Hypertension and propranolol therapy: effect on blood pressure, plasma catecholamines and platelet aggregation

Potential Protective Role of Blood Pressure-Lowering Drugs on the Balance between Hemostasis and Fibrinolysis in Hypertensive Patients at Rest and During Exercise

In patients with hypertension, the triad represented by endothelial dysfunction, platelet hyperactivity, and altered fibrinolytic function disturbs the equilibrium between hemostasis and fibrinolysis and translates into a hypercoagulable state, which underlies the risk of thrombotic complications. This article reviews the scientific evidence regarding some biological effects of antihypertensive drugs, which can protect patients from the adverse consequences of hypertensive disease, improving endothelial function, enhancing antioxidant activity, and restoring equilibrium between hemostatic and fibrinolytic factors. These protective effects appear not to be mediated through blood pressure reduction and are not shared by all molecules of the same pharmacological class.

Effect of timolol on platelet aggregation in coronary heart disease

The immediate effect of beta-blockers versus placebo in platelet function was studied in ten healthy men one hour after either 40 mg propranolol, 5 mg timolol or placebo was given. Both beta-blockers had similar platelet effects. They increased the ADP-threshold in a platelet aggregation test and reduced the plasma level of beta-thromboglobulin whereas the primary aggregation remained unchanged. Forty-four patients were given timolol 10 mg twice daily or corresponding placebo medication in a secondary prevention trial after a myocardial infarction. At rest and also immediately after a near maximal exercise test the platelet function was similar on timolol and placebo. During exercise a lower ADP-threshold and a higher plasma level of beta-thromboglobulin was observed irrespective of whether the patients received placebo or timolol. Thus, the acute platelet inhibiting effect of timolol observed after a single dose disappeared during chronic timolol treatment. During 24 hours continuous ambulatory ECG monitoring patients on timolol treatment had significantly less arrhythmias than patients on placebo. A general effect on platelets cannot explain this antiarrhythmic effect of timolol during chronic therapy.

Prolonged platelet activation in individuals with elevated blood pressure in response to a moderate exercise challenge

We examined the magnitude of 20-min moderate exercise-induced platelet activation in 50 volunteers with normal (n=31) or elevated blood pressure (EBP; n=19). Blood was drawn before, immediately after, and 25 min after exercise. Antibody-staining for platelet activation markers, P-selectin, and fibrinogen receptors was done with and without adenosine diphosphate (ADP) stimulation in whole blood for flow cytometric analyses. Exercise led to increases in percent aggregated platelets and percent platelets expressing P-selectin or PAC-1 binding (ps< or =.001). This increase in percent platelets expressing P-selectin continued even after a 25-min rest only in the EBP group (p< or =.01) accompanied by an increase in percent of aggregated platelets (p< or =.05). Although ADP stimulation led to increased platelet activation at rest, it was attenuated following exercise, even among EBP individuals. A moderate exercise challenge induced prolonged platelet activation in individuals with EBP but attenuation in activation to further stimulation by an agonist. Findings suggest that a recovery period after physical stress appears critical in individuals with high BP regarding platelet activation and aggregation, which can lead to an acute coronary syndrome in vulnerable individuals.

Conjugated estrogen plus medroxyprogesterone does not impair blood rheological properties in hypertensive postmenopausal women

OBJECTIVES

Hypertension and estrogens are both prothrombotic. We used the microchannel method to investigate whether hormone replacement therapy (HRT) with conjugated equine estrogen (CEE) plus medroxyprogesterone acetate (MPA) affects blood flow through the microchannels in hypertensive postmenopausal women being treated with antihypertensive drugs and in normotensive postmenopausal women.

METHODS

Sixty-two consecutive postmenopausal women were randomly assigned to a hypertensive HRT group (n=16), hypertensive control group (n=15), normotensive HRT group (n=16) and normotensive control group (n=15). Each HRT group received CEE 0.625 mg plus MPA 2.5 mg daily orally for 12 months. Both hypertensive groups were being treated with antihypertensive drugs before the study. Microvascular blood flow was assessed on the basis of blood passage time, the time required for 100 microl of whole blood to pass through a cylinder, was determined before and 12 months after the start of HRT by the microchannel method (micro channel array flow analyzer).

RESULTS

CEE plus MPA therapy did not change blood passage time in any of the groups. Microscopic observation showed that the whole blood passed smoothly through the microchannels in every group.

CONCLUSIONS

CEE plus MPA therapy may not impair blood flow through the microchannels in hypertensive postmenopausal women receiving antihypertensive drugs or in normotensive postmenopausal women. However, administration of CEE plus MPA to postmenopausal women with hypertension warrants caution against the occurrence of thromboembolic events.

beta-Blockers in hypertension: is carvedilol different?

Most studies assessing the effects of beta-blockers were carried out with traditional, beta(1)-selective beta-blockers, such as metoprolol and atenolol. Pathophysiologic and pharmacologic studies have documented that not all beta-blockers are created equal. In particular, the pharmacologic and clinical profiles of the newer, vasodilating beta-blockers, such as carvedilol, have been shown to differ from those of the traditional beta-blockers. These differences, although relevant in the younger patient with hypertension, are particularly important in elderly patients in whom traditional beta-blockers may not be as effective or as well tolerated as the newer vasodilating agents.

Why beta-blockers are not cardioprotective in elderly patients with hypertension

Despite the fact that beta-blockers have been used for the treatment of hypertension for more than 30 years, no study has shown that their use reduces morbidity and mortality in the elderly. To the contrary, the British Medical Research Council trial in the elderly documented that although blood pressure was lowered effectively and significantly by atenolol, morbidity and mortality in the beta-blocker group did not differ from that of the placebo group. Not only was beta-blocker monotherapy not effective, but patients who received the combination of beta-blockers and diuretics fared consistently worse than those on diuretics alone. beta-blockers are less effective than diuretics in lowering blood pressure, and are poorly tolerated in the elderly. The reason for their inefficacy in the elderly may be related to their inherent unfavorable effect on systemic hemodynamics and pathophysiologic findings in the arterial tree, heart, kidneys, brain, and on the metabolism of lipids and carbohydrates. Decreased beta-adrenergic responsiveness with age and comorbid conditions makes beta-blockers unattractive. Thus, they should not be considered appropriate for first-line therapy of uncomplicated hypertension in the geriatric population.

