose homeostasis, and have been associated with the development of both prediabetes and diabetes during use. There is controversy over the significance of diabetes that develops during treatment with antihypertensives and whether the benefits of blood pressure reduction offset the hazards of dysglycemia that can lead to diabetes. Many treatment guidelines have recently undergone revisions to include consideration for the metabolic effects of antihypertensive drugs, particularly in high-risk populations. This review summarizes the data related to the benefits of blood pressure reduction as well as the adverse metabolic effects and new-onset diabetes associated with some medications.

Cardiovascular response to beta-adrenergic blockade or activation in 23 inbred mouse strains

We report the characterisation of 27 cardiovascular-related traits in 23 inbred mouse strains. Mice were phenotyped either in response to chronic administration of a single dose of the β-adrenergic receptor blocker atenolol or under a low and a high dose of the β-agonist isoproterenol and compared to baseline condition. The robustness of our data is supported by high trait heritabilities (typically H²>0.7) and significant correlations of trait values measured in baseline condition with independent multistrain datasets of the Mouse Phenome Database. We then focused on the drug-, dose-, and strain-specific responses to β-stimulation and β-blockade of a selection of traits including heart rate, systolic blood pressure, cardiac weight indices, ECG parameters and body weight. Because of the wealth of data accumulated, we applied integrative analyses such as comprehensive bi-clustering to investigate the structure of the response across the different phenotypes, strains and experimental conditions. Information extracted from these analyses is discussed in terms of novelty and biological implications. For example, we observe that traits related to ventricular weight in most strains respond only to the high dose of isoproterenol, while heart rate and atrial weight are already affected by the low dose. Finally, we observe little concordance between strain similarity based on the phenotypes and genotypic relatedness computed from genomic SNP profiles. This indicates that cardiovascular phenotypes are unlikely to segregate according to global phylogeny, but rather be governed by smaller, local differences in the genetic architecture of the various strains.