Cardioselectivity of calcium antagonists

Calcium-channel modulators for cardiovascular disease

It is generally accepted that hypertension doubles the risk of cardiovascular disease, of which coronary heart disease is the most common and lethal. Hypertension is a predisposing factor for the development of stroke, peripheral arterial disease, heart failure and end-state renal disease. Atherosclerosis-causing coronary heart disease is related to the severity of hypertension. Inhibition of calcium entry reduces the active tone of vascular smooth muscle and produces vasodilatation. This pharmacological action has been the basis for the use of calcium-channel blockers (CCBs) for the management of hypertension. Other drug families may achieve this: diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor antagonists. Cardiovascular hypertrophy and atherosclerosis are major complications related to high blood pressure. Cardiac hypertrophy is considered as an independent risk factor associated with abnormalities of diastolic function and can result in heart failure. Atherosclerosis is associated with activation of innate immunity. Atherosclerosis is expressing itself not only as coronary heart disease, but as a cerebrovascular and peripheral arterial disease. By impairing physiological vasomotor function, atherosclerosis includes ultimately necrosis of myocardium. CCBs reduce blood pressure. Do they prevent the progress of the main complications of hypertension? This major question is the matter of the present paper.

Characterization of nifedipine-resistant calcium current in neonatal rat ventricular cardiomyocytes

Calcium current was recorded from ventricular cardiomyocytes of rats at various stages of postnatal development using the whole cell patch-clamp technique. In cultured 3-day-old neonatal cells, the current carried by Ca(2+) or Ba(2+) (5 mM) was not completely inhibited by 2 microM nifedipine. A residual current was activated in the same voltage range as the L-type, nifedipine-sensitive Ca(2+) current, but its steady-state inactivation was negatively shifted by 16 mV. This nifedipine-resistant calcium current was not further inhibited by other organic calcium current antagonists such as PN200-110, verapamil, and diltiazem nor by nickel, omega-conotoxin, or tetrodotoxin. It was completely blocked by cadmium and increased by isoproterenol and forskolin. This current was >20% of total calcium current in ventricular myocytes freshly isolated from neonatal rats, and it decreased during postnatal maturation, disappearing at the adult stage. This suggests that this current could be caused by an isoform of the L-type calcium channel expressed in a way that reflects the developmental stage of the rat heart.

The pharmacology of ion channels: with particular reference to voltage-gated Ca2+ channels

Ion channels are molecular machines that serve as principal integrating and regulatory devices for the control of cellular excitability. They are also major targets for drug action. The basic aspects of ion channel structure and pharmacological control are reviewed and illustrated with specific reference to a major class of therapeutic agents and molecular tools--the clinically available Ca2+ channel antagonists.

Pharmacological aspects of calcium channel blockers

Calcium channel blockers (CCBs) inhibit voltage-dependent L-type calcium channels. This leads to vascular smooth muscle relaxation and negative inotropic and chronotropic effects in the heart. The latter are counteracted in vivo by a vasodilatation-triggered, baroreceptor-mediated reflex increase in sympathetic tone, resulting in indirect cardiostimulation. The mean vascular/cardiac effect ratios of the first-generation CCBs-verapamil, nifedipine, and diltiazem-are relatively low and amount to approximately 3, 10, and 3, respectively. The pharmacokinetic properties of verapamil, nifedipine, and diltiazem are similar. The drugs are almost completely absorbed after oral administration, but their bioavailability is reduced because of first-pass hepatic metabolism. The onset of action of verapamil, nifedipine, and diltiazem, at least in immediate-release formulations, is relatively fast (0.5-2 hours), and their elimination half-lives range from 2 to 7 hours. The second-generation CCBs (e.g., amlodipine, felodipine, and nisoldipine) have a slower onset of action (due to either intrinsic properties of the drug or a slow-release formulation), a longer duration of action, and greater vascular/cardiac effect ratios. These features may provide therapeutic benefits, for example, a less pronounced increase in sympathetic tone and reflex tachycardia, and reduced likelihood of negative inotropic effects. These agents can therefore probably be used in patients with left ventricular dysfunction.

Calcium antagonists in patients with left ventricular dysfunction: back on the bridge?