Platelet activation and secretion in patients with major depression, thoracic aortic atherosclerosis, or renal dialysis treatment

Relatively little is known concerning the magnitude of alterations of platelet activation and secretion markers of patients with major depression when compared to patients at increased risk for, or with current, clinically significant atherosclerosis. Markers of in vivo platelet stimulation and secretion were measured under basal conditions in normal comparison subjects (n = 12) and three patient groups: patients diagnosed with DSM-IV major depression (n = 15), dialysis-dependent patients (n = 12), and patients with severe thoracic aortic atherosclerosis (n = 10). In comparison to normal comparison subjects, depressed patients and patients with thoracic aortic atherosclerosis exhibited the greatest platelet stimulation as detected by increased anti-LIBS platelet binding. Dialysis-dependent patients exhibited the highest plasma concentrations of the renally-excreted platelet-specific secretion protein, beta-thromboglobulin. This study extends previous observations of increased platelet activation in patients with major depression and documents similar alterations in patients with transesophageal echocardiography (TEE)-documented thoracic aortic atherosclerosis. Future studies will determine whether the magnitude of platelet stimulation and secretion in patients with comorbid depression and atherosclerotic aortic disease is greater than that observed in nondepressed patients with atherosclerotic aortic disease or major depression alone. These findings provide further evidence for either increased platelet activation and/or intrinsic heightened platelet reactivity as one of the biological substrates underlying the increased risk of depressed patients for cardiovascular disease.

Effect of the angiotensin-converting enzyme inhibitor perindopril on haemostasis in essential hypertension

Endothelial damage, platelet hyperactivity and other changes of blood coagulation may play a role in the vascular complications of essential hypertension. Undesirable changes of haemostasis induced by some anti-hypertensive drugs can encourage the acceleration of atherogenesis. Therefore, the effect of angiotensin-converting enzyme (ACE)-inhibitors on haemostasis is of interest. The therapeutic dose of perindopril was previously shown to reduce platelet aggregation. In the present study, selected parameters of haemostasis were investigated in 23 patients with first and second stage of non-treated essential hypertension. The measurements were carried out before therapy, after 1 week of placebo administration, and after 1 week and after 1 month of ACE-inhibitor perindopril therapy in a once-daily dose of 4 mg. Plasma prothrombin time, activated partial thromboplastin time, fibrinogen level, plasminogen and antithrombin III activities, protein C and free protein S antigens, total fibrinolytic activity as well as fibrin monomers and D-dimers were assayed. There were no significant changes in any haemostasis variables investigated following placebo administration or perindopril therapy. On the basis of this study, no unfavourable effects on haemostasis induced by this therapy were found. The platelet-inhibitory effect of perindopril, without any harmful effects on coagulation or fibrinolytic activity and coagulation inhibitors, is desirable in the new approach to hypertension treatment. These properties of perindopril may be important in terms of the beneficial role of anti-hypertensive drugs in cardiovascular morbidity.

Obesity and hypertension

Substantial evidence from epidemiological data supports a link between obesity and hypertension. However, the relationship between the two disorders is not straightforward and most likely represents an interaction of demographic, genetic, hormonal, renal, and hemodynamic factors. Age, race, and sex also modulate the strength of the association between obesity and hypertension. Hyperinsulinemia, which is characteristic of obesity, can contribute to the probability of developing hypertension by activating the sympathetic nervous system (SNS) and by causing sodium retention. The pressor effect of insulin in obesity may be further enhanced by the observation that its vasodilator action can be blunted in obese subjects. Preliminary data have shown that leptin, whose levels are increased in most obese individuals, can contribute to hypertension in obesity through its effects on insulin, SNS, and sodium excretion. The kidney may also have a role in the pathophysiology of hypertension in obesity. Abnormal renal sodium handling coupled with structural changes in the kidney of an obese patient can raise blood pressure. In addition, obesity is associated with distinct cardiovascular hemodynamic alterations and development of eccentric myocardial hypertrophy. Most of these obesity-associated abnormalities, as well as hypertension itself, can be reversed by weight loss. Furthermore, weight loss can prevent, or at least delay, the development of hypertension in patients with high-normal blood pressure. Weight reduction should be the first-line treatment in every obese hypertensive patient. However, the majority of patients will need pharmacologic intervention in conjunction with weight loss. Selection of antihypertensive agents in the overweight patient should take into account the mechanisms leading to hypertension and the metabolic abnormalities that characterize the obese patient.

ACE inhibitor effects on platelet function in stages I-II hypertension

Angiotensin II enhances platelet aggregation through activation of the G protein-linked pathway present in platelets. Studies of several angiotensin-converting enzyme (ACE) inhibitors have demonstrated marked differences on platelets. Therefore this prospective, randomized, double-blind, crossover study compared the ex vivo effects of equivalent antihypertensive doses of captopril, enalapril, and fosinopril on platelet aggregation and thromboxane B2 (TxB2) formation in subjects with stage I-II essential hypertension. Nineteen male subjects with a baseline mean seated blood pressure of 141 +/- 3/100 +/- 1 mm Hg were enrolled. The decline in mean arterial pressure after 4 weeks of stable dosing was 10 +/- 1, 12 +/- 1, and 11 +/- 1 mm Hg for captopril, enalapril, and fosinopril, respectively (p = NS). There was no significant change in adenosine diphosphate (ADP)-, epinephrine-, or thrombin-stimulated platelet aggregation from baseline or between ACE inhibitors. Compared with baseline, fosinopril decreased TxB2 concentrations 27.5-67.6% with all stimuli after 1 and 5 min. Captopril also decreased TxB2 formation, but this effect was stimulus and time dependent. Enalapril consistently increased TxB2 concentrations, independent of stimuli or time. We conclude that different ACE inhibitors have distinct effects on platelet TxB2 formation without significant effects on platelet aggregation. Fosinopril may be a direct antagonist ofTxA2 synthase, suggesting benefit in syndromes of platelet activation or vascular occlusion.

Aberrant adenylyl cyclase/cAMP signal transduction and G protein levels in platelets from hypertensive patients improve with antihypertensive drug therapy

We have previously demonstrated a decreased expression of Gi alpha 2 protein in platelets from spontaneously hypertensive rats that was associated with an altered responsiveness of adenylyl cyclase to hormone stimulation and inhibition. In the present studies, we have used platelets from hypertensive patients and examined the hormonal regulation of adenylyl cyclase as well as the levels of G proteins and their modulation by antihypertensive drug therapy. We performed these studies in platelets from four groups of subjects: normotensive subjects (group 1), untreated mildly essential hypertensive patients (group 2), and treated moderately to severely hypertensive patients whose blood pressure was uncontrolled (group 3) or controlled with drug treatment (group 4). GTP gamma S, 5'-(N-ethylcarboxamido)adenosine (NECA), and prostaglandin E1 stimulated adenylyl cyclase activity to a greater extent in hypertensive patients (group 2). This effect was partially corrected (by approximately 50% to 80%) in the patients under antihypertensive drug therapy (groups 3 and 4). In addition, inhibition of adenylyl cyclase mediated by a ring-deleted analogue of atrial natriuretic factor (C-ANF4.23) observed in control normotensive subjects was blunted in hypertensive patients (group 2) and was not corrected in treated patients. Gi alpha levels determined by immunoblotting were in the same range for the four groups, whereas Gi alpha 2 and Gi alpha 3 levels were decreased by 70% and 60%, respectively, in hypertensive patients (group 2) compared with normotensive subjects. Antihypertensive drug therapy (groups 3 and 4) partially restored Gi alpha 2 levels toward normal (group 1) by about 60% and 70%, respectively; however, the reduced Gi alpha 3 levels in group 2 hypertensive patients were not improved in group 3 but were raised toward normal levels in group 4 by about 55%. These results suggest that the altered responsiveness of platelet adenylyl cyclase to hormones in hypertension and the normalization of the response with antihypertensive drug therapy could partly be due to the ability of the latter to modulate Gi alpha protein expression. These effects on platelet function may underlie the beneficial effects of antihypertensive agents on some of the complications of hypertension.

