Vascular protection from atherosclerosis: potential of calcium antagonists

The new calcium antagonist lercanidipine and its enantiomers affect major processes of atherogenesis in vitro: is calcium entry involved?

Atherosclerosis results from multiple factors and involves several mechanisms, including endothelial monocyte and smooth muscle cell (SMC) changes, cholesterol accumulation, plaque rupture and thromboembolism. Calcium ions play a role in the initial and chronic development of atherosclerotic lesions. Several studies in experimental animal models have demonstrated the potential direct antiatherosclerotic effects of calcium antagonists. In this study the antiatherogenic activity of lercanidipine, a new lipophilic, second-generation calcium antagonist, was investigated. Lercanidipine and its enantiomers inhibited the replication and migration of arterial myocytes in concentrations ranging from 10 to 50 microM. The antiproliferative effect of lercanidipine was dose dependent, with a potency similar to that of lacidipine and nifedipine, and was unrelated to the stereoselectivity of enantiomers to bind L-type calcium channels. Lercanidipine and its enantiomers (25 microM) decreased the serum-induced elevation of [Ca2+]i in SMC, with the (S)-enantiomer (69% inhibition) being 2.4-fold more active than the (R)-counterpart (29% inhibition). The studies performed with enantiomers of lercanidipine suggest that the observed effects are not related to the blockade of voltage-dependent Ca2+ channels and confirm, at least in vitro, the pharmacological potential of the compound to influence negatively the process of atherogenesis.

Antiatherosclerotic and antiatherogenic effects of a calcium antagonist plus statin combination: amlodipine and lovastatin

Recently, the Regression Growth Evaluation Statin Study (REGRESS) demonstrated the synergistic, antiatherogenic effect of lipid-lowering therapy with pravastatin in combination with calcium antagonists. This combination retarded the progression of stenosis and reduced the number of new lesions more effectively than did statin therapy alone. In the present study, our objective was to elucidate the mechanism of this more pronounced effect of the statin-calcium antagonist combination on the atherosclerotic lesion. Smooth muscle cells cultured from the subendothelial intima of the human aorta were incubated with whole blood serum or with low-density lipoprotein (LDL) taken from patients cotreated with lovastatin and amlodipine. Serum added to the cells cultured from the atherosclerotic lesion reduced cell cholesterol. Such an antiatherosclerotic effect of cotreatment with amlodipine-lovastatin was revealed in this study and was more pronounced than the effect of treatment with either amlodipine or lovastatin alone. LDL isolated from atherogenic plasma stimulated cell cholesterol accumulation. Treatment with amlodipine alone and the amlodipine-lovastatin combination ameliorated the atherogenic effect of LDL. As compared with amlodipine alone, the combination demonstrated a considerably higher antiatherogenic effect on LDL atherogenicity. Amlodipine-lovastatin cotreatment increased sialic acid and decreased the susceptibility of LDL to oxidation more effectively than amlodipine alone. In addition, combination therapy reduced the LDL negative charge, while amlodipine alone was impotent. These findings may serve as an explanation of the more pronounced antiatherogenic effect at the lipoprotein level of amlodipine-lovastatin combined therapy compared with amlodipine therapy alone.

Nonlipoprotein risk factors for coronary heart disease: evaluation and management

Appropriate prevention and management of coronary heart disease (CHD) requires an integrated approach to the reduction of risk factors. These principally include reduction of elevated lipids, control of blood pressure, and cessation of smoking. In addition, appropriate exercise, diet, and weight reduction (where necessary) are also important. Control of diabetes and stress management may also be helpful. Aspirin therapy is appropriate for all patients with known CHD and selected patients without CHD who have several risk factors, including nonmodifiable risk factors such as age, a positive family history, and male gender.

