Interaction between two calcium antagonists and two beta blockers in conscious rabbits: hemodynamic consequences of differing cardiodepressant properties

Cardiogenic shock triggered by verapamil and atenolol: a case report of therapeutic experience with intravenous calcium

Cardiogenic shock developed in a 72-year-old Japanese woman during combination therapy with verapamil and atenolol for recurrent supraventricular arrhythmia. She had coronary atherosclerosis, liver cirrhosis and bradycardia-tachycardia syndrome. Despite of the high-dose catecholamines and counterpulsation, she progressively deteriorated. Bolus administration of intravenous calcium chloride (CaCl2) immediately resolved her hemodynamic collapse.

Haemodynamics and tissue specificity with isradipine

The significant effects of isradipine in producing arterial vasodilation and mild negative chronotropic effects without significant negative inotropic effects suggests that this agent should provide excellent antihypertensive efficacy in the treatment of perioperative hypertension. Isradipine may prove to be a safe antihypertensive treatment in patients with impaired ventricular function (cardiac failure), impaired myocardial perfusion (ischaemia), and in cases of selected conduction abnormalities or arrhythmias. The demonstration that its effects are limited to vascular resistance rather than vascular capacitance is an important distinguishing feature of isradipine compared with other antihypertensive agents. Finally, the potential application of this dihydropyridine calcium antagonist for cytoprotection and its effects on atherosclerosis remain exciting therapeutic prospects.

Acute hemodynamic effects of intravenous diperdipine, a new dihydropyridine derivative, in coronary heart disease

The acute hemodynamic effects of a new dihydropyridine calcium channel blocker, diperdipine, which is suitable for intravenous administration, were studied by right and left cardiac catheterization in 16 patients with coronary heart disease. Diperdipine markedly reduced systemic vascular resistance and improved stroke index and left ventricular ejection fraction. Mean pulmonary artery and wedge pressures were slightly increased as a possible consequence of enhanced venous return, whereas right atrial and left ventricular end-diastolic pressures were not significantly changed. Nevertheless, an increase in preload was clearly indicated by an augmented left ventricular end-diastolic volume index after administration of diperdipine. Left ventricular contractility, which was estimated by the end-systolic pressure-volume ratio and by dP/dt max was not significantly changed, though analysis of individual data suggests a minimally negative inotropic effect. However, such a minor effect on left ventricular contractility was largely counterbalanced by the marked reduction of afterload, which produced a sharp improvement of stroke index. Enhancement of left ventricular ejection fraction and reduction in systemic vascular resistance were inversely and directly correlated to control values. Overall, diperdipine was well tolerated, but one patient had a major untoward reaction that consisted of an ischemic episode that was possibly related to drug administration. In conclusion, intravenous diperdipine appears to be a potent arteriolar dilating agent that does not affect left ventricular contractility.

The Doppler method for measuring cardiac output in conscious rabbits: validation studies, uses, and limitations

The velocity of blood in the rabbit aorta is very fast, approaching the limits of some pulsed directional Doppler flow meters. Therefore, we thoroughly evaluated a 20- and a 10-MHz device for measuring cardiac output in rabbits. Flow probes were implanted around the ascending aorta and catheters were implanted into the left atrium (for microsphere injection), femoral artery, and vein. About 2 weeks later, cardiac output was determined with the Doppler method and simultaneously with tracer microspheres. Cardiac output was manipulated with isoproterenol, dihydralazine, guanfacine, or alinidine, intravenously. With the 20-MHz device, only normal and decreased cardiac output could be measured accurately, even with a 60 degrees implantation angle of the crystals. The 10-MHz device yielded accurate measurements also at very high flow. Surprisingly, at high aortic flow rates, both the 10- and the 20-MHz devices were unable to measure correctly diastolic flow, which is close to zero. It was necessary to adjust the position of the late diastolic Doppler signal manually to the electrical zero line. With this precaution, the 10-MHz device yielded an excellent correlation between mean Doppler signal and cardiac output. Cardiac output can be measured in absolute flow units if the flow-probe can be calibrated in vivo with an independent, accurate method about 2 wk after implantation. The baroreflex was not affected by the implanted flow probes. Within these limits, Doppler flow meters are good tools to assess drug effects on cardiac output in conscious rabbits.