Fosinopril reduces ADP-induced platelet aggregation in hypertensive patients

Platelets are intimately involved in atherosclerosis, and hypertension is a known risk factor for coronary artery disease. The angiotensin-converting enzyme (ACE) inhibitors were demonstrated to reduce hypertension and attenuate atherosclerosis. Because increased platelet aggregation was shown in hypertensive patients, the effect of a new ACE inhibitor, fosinopril, on platelet aggregation was studied. Fosinopril therapy (10 mg/day for 4 weeks) in 18 male hypertensive patients showed > or = 31% reduction in ADP-induced platelet aggregation. In vitro studies showed that fosinopril had similar inhibitory effect on ADP-induced platelet aggregation. No inhibitory effect could be detected with collagen as the aggregating agent. Finally, inhibition of platelet aggregation by fosinopril was less effective in platelets derived from hypertensive patients as compared with platelets derived from normal subjects. We conclude that fosinopril possesses a significant inhibitory activity on ADP-induced platelet aggregation both in vitro and in vivo.

The role of platelets in essential hypertension

Recent research is helping us understand the complex interactions that occur between platelets and their environment. The several intracellular events that occur during platelet activation are being identified as ar their effects on other platelets, the endothelium and coagulation factors. Heightened platelet activation is seen early in essential hypertension and probably plays an important role in the initiation and progression of atherosclerosis and the disorders associated with it. This review identifies some of the changes in platelet structure and function in essential hypertension and their role in the pathogenesis of hypertensive vascular disease.

Original Article: Intracellular Ca(2+) Mobilization and Aggregatory Response to ADP and Thrombin in Aged Rat Platelets

We previously reported that thrombin-induced Ca(2+) mobilization was enhanced in aged rat platelets. Since Ca(2+) mobilization in platelets is believed to be closely associated with platelet activation, we examined Ca(2+) mobilization and the aggregatory response to ADP and thrombin in young (3 months) and aged (24 months) rat platelets. Blood levels of fibrinogen and Ca(2+) in aged rats were higher than those in young rats. ADP-induced platelet aggregation in aged rats was significantly enhanced in platelet rich plasma and in washed platelet suspension, suggesting that age-associated hyperaggregability to ADP is attributable to changes in platelets themselves. On the other hand, thrombin (0.03-0.3 unit/ml)-induced aggregation in washed platelet suspension from aged rats was comparable to that from young rats. But, thrombin (0.3 unit/ml)-induced intracellular Ca(2+)mobilization was enhanced in aged rat platelets in the presence of extracellular Ca(2+). Likewise, ADP-induced Ca(2+) mobilization was enhanced in aged rat platelets. These results suggest that enhanced Ca(2+) mobilization in aged rat platelets is associated with hyperaggregability to ADP but not to thrombin.

Effects of acute beta-adrenergic receptor blockade on age-associated changes in cardiovascular performance during dynamic exercise

The cardiovascular response to beta-adrenergic stimulation is markedly blunted with advancing age, and this blunting may underlie some of the prominent age-associated changes in the hemodynamic profile during dynamic exercise. To examine this hypothesis, we administered the nonselective beta-adrenergic receptor blocker propranolol (0.15 mg/kg IV) to 25 healthy normotensive men ages 28 to 72 years from the Baltimore Longitudinal Study of Aging (BLSA) immediately before maximal upright cycle ergometry with 99mTc gated cardiac blood pool scintigraphy. Their hemodynamic responses to exercise were compared with those of 70 age-matched healthy unmedicated male BLSA control subjects. The maximal cycle work rate achieved was similar in propranolol-treated men (158 +/- 32 W) and control subjects (148 +/- 32 W) and declined similarly with age in both groups. Hemodynamics at seated rest were not age-related in either group; however, propranolol-treated men had lower heart rates (HR), systolic blood pressure (SBP), ejection fraction, and cardiac index than control subjects but higher end-diastolic volume index (EDVI) and end-systolic volume index (ESVI) by covariance analysis. At maximal effort, several striking age-drug interactions were evident: Propranolol caused a greater reduction in HR and greater increases in EDVI and stroke volume index (SVI) in younger than in older men. Hence, at maximal work rate, HR declined less with age in the propranolol group (0.46 versus 1.09 beats per minute per year, P < .05 by covariance analysis); EDVI and SVI decreased with age (0.27 and 0.48 mL/m2 per year, respectively) after propranolol compared with increases of 0.47 and 0.16 mL/m2 per year in control subjects, respectively, each P < or = .05 by covariance analysis. The left ventricular contractility index, SBP/ESVI, at exhaustion was reduced by propranolol to a greater extent in younger than older men. Thus, acute beta-adrenergic blockade reverses the age-associated ventricular dilation at end diastole and end systole observed during upright cycle exercise and blunts the decline in maximal HR and myocardial contractility. These data suggest that the age-associated declines in maximal HR and left ventricular contractility during vigorous exercise are manifestations of reduced beta-adrenergic responsivity with advancing age which is partially offset by exercise-induced ventricular dilation.

Effects of nadolol on hemodynamic and hemostatic responses to potential mental and physical triggers of myocardial infarction in subjects with mild systemic hypertension

Although beta-adrenergic blocking agents are known to reduce the risk of myocardial infarction, the mechanism of this protective effect is not well understood. The recent demonstration that beta blockers selectively blunt the increased morning risk of myocardial infarction suggests that these agents block the pathophysiologic consequences of stressors concentrated in the morning. We determined the effect of nadolol on the hemodynamic and hemostatic responses to mental stress and isometric exertion (handgrip), 2 potential triggers of infarction. The study was conducted in 15 subjects with mild systemic hypertension, using a placebo-controlled, double-blind, crossover design. Nadolol reduced systolic pressure and heart rate after mental stress. Poststress systolic pressure was 139 +/- 4 mm Hg during therapy with nadolol versus 161 +/- 4 mm Hg during placebo administration (p < 0.05). Heart rate increased to 61 +/- 2 during nadolol therapy versus 89 +/- 5 beats/min during placebo therapy (p < 0.05). The systolic pressure increase was similar during therapy with nadolol and placebo (29 +/- 2 vs 33 +/- 2 beats/min, p = NS); however, heart rate increase was less during nadolol therapy (4 +/- 1 vs 12 +/- 4 vs beats/min, p < 0.01). The responses to handgrip and their modification during nadolol therapy were similar to those observed after mental stress. Neither platelet aggregability nor fibrinolytic potential was altered by nadolol. Thus, nadolol modified hemodynamic indexes without altering the hemostatic indexes measured. This hemodynamic effect may contribute to the decrease in morning cardiovascular events by beta-adrenergic blockers and their well-documented cardioprotective effect.