Prognosis of patients with stable angina pectoris on antianginal drug therapy

Antianginal drug treatment reduces symptoms and ischemia but may also influence the prognosis of patients with stable angina pectoris. The Atenolol Silent Ischemia Study (ASIST) compared atenolol and placebo treatment (about 140 patient-years on each) in patients with mainly silent ischemia and found less aggravation of angina and a tendency toward fewer cardiac complications with atenolol treatment. The Total Ischaemic Burden European Trial (TIBET) compared slow release nifedipine, atenolol, or the combination (about 450 patient-years on each) and found no significant differences with regard to cardiac complications, a nonsignificant trend toward better prognosis on combined treatment, and more side effects on nifedipine alone compared with the other treatments. The Angina Prognosis Study in Stockholm (APSIS) compared metoprolol and verapamil (about 1,400 patient-years on each) and found similar effects on cardiovascular endpoints, tolerability, and psychosocial variables with the 2 treatments. Hypothesis-generating subgroup analyses in APSIS suggest that treatment effects may differ in hypertensive and diabetic subgroups. Beneficial effects in primary and secondary prevention, together with data from ASIST, suggest that beta 1 blockade influences prognosis favorably. The safety of short-acting nifedipine in ischemic heart disease is questioned, but TIBET data suggest that slow release nifedipine may be safe. Verapamil has beneficial effects after myocardial infarction (Danish Verapamil Infarction Trial II) and shows similar efficacy as metoprolol in the APSIS study. The paucity of placebo data (antianginal treatment cannot be withheld during long periods of time in symptomatic patients) precludes firm conclusions regarding effects of drug treatment on prognosis. It is argued that patients with stable angina pectoris do well on medical treatment, and that beta 1 blockers, verapamil, and, possibly, slow-release nifedipine may influence their prognosis favorably.

Calcium antagonists and left ventricular dysfunction

Calcium antagonists are used in the management of a variety of cardiovascular disorders. Ischemia leads to left ventricular dysfunction, which is the clinical entity on which the calcium antagonists are expected to have their effect as a result of their anti-ischemic action. This article reviews the efficacy of calcium antagonists in several different settings of left ventricular dysfunction due to ischemia and reperfusion.

Effect of verapamil and nifedipine on cholesteryl ester metabolism and low-density lipoprotein oxidation in macrophages

Using mouse macrophage cultures, the effects of verapamil and nifedipine on cholesteryl ester and low-density lipoprotein (LDL) metabolism were studied with special reference to the following parameters: (a) incorporation of [14C]oleate into cholesteryl esters (ChE), (b) contents of total and free cholesterol (FCh), (c) liberation of [14C]oleate from ChE and incorporation of [3H]FCh into ChE, (d) excretion of [3H]Ch from the cells, and (e) LDL oxidation. Verapamil and nifedipine (10-100 microM) were shown to decrease in a dose-dependent manner the incorporation of [14C]oleate into ChE and to increase the concentration of FCh but had no appreciable effect on the concentration of total cholesterol in macrophages cultured in the presence of acetylated LDL. The drugs stimulated the liberation of [14C]oleate from cellular ChE. The pharmacological concentrations (25-75 microM) of verapamil and nifedipine increased the excretion of [3H]FCh from ChE of macrophages in the presence of serum and high-density lipoproteins. The same concentrations of the drugs inhibited both LDL-derived malonyldialdehyde-like products and nitroblue tetrazolium dye reduction in a dose-dependent fashion. The results obtained suggest that verapamil and nifedipine exert their macrophage-mediated antiatherosclerotic effect via reduction of LDL oxidative modification, reduction of intracellular ChE synthesis, stimulation of ChE hydrolysis and cholesterol excretion from the cells.

Calcium-channel antagonists for prevention of atherosclerosis

OBJECTIVE

To critically evaluate the current literature regarding the role of calcium-channel antagonists in preventing atherosclerosis.

DATA SOURCES

English language clinical studies, abstracts, conference proceedings, and review articles pertaining to calcium-channel antagonists and atherosclerosis.

STUDY SELECTION

Relevant animal and human studies examining the role of calcium-channel antagonists in atherosclerosis prevention and treatment.

DATA EXTRACTION

Potential mechanisms for the development of atherosclerosis and the use of calcium antagonists for preventing and treating coronary artery disease are discussed. Animal studies are summarized; next, significant data from human clinical studies are presented.

DATA SYNTHESIS

Available studies are described and discussed.

CONCLUSIONS

Results from animal and clinical trials in humans suggest that calcium antagonists may retard the development and progression of atherosclerosis. However, most clinical trials to date have been conducted in patients with proven atherosclerotic plaques. Further studies examining the role of calcium-channel antagonists in preventing and treating atherosclerosis are needed, but may be difficult to conduct because of the large numbers of patients required, long trial duration, and associated costs.