Antivasoconstrictor effects of isradipine. A quantitative approach in anesthetized rats and conscious rabbits

Calcium antagonists blunt the constrictor effects of vasoconstrictor agents. Differences in the sensitivity of several vasoconstrictors to the constrictor effect of calcium antagonists were quantified in experiments on rats and rabbits. In rats, the dose-response curves for pressor effects to angiotensin II were shifted in parallel to the right after treatment with isradipine, but not with prazosin and dihydralazine, suggesting that the antivasoconstrictor effect of isradipine was of a specific type. Blood pressure increases elicited by angiotension II or norepinephrine (alone, or with propranolol or propranolol plus prazosin) were also measured in rabbits and, again, isradipine caused parallel shifts of the dose-response curves. Both agonists thus appear to stimulate calcium entry, at least in resistance vessels, and via the same pathway, the L-type calcium channel. However, the angiotension II pressor effects were more sensitive to isradipine than those of norepinephrine in the presence of propranolol, and even more so in the presence of propranolol plus prazosin. These results suggest subtle and as yet unexplained differences, possible related to the activity of the adenylate cyclase system, in the chain of events leading to activation of the L-channels in vivo.

Improved blood pressure control with isradipine in hypertensive patients treated with pindolol

Isradipine is a new calcium antagonist of the dihydropyridine type with marked vasodilator activity and minimal negative inotropic effects. It is a potent antihypertensive drug when given as monotherapy. This was a randomized double-blind crossover study of 16 weeks' duration, including 80 hypertensive patients with diastolic blood pressures of at least 95 mm Hg who had shown clinically relevant antihypertensive responses, but no normalization of blood pressure during pindolol 10 to 15 mg once daily as monotherapy. Either isradipine or placebo was added to the beta-blocker at doses of either 2.5 mg or 5 mg twice daily, which was doubled after four weeks if the diastolic blood pressure remained more than 90 mm Hg. The addition of isradipine (in either dose regimen) caused a pronounced reduction of blood pressure with no changes in heart rate. Five patients were withdrawn from the study because of adverse events while receiving isradipine compared with three taking placebo. A further three patients withdrew from the study because of adverse events (one patient) or lack of efficacy (two patients) during placebo treatment. These results indicate that isradipine is an effective and well-tolerated adjunct to beta-blockers in hypertensive patients.

Cerebrovascular, biochemical, and cytoprotective effects of isradipine in laboratory animals

Dose-response curves of isradipine for blood pressure, total peripheral conductance, and regional cerebral conductances and blood flows were obtained in anesthetized cats and rabbits using the microsphere method. Cerebrovascular effects occurred at lower doses than systemic effects, and the effective duration was longer in the brain than in the periphery. In a rat model of embolic stroke (unilateral occlusion of the middle cerebral artery), isradipine has been shown to have cytoprotective efficacy (Sauter A, Rudin M: Stroke 1986; 17: 1228-1234; Rudin M, Sauter A, Wiederhold K-H: Therapie 1987; 42: 477-481; Sauter A, Rudin M, Wiederhold K-H: Neurochem Pathol 1989 [in press]). Using this model, dose-response curves for infarct size, measured by magnetic resonance imaging, and biochemical markers of infarction were obtained for various calcium antagonists. Isradipine showed the biggest improvements (50 to 60 percent at 2.5 mg/kg subcutaneously), followed by nimodipine (30 to 40 percent at 5 mg/kg subcutaneously), nitrendipine (30 to 40 percent at 10 mg/kg subcutaneously), darodipine (20 to 30 percent at 10 mg/kg subcutaneously), and nicardipine (10 percent at 10 mg/kg subcutaneously). It is concluded that isradipine differs in both efficacy and potency from the other calcium antagonists tested. The effects of isradipine, nimodipine, and darodipine on cerebral blood flow were further investigated in this model using the [14C]iodoantipyrine method. Despite systemic hypotension, cerebral blood flow was dose dependently increased in the normal and ischemic hemispheres. Isradipine elicited maximal improvements over a wider dose range than the other drugs tested (0.1 to 2.5 mg/kg), preferentially affecting cerebral blood flow in the ischemic areas, as further demonstrated using autoradiographic techniques. These effects are in good, quantitative agreement with the reductions in infarct size, observed by magnetic resonance imaging and histology, emphasizing the importance of cerebrovascular mechanisms for cytoprotection in stroke. The concurrence between cat, rabbit, and rat experiments suggests that the findings may also apply to humans.