Enhanced thromboxane formation by blood but not whole platelets from spontaneously hypertensive rats

Increased serum levels of immunoreactive thromboxane B2 (iTXB2) were observed in spontaneously hypertensive rats of the Okamoto-Aoki strain (SHR) compared with normotensive Wistar-Kyoto rats (WKY). Serum iTXB2 levels in whole blood allowed to clot at 37 degrees C for 1 hour were significantly greater in SHR than WKY at 8, 16-20, and 38 weeks of age, whereas formation of iTXB2 by thrombin-stimulated whole platelets from 6 16-week-old SHR and 6 age-matched WKY was 399 +/- 44 and 377 +/- 38 ng/10(9) platelets/30 min, respectively. No significant difference in radioconversion of exogenous arachidonic acid to TXB2 was observed in whole platelets from SHR (18.2 +/- 2.5%, n = 4) and WKY (20.1 +/- 3.0%, n = 4) at 16 weeks of age. These results support the proposal that enhanced ability of blood from SHR to generate iTXB2 is independent of the stage of hypertension development. This enhancement probably depended on factors or blood elements other than platelets since no difference in formation was observed on stimulation of whole platelets.

The effect on platelet behaviour of treatment with atenolol and the combination of atenolol and nifedipine in healthy volunteers

Two double blind crossover studies have been carried out in healthy volunteers to determine the effect on platelet behaviour and on blood coagulation of treatment with atenolol and with a fixed combination of atenolol and nifedipine. The first study compared atenolol with placebo, whilst the second compared atenolol alone with the combination of atenolol and nifedipine. Treatment with atenolol alone had no effect on platelet behaviour. In contrast, treatment with the combination of the beta blocker and the calcium antagonist gave rise to a small but significant increase in platelet dense granule release ex vivo in response to a wide range of agonists. This was not associated with any change in serum levels of thromboxane B2 nor with any alteration in plasma concentrations of platelet factor 4 and beta-thromboglobulin. Neither treatment had any effects on coagulation parameters. The mechanism and clinical significance of the observed increase in the extent of the platelet release reaction during combined atenolol/nifedipine treatment remain speculative.

Influence of beta-blockade on circulating plasma levels of 3-methoxy-4-hydroxy phenylethylene glycol (MHPG) during exercise in moderate hypertension

1. The effect of exercise testing and beta-blockade on plasma norepinephrine (PNE), and secretion of its metabolite 3-methoxy-4-hydroxyphenylethylene glycol (MHPG), was assessed in 28 mild-to-moderate hypertensives before and after the administration of dilevalol, a new beta-blocker with beta 2-agonism. 2. This double blind, placebo-controlled study consisted of two successive submaximal exercise tests before and after the administration of a single oral dose of dilevalol (200 mg, 400 mg or 600 mg). Plasma norepinephrine levels were determined at rest, at 100 watts step of exercise and at maximal effort (Emax). 3. During the control test, mean PNE levels increased from 1.73 +/- 0.52 nmol/L (resting value) to 8.01 +/- 4.01 nmol/L at Emax (P less than 0.01) as MHPG levels increased from 11.18 +/- 1.33 nmol/L (rest) to 17.50 +/- 1.15 nmol/L (Emax, P less than 0.01). After dilevalol, PNE increased significantly as compared to controls (P less than 0.05), from 2.32 +/- 0.99 to 12.42 +/- 5.97 nmol/L (P less than 0.01). PNE and MHPG levels were correlated, both at rest and during exercise. PNE levels after beta-blockade were linearly related to the dose of beta-blocker administered. MHPG levels were unaltered by the administration of dilevalol, both before and after exercise. 4. The increase in MHPG that occurs during bicycle exercise is largely generated from an increase in central nervous system noradrenergic activity. While dilevalol increases the peripheral sympathetic nervous system, both at rest and during exercise (which is reflected by increases in PNE levels) the drug does not alter resting central nervous system noradrenergic activity nor amplify the increase in central noradrenergic activity that occurs during exercise.

The effect of prazosin therapy on platelet activation in essential hypertension

1. Plasma levels of beta-thromboglobulin, initial and total platelet aggregation (induced by adrenaline or adenosine diphosphate [ADP]) were determined in 26 normotensive subjects and 26 patients with untreated essential hypertension. Groups of 18 essential hypertensive patients and 18 age- and sex-matched normotensives were compared. 2. After 7 days of treatment with prazosin in a dose of 2-8 mg daily the above measures were repeated in 18 essential hypertensive patients. A significant increase in plasma levels of beta-thromboglobulin, initial and total adrenaline-induced as well as ADP-induced platelet aggregation was found in hypertensives. Prazosin restored the mean arterial blood pressure in hypertensives to normal, but it had no significant influence either on increased beta-thromboglobulin levels or on initial and total aggregability. 3. The results confirm increased platelet aggregation and in vivo platelet activation in patients with essential hypertension; however there is a discrepancy with previous reports about those results obtained after prazosin therapy. The results suggest that increased platelet aggregation and in vivo activation need not be restored to normal after effective antihypertensive therapy alone. They give reason for the combination of antihypertensive together with anti-aggregatory therapy in essential hypertension.

Fish oil amplifies the effect of propranolol in mild essential hypertension

Forty-seven male patients with mild essential hypertension were randomly allocated to three subgroups. After a run-in period of 4 weeks, the first subgroup (n = 16) received propranolol (80 mg/day) for 36 weeks followed by a placebo period of 4 weeks. The second subgroup (n = 15), after a run-in period of 4 weeks, was given a supplement of encapsulated fish oil (9 g/day) for 36 weeks with a subsequent period of 4 weeks in which fish oil placebo was given. The third subgroup (n = 16), after a run-in period of 4 weeks, was given propranolol (80 mg/day) for 12 weeks, propranolol (80 mg/day) plus fish oil capsules (9 g/day equivalent to 1.8 g/day of eicosapentaenoic acid and 1.1 g/day of docosahexaenoic acid) for 12 weeks, propranolol plus fish oil placebo (same doses for 12 weeks) with a subsequent period of 4 weeks when propranolol placebo was administered. The results indicate a blood pressure-lowering effect of fish oil, which was comparable with that of propranolol. The simultaneous intake of fish oil plus propranolol was more effective than propranolol or fish oil alone. Propranolol treatment resulted in a decrease of plasma norepinephrine, plasma renin activity, and thromboxane B2 formation. After fish oil supplementation, plasma norepinephrine and thromboxane B2 formation were likewise reduced, whereas plasma renin activity appeared increased. The decrease of serum triglycerides, total and low density lipoprotein cholesterol as well as the rise of high density lipoprotein cholesterol are concomitant beneficial effects, which justify the consideration of fish oil alone or in combination with antihypertensive drugs for the treatment of mild hypertension.