Beta-blockers: propranolol, metoprolol, atenolol, pindolol, alprenolol and timolol, manifest atherogenicity on in vitro, ex vivo and in vivo models. Elimination of propranolol atherogenic effects by papaverine

The addition of the beta-blockers propranolol, metoprolol, atenolol, pindolol, alprenolol and timolol to a culture of peritoneal macrophages or smooth muscle cells induced an increase in the intracellular cholesterol content. Blood serum obtained from a rabbit after a peroral administration of beta-blockers also induced cholesterol accumulation. This property of drug or blood serum obtained after peroral administration is conventionally referred to as atherogenic potential or atherogenicity. Regular administration of propranolol during a 21-day period evoked stable atherogenicity of rabbit blood serum. This was accompanied by stimulation of manifestations of atherosclerosis in the aorta deendothelialized with a balloon catheter. Propranolol increased neointimal thickening, lipid accumulation, an increase in cell number and in the collagen content. In vitro, the combination of propranolol with papaverine eliminated the atherogenic effect of propranolol which manifested itself as stimulation of cholesterol accumulation in cultured cells. Simultaneous peroral administration of propranolol and papaverine prevented the appearance of serum atherogenicity. Papaverine eliminated neointimal thickening, an increase in cell number and in the lipid and collagen contents evoked by propranolol. Papaverine itself had no effect on these parameters. Thus, the atherogenicity of propranolol as well as capacity of papaverine to eliminate beta-blocker atherogenicity revealed in cell culture was confirmed in vivo. We hope that these results may be useful in the development of new drugs and optimization of antiatherosclerotic drug therapy.

Efficacy and safety of calcium channel blockers in hypertensive patients with concomitant left ventricular dysfunction

The use of calcium channel blockers (CCBs) in the treatment of hypertension and concomitant left ventricular dysfunction is reviewed. Some CCBs, particularly second-generation dihydropyridine agents such as felodipine, isradipine, nicardipine, nimodipine, and nitrendipine, have properties that enhance their usefulness in these patients. All CCBs have a similar mechanism of action. Differences in their selective action at various tissue sites determine which are most appropriate for patients with concomitant hypertension and left ventricular dysfunction. Most CCBs do not produce reflex stimulation of the heart or induce intravascular expansion. While all CCBs produce arteriolar dilation, all local beds and regional circulations in target organs are not affected equally. Most CCBs can decrease cardiac mass, and second-generation CCBs tend to have little or no negative inotropic effects at therapeutic dosages. In addition, they increase blood flow and reduce myocardial oxygen requirements. Because of differences in functional and electrophysiologic effects, specific CCBs may not be appropriate for all patients. Since second-generation dihydropyridine CCBs lack clinically relevant negative inotropic effects, and have been shown to improve exercise tolerance and coronary artery perfusion, they are appropriate for hypertensive patients with left ventricular dysfunction, angina, and coronary heart disease. Second-generation CCBs tend to lack cardiodepressant side effects and are less likely to react with digoxin than are first-generation CCBs.

Therapeutic targets in ischaemic heart disease

The adequate treatment of a disease syndrome is dependent upon a clear definition of the symptomatic, pathological, physiological and prognostic targets against which therapy is to be deployed. The syndromes of ischaemic heart disease, including angina pectoris, are complex in origin, pathology, pathophysiology and natural history, and a complete clinical profile is difficult, if not impossible, to achieve in individual patients. The prime goals of pharmacotherapy in ischaemic heart disease are easy to define, but difficult to accomplish in practice. Relief of pain, breathlessness and fatigue are the prime clinical targets for pharmacotherapy. In view of their sinister significance, the electrophysiological indications of myocardial ischaemia, whether symptomatic or silent, are also crucial targets towards which therapy must be directed. Ischaemic heart disease is accompanied by a wide variety of regional and global abnormalities of myocardial contractile function associated with widespread reflex stimulation of the peripheral vascular system and neuroendocrine systems. Primarily, drug therapy must be directed at correction of these pathophysiological components of the syndrome. Longer term but no less essential goals in the treatment of ischaemic heart disease are the prevention of the clinical sequelae of the syndrome and its progression. A natural sequel of coronary artery obstructive disease is successive thrombotic events and loss of myocardium. Calcium antagonists, by preventing the increase in myocardial cytosolic calcium during acute ischaemic episodes, defer cell necrosis; in this respect, they are unique among currently available antianginal drugs. With regard to progression, the prime pathological cause of ischaemic heart disease is coronary atheroma.(ABSTRACT TRUNCATED AT 250 WORDS)