Effects of a new calcium antagonist, Rec 15/2375, on cardiac contractility of conscious rabbits

The new calcium antagonist Rec 15/2375, supposed to be selective for the vascular tissue, was compared to nifedipine, a non-selective agent that reduces blood pressure and impairs cardiac inotropism as well. Six rabbits, chronically catheterized and continuously monitored for systemic blood pressure, heart rate and the isovolumic contractility index dP/Tmax, were alternatively treated with Rec 15/2375 and nifedipine, according to a randomized cross-over design. Both drugs were given under either autonomically intact (AI) or suppressed (AS) heart function control, induced by cholinergic and beta-adrenoceptor blockade. The two agents reduced mean arterial blood pressure comparably and dose-dependently (P less than 0.01) under both experimental conditions (from 10 to 40%), thus causing heart rate to increase reflexly (P less than 0.01), similarly between drugs in AI rabbits, whereas the AS manoeuvre totally abolished such a response. Cardiac contractility, on the other hand, displayed opposing behaviour between the two drugs. Rec 15/2375 caused mild but significant (P less than 0.01) increases, which were similar at all doses (+10, +15%) and insensitive to the AS intervention, whereas nifedipine caused dose-dependent reductions (from -10 to -60%; P less than 0.01) of comparable intensity as mean blood pressure decrease in both protocols. We conclude that Rec 15/2375 effectively lowers blood pressure with no impairment, unlike nifedipine, of cardiac inotropism and we discuss the possibility that dP/dTmax may be increased as a result of the haemodynamic rearrangement following after-load reduction.

Effect of calcium entry and beta blockade during infrarenal aortic clamping

Clamping and declamping during aortic surgery produce a hemodynamically significant myocardial stress. The cardiovascular (CV) response to this stress may be adversely altered by calcium antagonists and beta-adrenoreceptor blockade employed to control symptomatic coronary artery disease. This study evaluated the effect of verapamil (V), propranolol (P), and their combination (P + V) on the CV response to infrarenal abdominal aortic cross-clamping and declamping in anesthetized dogs. Six dogs received P as a bolus of 0.5 mg/kg 20 min before clamping. Six additional dogs received V as a 300 micrograms/kg bolus followed by a V infusion of 6 micrograms/kg/min for 20 min before clamping. A third group of six dogs received the P bolus followed 20 min later by the V regimen (P + V). In both the V and P + V groups, 6 micrograms/kg/min V was infused throughout the clamping and declamping sequence. A fourth group of six control dogs received no cardioactive drugs during the experiment. Heart rate, mean aortic blood pressure, left ventricular end-diastolic pressures, peak rate of rise of left ventricular pressure, cardiac output, and systemic vascular resistance were measured in all animals before aortic cross-clamping, at 5 and 40 min after clamping, and 5 min after declamping. The results demonstrated additive negative chronotropic and inotropic properties of P + V therapy with a more significantly adverse effect than that of either drug alone. The implications of this study warrant added caution when patients treated with these drugs undergo abdominal aortic surgery.