Platelet calcium and quenched-flow aggregation kinetics in essential hypertension

Abnormal platelet function may contribute to the complications of essential hypertension. We have studied the kinetics of platelet aggregation induced by adenosine diphosphate (ADP) or epinephrine, plasma beta-thromboglobulin, and basal, cytosolic, and free calcium, as correlates of platelet function. Fifteen untreated patients with essential hypertension and without detectable atherosclerosis, 18-40 years old, were compared with 30 matched normotensive control subjects. Maximal rates of platelet aggregation (Vmax) with ADP and epinephrine were significantly higher in patients than in control subjects (p less than 0.03), as assessed by quenched-flow aggregometry. However, significance was lost when Vmax was corrected for the platelet count. Paradoxically, the activation constants (Ka) for ADP were higher in patients than in control subjects (p less than 0.03). With ADP as the inducing agent, onset time (t) or lag period before aggregation begins was longer in patients than in control subjects (p less than 0.02). beta-thromboglobulin levels, an index of in vivo platelet activation, were not significantly different between the two groups (p = 0.13). The mean platelet cytosolic free calcium concentration was higher in patients (213 +/- 19 nM) than in control subjects (172 +/- 14 nM), but this difference was not statistically significant (p = 0.07). However, there was a close correlation between the free calcium level and systolic, diastolic, and mean blood pressure (p less than 0.003, p less than 0.04, p less than 0.004, respectively). No difference in platelet volume between the two groups was found. Our data suggest that platelets in the early stages of essential hypertension display an overall increased aggregation potential but a diminished sensitivity to ADP.(ABSTRACT TRUNCATED AT 250 WORDS)

Epinephrine potentiation of in vivo stimuli reverses aspirin inhibition of platelet thrombus formation in stenosed canine coronary arteries

In 18 anesthetized dogs with a 70% mechanically produced coronary artery stenosis, blood flow measured with an electromagnetic flowmeter showed cyclical reductions in flow due to periodic acute platelet thrombus formation. These were abolished in eight of nine dogs with 2.5 mg/kg of aspirin given intravenously and in nine of nine dogs with 5 mg/kg of aspirin. However in 14 of 18 dogs the cyclical flow reductions were temporarily renewed with the infusion of epinephrine 0.4 microgram/kg/min. Human platelets inhibited with aspirin can be reactivated with physiologic amounts of epinephrine. We postulate that in patients with atherosclerotic stenotic lesions the use of aspirin to inhibit arterial thrombus formation may be less effective when they have elevated catecholamines.

Antiplatelet effects of oral diltiazem, propranolol, and their combination

1. The antiplatelet effects of a single oral dose of the calcium entry blocker diltiazem (60 mg), the beta-adrenoceptor blocker propranolol (40 mg), and their combination were studied in five healthy subjects. 2. Platelet aggregation and ATP release induced by adrenaline and ADP and ADP induced platelet thromboxane A2 generation were significantly inhibited (P less than 0.05) by either diltiazem or propranolol, although propranolol tended to have greater inhibitory effects on platelet function than diltiazem that did not reach statistical significance. 3. Combination therapy resulted in additive antiplatelet effects that were significantly (P less than 0.05) greater than either drug alone. 4. These data indicate that combined administration of a calcium entry blocker and a beta-adrenoceptor blocker results in additive inhibitory effects on platelet function. These effects may mediate part of the therapeutic efficacy of combination therapy in patients with coronary artery disease.

Study of in vivo platelet activation in uncomplicated essential hypertension

Beta-thromboglobulin (BTG) and platelet factor 4 (PF4), platelet alpha-granule specific proteins, and serotonin (5-HT) which is stored in dense granules are released when platelets are activated. To investigate in vivo platelet activation in uncomplicated essential hypertension, platelet 5-HT and PF4 contents, plasma BTG and PF4 concentrations, as well as urinary BTG levels were assessed in normotensive and hypertensive subjects. Plasma BTG and PF4 concentrations and urinary BTG levels were comparable in both groups. Mean platelet 5-HT content was significantly decreased in hypertensive subjects without modification of the intraplatelet PF4 content. These data suggest first of all that the decrease in platelet 5-HT content is due mainly to the inhibition of platelet 5-HT uptake previously described, and second of all that no significant in vivo platelet activation occurs in essential hypertensive subjects devoid of cardiovascular complications.

Reduced serotonin content and uptake in platelets from patients with essential hypertension: is a ouabain-like factor involved?

Platelet serotonin (5-HT) content was investigated in 35 essential hypertensive patients and in 58 normotensive subjects. A significant decrease of platelet 5-HT content was observed in both hypertensive men and women in respect to normotensive controls. This decreased platelet 5-HT content appears to be linked to a reduced capacity of platelets to take up 5-HT. Maximal velocity of 5-HT uptake was shown to be reduced in platelets from hypertensive patients and significantly correlated to platelet 5-HT content. No concomitant change of uptake Michaelis constant (KM) was observed. The great sensitivity of human platelets to very low concentrations of ouabain was demonstrated when incubation times were prolonged. The decreased Vmax observed in platelets from hypertensive patients and reproduced by ouabain inhibition could conceivably be linked to the presence of a circulating ouabain-like factor in hypertension.

Increased platelet release reaction in 50-year-old men with essential hypertension: correlation with atherogenic cholesterol fractions

Beta-thromboglobulin (BTG) is a platelet-specific release product. Plasma BTG was significantly increased (p less than 0.01) in 50-year-old, untreated essential hypertensive men (1.22 +/- 0.13 nmol/L, n = 39, mean +/- SE) compared to 50-year-old, healthy normotensive control men (0.82 +/- 0.07 nmol/L, n = 31). Plasma BTG in the hypertensive group correlated significantly with the total serum cholesterol concentration (r = 0.47, p less than 0.01) and with the atherogenic cholesterol fractions low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL) cholesterol (r = 0.50, p less than 0.01). In the normotensive group, no significant correlation was observed between plasma BTG and total serum cholesterol (r = 0.14) or between plasma BTG and LDL + VLDL cholesterol (r = 0.08). Neither was any significant correlation found between plasma BTG and serum high-density lipoprotein (HDL) cholesterol or total triglycerides in either group. Thus, middle-aged men with untreated essential hypertension have an increased blood platelet release reaction related to their concentrations of atherogenic blood lipids. This relationship may be of pathogenetic importance for atherogenesis in hypertension.