Calcium antagonists have a useful role in the management of patients with cardiac disease, producing coronary and systemic vasodilatation and an additional possibly beneficial effect on ventricular diastolic function. On the other hand, the myocardial depressant effect of the first-generation drugs and the abrupt changes in blood pressure, with neurohormonal activation, have been associated with worsening heart failure in certain patients. The present review summarizes the data currently available, with emphasis on the newer slow-release and long-acting calcium antagonists. Use of these drugs minimizes the peak and trough effect associated with short-acting preparations, and particularly when administered against a background of digoxin, diuretic and angiotensin converting enzyme inhibitors, may be associated with better long-term results in patients with ventricular dysfunction. The DEFIANT studies, using nisoldipine-coat core, showed that nisoldipine-CC improved diastolic ventricular function and had a significant anti-ischemic effect in patients with mild-moderate ventricular dysfunction after acute myocardial infarction. The VHeFT III trial showed that felodipine had no effect on exercise capacity or survival in patients with Class 2-3 heart failure. In the PRAISE study of Class 3-4 patients, amlodipine was neutral in patients with ischemic disease, but a strikingly beneficial effect was observed in non-ischemic heart failure (45% decrease in mortality). The precise mechanism for the beneficial effect of amlodipine in these patients is unknown. Further studies are needed to examine the issue of survival benefit in patients with non-ischemic heart failure and the mechanisms involved.

Synergistic actions of glucagon and miniglucagon on Ca2+ mobilization in cardiac cells

It has been recently shown that the physiological processing of glucagon into its C-terminal (19-29) fragment, miniglucagon, by cardiac cells was essential for the contractile positive inotropic effect of the hormone. However, the mechanisms underlying the effects of miniglucagon remained undetermined. In the present study, we assessed the effects of miniglucagon on Ca2+ homeostasis in embryonic chick ventricular myocytes. In quiescent cells, short-term applications of 0.1 nmol/L miniglucagon markedly increased the accumulation of 45Ca into intracellular compartments resistant to digitonin lysis and sensitive to caffeine. Ca2+ accumulation into the sarcoplasmic reticular (SR) store was further attested by fura 2 imaging studies on quiescent or prestimulated cells: miniglucagon potentiated Ca2+ release from the SR compartment triggered by caffeine and evoked a rise in cytosolic Ca2+ when applied on cells pretreated with 1 mumol/L thapsigargin, a specific inhibitor of the SR Ca2+ pump. Glucagon alone produced a small cytosolic Ca2+ signal that was considerably amplified by miniglucagon. The action of glucagon was mimicked by 8-bromo-cAMP and was blocked by isradipine, suggesting that it relied on the activation of L-type Ca2+ channels, via phosphorylation. We conclude that the combined actions of miniglucagon and glucagon on Ca2+ accumulation into SR stores and Ca2+ release from the same stores are likely to support the positive inotropic effect elicited in vivo by glucagon on heart contraction.

Vascular selective calcium entry blockers in the treatment of cardiovascular disorders: focus on felodipine

Calcium entry through L-type calcium channels is essential for contraction of both arterial smooth muscle and the myocardium, and is important in cardiac conduction. First-generation calcium entry blockers lack or have a modest degree of vascular selectivity and inhibit cardiac function at doses producing therapeutic arterial dilatation. Such agents may cause deterioration in patients with left ventricular dysfunction, and their combination with a beta-adrenergic blocker may adversely affect cardiac contractility and conduction. Development of newer agents has focused on obtaining a higher degree of vascular selectivity. Felodipine is a highly vascular selective calcium entry blocker, with a vascular selectivity ratio greater than 100, as shown experimentally. Isradipine and nicardipine are also vascularly selective calcium entry blockers. Hemodynamic studies in patients with hypertension, coronary artery disease, congestive heart failure, or in patients receiving beta-adrenergic blockade, show that felodipine can produce profound arteriolar dilatation without the negative effects of left ventricular systolic performance. Furthermore, felodipine alone or when added to a beta-adrenergic blocker does not interfere with cardiac conduction. The primary mechanism that accounts for the efficacy of dihydropyridine calcium entry blockers in hypertension and angina pectoris is arterial dilation, whereas nondihydropyridines may also derive part of their effect from inhibition of cardiac performance. As some of these patients, most commonly the elderly, have concomitant left ventricular dysfunction, it should be advantageous to avoid myocardial depression in the treatment of their primary disease. Preliminary studies in patients with heart failure indicate that felodipine and amlopidine may improve hemodynamics, reduce neurohormonal activation, and increase exercise tolerance, but final conclusions must await the randomized clinical trials now underway.

Clinical pharmacology of nisoldipine coat core

Nisoldipine is a second-generation dihydropyridine calcium antagonist structurally related to nifedipine and used in the treatment of stable angina and arterial hypertension. It is also under investigation for the treatment of left ventricular dysfunction. It was first developed as an immediate release tablet, but this formulation was not considered optimal for once-daily administration because of the variable results obtained at peak and trough in clinical studies. Consequently, nisoldipine coat core (CC) was developed with the aim of optimizing the drug's time--effect profile over the 24-hour dosing interval. The in vitro release pattern classifies this tablet as an "extended release" formulation according to European Community guidelines. The present article outlines the pharmacokinetic and pharmacodynamic profiles of nisoldipine CC, as obtained from recent clinical studies.