Myocardial properties of the new dihydropyridine calcium antagonist isradipine compared to nifedipine with or without additional beta blockade in coronary artery disease

Isradipine is a new dihydropyridine calcium antagonist with myocardial effects significantly different from those of nifedipine, as shown by in vitro and animal experimental data. Isradipine selectively inhibits the sinus node but not the atrioventricular conduction and its negative inotropic action is much less if administered in a dose of comparable peripheral effects. To study these effects in man, 40 patients with coronary artery disease were divided into 2 groups receiving either a continuous 30-minute intravenous infusion of 2 mg of nifedipine or 0.5 mg of isradipine, doses that resulted in a comparable afterload reduction (decrease of systemic vascular resistance: nifedipine -22.1%, isradipine -25%, p less than 0.001). Ten patients in each group received an additional intravenous bolus of 5 mg of propranolol at the end of the calcium antagonist administration to antagonize its induced adrenergic reflex mechanisms. The heart rate significantly increased after nifedipine only (+9.2%, p less than 0.001), experienced no change after isradipine and the nifedipine and propranolol combination and decreased after the combination of isradipine and propranolol (-9.6%, p less than 0.001). This resulted in a significant decrease of the rate pressure product with isradipine (-12.5%, p less than 0.001) but not with nifedipine. As a result of the afterload-induced adrenergic reflex mechanisms, the maximal derivative of the left ventricular pressure increased after isradipine administration (+13.5%, p less than 0.001) and was unchanged after nifedipine, which demonstrates the significantly less negative inotropic properties of isradipine as compared with nifedipine.

Vasoconstrictor and vasodilator effects in normal and atherosclerotic conscious rabbits

1. Rabbits were fed a cholesterol-rich diet for 5 two-week intervals. Polyvinyl catheters were then implanted into the femoral artery and vein. Dose-response curves to acetylcholine (ACh), noradrenaline (NA), phenylephrine (Phen) and angiotensin II (AII), were obtained in 6 cholesterol-fed and 6 control rabbits before and after isradipine (code name PN200-110) 100 micrograms kg-1. After these experiments the animals were killed and aortic rings were suspended in an organ bath. ACh but not nitroprusside-induced relaxation was impaired in atherosclerotic but not in control preparations. 2. ACh decreased blood pressure dose-dependently in both groups of rabbits even though ACh did not relax the aortae of the same rabbits in vitro. 3. Blood pressure effects reflect mostly changes in resistance vessels. The pressor effects of NA, Phen and AII were enhanced in atherosclerotic compared with normal rabbits. 4. After a dose of 100 micrograms kg-1 isradipine the dose-response curves of all agents were shifted to the right. The differences between atherosclerotic and control rabbits disappeared, except for the AII-induced pressor response, which remained enhanced in atherosclerotic animals. The calcium antagonist thus only partly corrected the atherosclerosis-associated hyperresponsiveness to vasoconstrictor agents.

Selective effects of PN 200-110 (isradipine) on the peripheral circulation and the heart

PN 200-110 (isradipine) is a new dihydropyridine calcium antagonist with selective actions on the heart as well as the peripheral circulation. It selectively inhibits the sinus node but not atrioventricular conduction and its negative inotropic action is minimal, about 20 times weaker than its negative chronotropic effect. This in vitro pattern also expresses itself in vivo: partial suppression of the reflex tachycardia induced by its peripheral vasodilatation and no effect on the P-Q interval on the electrocardiogram even at large doses. The presence of first- or second-degree heart block should therefore not limit its use, whereas the sick sinus syndrome might. PN 200-110 does not decrease myocardial contractile force even in vagotomized animals with full beta blockade. PN 200-110 nevertheless lowers myocardial oxygen consumption mainly by its action on afterload. It should therefore be useful in angina pectoris. PN 200-110 is a powerful peripheral vasodilator. It preferentially dilates coronary, cerebral and skeletal muscle vasculature. Its long lasting (24 to 48 hours) antihypertensive action is not accompanied by tachycardia in spontaneously hypertensive rats and it enhances sodium and water excretion in normotensive rats. It should be useful in the treatment of hypertension, and, considering its pattern of cardiac actions, perhaps also as an after-load-reducing agent for the treatment of heart failure. Antiarteriosclerotic effects in conscious rabbits were found at reasonably small doses, suggesting that such effects might occur in man at therapeutic doses.