Platelet function in patients admitted with a diagnosis of myocardial infarction

Platelet function and thromboxane A2 release were measured in 71 patients admitted to a coronary care unit with a provisional diagnosis of acute myocardial infarction (AMI). All measurements were carried out within twenty-four hours of admission. Of these, 35 patients had the diagnosis of AMI confirmed. The remainder (n = 36), who did not have AMI (NMI), were divided into two groups: those (n = 18) with an unequivocal history of previous vascular disease and those without vascular disease (n = 18). Platelet aggregation and thromboxane A2 (TXA2) release were significantly increased in the AMI group when compared with those in the NMI without vascular disease group or a healthy control group with similar age and sex distribution. Aggregation and TXA2 release in the NMI patients with vascular disease were greater than those in controls and did not differ significantly from those in the AMI group. Patients in the AMI or NMI with vascular disease groups who were taking beta-blockers or calcium channel antagonists at the time of admission showed significantly less platelet aggregation than those who were not taking these drugs. Heparin, added in vitro at therapeutic concentrations, induced significantly more aggregation in patients in the AMI and NMI with vascular disease groups than in the NMI without vascular disease group. We conclude that: platelets obtained from patients with AMI are hyperaggregable and release more TXA2; platelets from patients with significant vascular disease are hyperaggregable, even in the absence of AMI, although they are not as hyperaggregable as those from AMI; treatment with nifedipine and beta-blockers protects these patients from platelet hyperaggregability; heparin induces significant aggregation of platelets from patients with AMI and NMI with vascular disease. These observations are of importance in considering the pathogenesis and treatment of AMI and ischemic heart disease.

Blood platelets in human essential hypertension

Blood platelets of patients with essential hypertension display signs of both increased sensitivity in vitro to aggregating stimuli believed to contribute to thrombosis and of activation in vivo possibly expressing the release of vasoactive products. The mean features of the modified platelet profile in hypertension include an increased alpha 2-adrenergic receptor density, an enhanced rate of adhesion/aggregation in particular in response to ADP and arachidonic acid, a greater sensitivity for thrombin and adrenaline to stimulate increases in cytoplasmic-free Ca2+, increased resting levels of cytoplasmatic-free Ca2+, a reduced content of serotonin often combined with a defective uptake mechanism, a facilitated efflux rate of noradrenaline, an exaggerated release reaction in vivo as indicated by the increased plasma levels of Beta-thromboglobulin and a shortened platelet life span. These changes occur to various extents in some, but not all, hypertensive patients and are not always strictly related to the degree of blood pressure increase. On the contrary, platelet cyclooxygenase and thromboxane synthetase activity are in the normal range.

[Predictor function of hemorheologic parameters with reference to the incidence of manifest circulatory disorders: Concept of the Aachen study]

The prevention of cardiovascular disease has up till now generally been limited to control of the classical risk factors. The primary problem of the risk factor model is, that although a statistically verified relationship exists between risk factors and vascular disease, an individual prognosis is presently impossible. Surveys that show a relation between risk factors and impaired blood fluidity support the conception that a change in blood fluidity could be considered an early detection screening of vascular diseases. Prospective studies have shown that the hematocrit is related to circulatory disturbances. The main aim of the present study was to determine the clinical relevance of rheological parameters (hematocrit, plasma viscosity, erythrocyte rigidity, thrombocyte aggregation, erythrocyte aggregation), and the importance of altered blood fluidity as a predictor of manifest cerebral, cardiac or peripheral vascular disturbance.

Leukocyte ionized calcium and sodium content and blood pressure in humans

The relationship between leukocyte ionized calcium concentration, sodium content, and blood pressure was studied in normotensive subjects with (n = 17) and without (n = 21) a family history of hypertension and in untreated patients with essential hypertension (n = 22). There was a highly significant correlation between intracellular ionized calcium and mean supine blood pressure (measured on the same occasion) in normal subjects with no family history of hypertension (r = +0.73, p less than 0.01). This relationship was lost in normal subjects with a family history of hypertension, and in hypertensive patients there was a nonsignificant negative correlation between intracellular ionized calcium and blood pressure (r = +0.08 and -0.31, respectively). Intracellular ionized calcium was similar in the normotensive groups (both, 126 +/- 7 nmol/L) and slightly but nonsignificantly elevated in hypertensive patients (143 +/- 10 nmol/L; p = 0.09). There was no correlation between intracellular ionized calcium and sodium content in any group (r less than 0.1). These results indicate that while leukocyte ionized calcium in normotensive subjects with no family history of hypertension may reflect smooth muscle contractility resulting in the positive correlation between leukocyte ionized calcium and blood pressure, this relationship is lost in hypertensive patients and subjects predisposed to hypertension. This may be due to an altered relationship between leukocyte and smooth muscle calcium handling in these subjects or to non-calcium-mediated influences on blood pressure.

Evidence that the rat is not an appropriate model to study the role of prostaglandins in normal or abnormal platelet aggregation

Abnormal platelet aggregation seen in experimentally induced diabetic, hypercholesterolemic and spontaneously hypertensive rats (SHR) has been linked with increased prostaglandin synthesis. The present study was conducted to examine the role of prostaglandins in rat platelet activation using normal Wistar Kyoto (WKY) and SHR rats. Up to 30 microM ADP did not induce secondary phase of platelet aggregation in rat PRP and up to 30 microM epinephrine did not produce any response in rat PRP. In other experiments ADP (1.0 microM) and epinephrine (2.0 microM) induced typical biphasic aggregation responses in human PRP. Up to 20 microM U46619, a stable analog of prostaglandin H2, did not induce platelet aggregation in rat PRP or washed rat platelets. In contrast 2.0 microM U46619 caused maximal aggregation in human PRP and washed human platelets. Arachidonic acid (1.5-2.0 mM) induced aggregation in washed rat platelets. However, this was associated with excessive (67% and 94%) loss of cytoplasmic LDH. The low concentrations of thrombin (0.04 and 0.05 U/ml), induced two to three-fold increase in aggregation response in SHR platelets as compared to WKY platelets. Higher concentrations of thrombin (0.1 and 0.3 U/ml) induced similar aggregation responses in SHR and WKY platelets. Thrombin (0.04-0.3 U/ml) induced serotonin secretion in a concentration dependent manner. The extent of secretion was the same in SHR and WKY platelets at all concentrations. Thrombin-induced synthesis of thromboxane A2 (TXA2) in WKY and SHR platelets was quantified using a radioimmunoassay for TXB2. Thrombin (0.04-0.3 U/ml) produced TXB2 in WKY and SHR platelets in a concentration dependent manner. The SHR platelets produced significantly larger amounts of TXB2 as compared to WKY platelets. In other experiments aspirin (500 microM) inhibited thrombin (0.05 U/ml) induced TXB2 synthesis by 75% in both WKY and SHR platelets but failed to inhibit aggregation or secretion in either WKY or SHR platelets. Based on these data it is suggested that: (a) rat platelets inspite of their ability to synthesize TXA2 do not require TXA2 for aggregation; and (b) the rat may not be an appropriate model to study the role of prostaglandins in normal or abnormal platelet aggregation.

Physiological concentrations of epinephrine potentiate thromboxane A2 release from platelets in the isolated rat heart

The isolated rat heart perfused with washed platelets was used as a model to examine platelet-vessel wall interactions. Release of prostacyclin and thromboxane A2 was measured, using a cascade of smooth muscle bioassay tissues or radioimmunoassays of the stable hydration products. In hearts perfused with rabbit or human platelets, injection of sodium arachidonate caused release of both prostacyclin and thromboxane A2. In hearts perfused with aspirin-pretreated platelets, arachidonate released only prostacyclin indicating that thromboxane A2 originates largely in the platelets. Infusion of epinephrine (0.6-6 nmol/liter) through the heart potentiated arachidonate-induced release of thromboxane A2. Similar potentiation of thromboxane A2 release was observed in rat hearts perfused with either rabbit or human platelets, and in rabbit hearts perfused with rabbit platelets. In contrast, when rabbit platelets were infused through an incubation coil of tubing in place of the heart, epinephrine did not alter thromboxane A2 release. There was no significant loss of rabbit platelets on perfusion through rat hearts, and no aggregates were observed in the effluent either before or immediately after arachidonate injections, even in the presence of epinephrine. Thus, potentiation of thromboxane A2 production could not be explained by aggregation. However, it is clear from these studies that physiological concentrations of epinephrine can potentiate thromboxane A2 release from platelets when they are stimulated by arachidonic acid within the heart. This could result from a redirection of arachidonate metabolism to a local potentiating factor in the vessel wall. Potentiation of thromboxane A2 release might contribute to myocardial ischemia associated with platelet activation.

Platelet-vessel wall interactions: implication of 5-hydroxytryptamine. A review

The evidence for an impact of platelet-derived 5-hydroxytryptamine (5-HT) on local tissue perfusion is reviewed. By interacting with 5-HT2 serotonergic receptors, 5-HT, directly or through amplification, activates platelets, endothelial and vascular smooth muscle cells producing platelet aggregation, vascular permeability increase and large vessel constriction. Pharmacodissection in experimental animals with selective serotonergic 5-HT2 receptor antagonists, e.g. ketanserin, shows that 5-HT largely contributes to the platelet-mediated increase in vascular permeability, to platelet-vessel wall interaction during hemostasis, to cardiopulmonary dysfunction provoked by thromboembolism and to the platelet-mediated inhibition of peripheral collateral circulation. Clinical results obtained with ketanserin further substantiate an involvement of platelet-derived 5-HT in the pathogenesis of impaired tissue perfusion in some cardiovascular conditions.

Aggregation, membrane potential, and transport in platelets of spontaneously hypertensive rats

Aggregation, plasma membrane potential, and calcium uptake by platelets of spontaneously hypertensive rats (SHR) were studied. The sensitivity of SHR platelets to the action of ADP and collagen was increased. The addition of Ca-ionophore (A-23187) resulted in aggregation of SHR platelets at a Ca2+ concentration in the incubation medium 20%-30% lower than that required for aggregation of platelets from normotensive rats. The plasma membrane of SHR platelets was found to be partially depolarized (by 8-10 mV) as compared to that of normotensive controls. This difference was apparently due to a higher membrane permeability for Na+. It is suggested that the increase in 45Ca uptake by SHR platelets is related to an increased rate of Ca2+ diffusion along a potential-dependent channel, due to partial depolarization of plasma membrane.

Role of alpha adrenoceptors in hypertension and in antihypertensive drug treatment

Recent plethysmographic experiments suggest that both postsynaptic alpha 1 and alpha 2 adrenoceptors in human resistance vessels play an important role in the maintenance and regulation of vascular tone. Central alpha 2 adrenoceptors are assumed to be involved in the central regulation of blood pressure. Radioligand binding studies on the density and characteristics of alpha adrenoceptors have not revealed consistent differences between normotensive and hypertensive subjects, with the exception of pheochromocytoma, in which a consistent down regulation of alpha 2 adrenoceptors in thrombocytes has been demonstrated. The radioligand binding studies are limited, since they cannot be performed on vascular tissues. Alpha adrenoceptors are vitally important as targets of several antihypertensive drugs; the activities of these agents and the principles and clinical relevance of mechanisms involving alpha adrenoceptors are reviewed.

Calcium-dependent proteolytic stimulation of adenylate cyclase in platelets from spontaneously hypertensive rats

Abnormalities of platelet aggregation and cyclic nucleotide metabolism are present in hypertension. We observed a greater increase in the level of cyclic adenosine monophosphate (AMP) after prostaglandin E1 (PGE1) stimulation and a lack of decrease of this cyclic nucleotide by epinephrine in platelets from spontaneously hypertensive rats (SHR) as compared to normotensive rats. The difference in cyclic AMP production between SHR and control rats in response to PGE1 is dependent upon platelet exposure to calcium. Since calcium and cyclic AMP are closely related and are both abnormally regulated in hypertension, we have studied the effect of calcium on adenylate cyclase activity. We show here that two forms of endogenous calcium-dependent proteases (membrane-bound and soluble) stimulate the basal activity and the hormonal responsiveness of adenylate cyclase. The sensitivity of calcium-dependent proteolytic control of adenylate cyclase to very-low concentrations of calcium indicates that the regulation may be physiologically important. Furthermore, calcium exerts a greater influence on platelet adenylate cyclase from SHR than on that from normotensive rats. The adenylate cyclase defect seems to be located in the membrane fraction and may, therefore, result from an increase in the activity of the membrane-bound calcium-protease or may be intrinsic to adenylate cyclase itself. The exact site that is sensitive to proteolysis remains to be established.

Effect of beta blockade on plasma catecholamine levels during psychological and exercise stress

The effect of a single oral dose of 50 mg of metoprolol on plasma catecholamine levels was examined in 11 healthy young men. Subjects were studied during baseline at rest, postural challenge, psychological stressors and graded maximal exercise testing. Metoprolol induced significant increases in plasma norepinephrine (NE) levels across most experimental conditions. Metoprolol did not have a consistent effect on plasma epinephrine levels. Because of wide interindividual variation in drug levels, the NE levels in subjects with high drug levels were compared with the NE levels in subjects who had negligible drug levels. NE levels were higher in subjects with higher drug levels.

Correlation of platelet calcium with blood pressure. Effect of antihypertensive therapy

Intracellular free calcium has been implicated in vascular smooth-muscle contraction and in the pathophysiology of essential hypertension. We studied free-calcium levels in blood platelets, which have many features in common with vascular smooth-muscle cells. With use of an intracellularly trapped fluorescent dye, the free-calcium concentration in platelets was found to be elevated in 9 patients with borderline hypertension and 45 patients with established essential hypertension, who were compared with 38 normotensive subjects. There was a close correlation between the free-calcium level and both systolic and diastolic blood pressure (n = 92; r = 0.883 for systolic pressure and 0.931 for diastolic pressure; P less than 0.001 for both). Antihypertensive treatment with calcium-entry blockers (n = 15), beta-adrenoceptor blockers (n = 12), or a diuretic (n = 6) resulted in a reduction in free calcium, and this correlated with the fall in blood pressure (P less than 0.001). The intracellular free-calcium concentration in platelets may be determined by the same humoral or pharmacologic factors that determine the height of blood pressure.

Hypoaggregability of washed platelets from stroke-prone spontaneously hypertensive rats (SHRSP)

The aggregation properties of washed SHRSP platelets were investigated in comparison with normotensive WKY platelets at prehypertensive (4 weeks), early hypertensive (11 weeks) and late hypertensive (17 weeks) ages in the absence of plasma factors. The number of platelets in SHRSP was markedly lower with the development of hypertension than that in WKY. The thrombin- and collagen-induced aggregation was markedly reduced in the platelets from 11 and 17 week old SHRSP compared with that of age-matched WKY, whereas the degree of platelet aggregation in 4 week old SHRSP showed a tendency to be even greater than that in WKY. The changes in blood pressure and platelet aggregability were correlated inversely. ADP did not induce aggregation in the same system used for thrombin and collagen stimulation but in another system it aggregated washed rat platelets. Aggregation responses to ADP and ionophore A23187 were also significantly lower in 14 week old SHRSP platelets than age-matched WKY platelets. Together with other evidence, these results suggest that defective Ca2+ function, rather than the presence of exhausted platelets, is responsible for hypoaggregability in SHRSP platelets.

Alpha- and beta-blockade in angina pectoris

Angina pectoris encompasses a clinically diverse group of syndromes in which the common factor is myocardial ischaemia resulting from an imbalance between oxygen requirement and delivery. Anginal pain is most frequently precipitated by exercise, but may occur without any apparent cause at rest. Fixed obstructions in the coronary vessels, often attended by thickening of the overlying coronary artery media, are the most frequent cause of ischaemic cardiac pain. The resulting myocardial fibrosis impairs efficient filling and emptying of the ventricles, further aggravating the functional embarrassment resulting from the reduced coronary blood flow. In stable coronary heart disease the increased energy demands during exercise are associated with the rapid development of a haemodynamic profile characteristic of acute left ventricular failure. This results in further substantial increases in pressure work, wall stress and oxygen consumption of the left ventricle. The reflex sympathoadrenal consequences of these primary haemodynamic changes lead to further mechanical and electrical embarrassment of the ischaemic heart. Increased stimulation of beta 1- and beta 2-receptors in the heart increases heart rate and contractility and thereby myocardial oxygen demand. Increased stimulation of alpha-receptors in the peripheral veins and arteries indirectly increases left ventricular oxygen demand still further by increasing preload and afterload, respectively. The reduced blood flow to the endocardium enhances its sensitivity to increased sympathoadrenal stimulation and facilitates initiation of arrhythmias. Blockade of all adrenergic activity, particularly in the myocardium, coronary arteries and peripheral blood vessels should, therefore, help alleviate the myocardial ischaemia. There is a rational argument for the use of alpha-blockade in coronary heart disease, particularly in conjunction with beta-blockade. Attenuation of the risk of coronary spasm and ventricular arrhythmias and reduction of pressure work and left ventricular afterload are amongst the potential attributes of alpha-blockade. Alone, however, their utility is severely limited by the risks of hypotension and reduction in coronary perfusion pressure and reflex oxygen-wasting tachycardia. Alone, alpha-adrenoceptor antagonists have no place in the treatment of angina pectoris. beta-Adrenoceptor blocking drugs competitively inhibit catecholamines at both cardiac and peripheral vascular beta-adrenergic receptors. Their main advantage is that they reduce many of the important determinants of myocardial oxygen consumption, particularly by reducing the heart rate during exercise.(ABSTRACT TRUNCATED AT 400 WORDS)

Increased platelet adhesion and aggregation in hypertensive patients: effect of atenolol

Fourteen patients with established hypertension followed a double-blind crossover-styled trial to study the effects of 100 mg/day atenolol compared to placebo. Atenolol was found to be an effective antihypertensive agent, reducing both systolic and diastolic blood pressure. Hypertensive patients appear to have increased in vitro platelet adhesion and aggregation. Atenolol significantly reduced platelet adhesion, but had little effect on aggregation. This may be important in contributing towards the now-recognised cardio-protective effect of the beta-adrenoceptor blocking agents. Blood chemistry and haematological parameters were unchanged; but whereas plasma cholesterol and plasma triglyceride levels remained normal, there was a significant fall in plasma high-density lipoprotein cholesterol levels. Side effects were very few.

Intrinsic sympathomimetic activity: clinical fact or fiction?

The therapeutic importance of the ancillary pharmacologic property of partial agonist activity, or intrinsic sympathomimetic activity (ISA), of a beta-adrenoceptor antagonist is controversial. Its pharmacologic definition and accepted physiologic potential are now joined by convincing evidence that ISA may have important therapeutic implications. The ability to support basal cardiac functions while preventing the potential hazards of random sympathetic stimulation is an important attribute of this property, particularly in the damaged heart. The beneficial effects of ISA on peripheral blood flow, systemic vascular resistance and left ventricular afterload are established. Although all beta-blocking drugs are contraindicated in patients with asthma, ISA appears to be at least as important as cardioselectivity in offsetting some of the increase in airway resistance that results from beta blockade alone both at rest and during exertion. These pharmacodynamic consequences of ISA may explain the lesser reduction in exercise tolerance afforded by beta-blocking drugs with ISA than by those without. ISA may also enhance the primary oxygen-sparing effects of beta blockade in the ischemic myocardium by reducing coronary resistance, enhancing coronary blood flow, and reducing anaerobic metabolism. The adverse effects of beta-blocking drugs on blood lipids and carbohydrate metabolism also appear to be largely negated in drugs with ISA. The risks of rebound effects from abrupt withdrawal are significantly less in drugs with ISA than in those without.

Medroxalol combined with hydrochlorothiazide in the treatment of hypertension

The antihypertensive effect and safety of hydrochlorothiazide administration as a single drug and together with medroxalol were determined in 20 patients with primary hypertension. Following two biweekly intervals on placebo and hydrochlorothiazide, medroxalol was started at 100 mg three times a day and titrated against blood pressure response up to a maximum of 300 mg three times a day. In nine patients the effect of the single and the combined drug therapy on blood pressure during isometric handgrip exercise, on plasma renin activity, and on plasma catecholamines and their deaminated metabolites was investigated. The administration of hydrochlorothiazide was associated with a significant decrease in blood pressure, but heart rate did not change. The addition of medroxalol produced a substantial decrease in blood pressure and heart rate in both the recumbent and upright positions (P less than 0.001). Due to careful titration of medroxalol, orthostatic hypotension was observed only in one patient. Neither hydrochlorothiazide alone nor the combined drug regimen prevented or diminished the rise in blood pressure with exercise. Although plasma renin activity decreased during the combined drug therapy, there was no correlation between the initial levels or the change in plasma renin activity and the extent of decrease in blood pressure. The concentration of plasma epinephrine increased during the combined drug period, whereas catecholamine metabolites increased significantly during both periods of the study. It is concluded that medroxalol combined with hydrochlorothiazide constituted a potent and safe antihypertensive therapy for the duration of the present study.