Captopril impairs the vascular smooth muscle contraction mediated by postsynaptic alpha 2-adrenoceptors in the pithed rat

Captopril or atenolol in essential hypertension

Twenty-five patients with essential hypertension were randomly assigned to treatment with either captopril or atenolol. There were 15 males and 10 females and their mean age was 53 years, range 32-66 years. Systolic and diastolic blood pressures were significantly reduced by atenolol 50-100 mg once daily. Captopril 25-50 mg 3 times daily caused a significant decrease in supine diastolic but not in systolic blood pressure. After the addition of hydrochlorothiazide (25-50 mg) to those who did not become normotensive (supine diastolic blood pressure less than 95 mm Hg) on captopril or atenolol alone, blood pressure was further reduced. Captopril combined with hydrochlorothiazide significantly reduced both supine and standing blood pressure by 31/17 mm Hg (p less than 0.01) and 33/18 mm Hg (p less than 0.001) respectively. Atenolol combined with hydrochlorothiazide caused a significant decrease of both recumbent and standing blood pressure by 21/10 mm Hg (p less than 0.01) and 23/13 mm Hg (p less than 0.05 systolic, p less than 0.001 diastolic). The reduction of systolic blood pressure was significantly better with the captopril/hydrochlorothiazide combination, while there was no difference between the groups as regards diastolic blood pressure reduction. Thus, hydrochlorothiazide potentiates the blood pressure lowering effect of captopril more than of atenolol. This could be due to a synergistic interaction between captopril and hydrochlorothiazide.

Long-term effects of captopril and atenolol in essential hypertension

Fifty patients with mild or moderate essential hypertension were randomized (double-blindly) to treatment with either captopril (n = 26) or atenolol (n = 24). Their mean supine diastolic blood pressure after placebo was 100-125 mmHg. The study included an initial dose finding phase (12 weeks) during which the dosages of captopril and atenolol were increased stepwise every second week in order to obtain normotension (supine diastolic blood pressure less than 95 mmHg). Hydrochlorothiazide was added when necessary. During the second phase of the study the patients were followed on active treatment for 2 years. After the initial 12 weeks of active treatment, recumbent and standing blood pressures had fallen significantly both in the captopril group (by 31/20 and 33/19 mmHg, p less than 0.001) and in the atenolol group (by 24/18 and 30/20 mmHg, p less than 0.01 (systolic), p less than 0.001 (diastolic)). The antihypertensive effect was maintained in both groups during long-term treatment. The antihypertensive effect of both agents was potentiated to the same extent by addition of hydrochlorothiazide. Side-effects were few and mild. It can be concluded that both captopril and atenolol are safe and effective antihypertensive drugs.

Pressor responses to the alpha 1-adrenoceptor agonist cirazoline: effects of captopril, phenoxybenzamine and nifedipine

We have examined the effects of captopril on pressor responses to the selective alpha 1-adrenoceptor agonist cirazoline in the pithed rat preparation following treatment with phenoxybenzamine and/or nifedipine. Pretreatment with captopril reduced the pressor responses to cirazoline and displaced the dose-response curve for this agonist to the right, significantly increasing the ED50 without altering the maximum response. Pretreatment with phenoxybenzamine accentuated the inhibitory actions of captopril and a combination of phenoxybenzamine and captopril significantly increased the ED50 without altering the maximum response. Administration of nifedipine in animals, which had already received phenoxybenzamine and captopril, led to a further displacement to the right of the cirazoline dose-response curve. The ED50 was found to be significantly increased and the maximum response was now significantly depressed. Captopril produced further additive inhibition with nifedipine and phenoxybenzamine of the vasoconstrictor effects of cirazoline. These data indicate, perhaps not surprisingly, that the cellular basis for the inhibitory effects of captopril is different from that of nifedipine and phenoxybenzamine, however, more importantly, that captopril may directly, or indirectly, inhibit receptor-operated cation channel mediated pressor responses.

No relation of the suppressive effect on the sympathetic nervous system to the acute hypotension caused by imidapril and enalapril

To investigate the involvement of the sympathoinhibitory effect of imidapril and enalapril in their antihypertensive effect at a clinically reasonable dose, we studied whether some responses induced by the stimulation of the sympathetic nervous system (SNS) were affected by intravenous administration of imidaprilat and enalaprilat in curarized pithed spontaneously hypertensive rats. Imidaprilat and enalaprilat (both at 100 micrograms/kg, i.v.), which are active metabolites of imidapril and enalapril, respectively, suppressed the pressor responses to electrical stimulation (ES) of the spinal cord (T1-L7) and exogenous noradrenaline (NA). The pressor responses to NA were significantly suppressed after either alpha 1- or alpha 2-adrenoceptors were blocked. Furthermore, imidaprilat (100 micrograms/kg, i.v.) suppressed these reduced responses. When the reduced basal blood pressure was restored by vasopressin infusion, imidaprilat and enalaprilat (both at 100 micrograms/kg, i.v.) did not suppress the responses to ES and exogenous alpha-adrenoceptor agonists. They affected neither basal plasma concentrations of NA and adrenaline nor ES-induced increase of these catecholamines. These results suggest that the suppressive effects of imidaprilat and enalaprilat on the pressor responses to ES and alpha-adrenoceptors agonists are apparently observed in pithed SHR because of a reduction of vascular tone and that imidapril and enalapril do not lower the blood pressure through suppressing SNS.

The effect of captopril on the superior mesenteric artery and portal venous blood flow in normal man

1. Measurements of superior mesenteric artery and portal venous blood flow were made non-invasively along with systemic and other regional (cardiac index, forearm and cutaneous blood flow) vascular responses to acute ingestion of the ACE inhibitor captopril (50 mg) or placebo (50 mg vitamin C), in 12 healthy subjects while supine and during head-up tilt. 2. After captopril, superior mesenteric artery and portal blood flow rose markedly with a reduction in superior mesenteric artery vascular resistance. Supine blood pressure was unchanged but cardiac index and forearm blood flow rose; during head-up tilt, blood pressure fell in some subjects. 3. There was a rise in levels of plasma renin activity and a fall in levels of plasma angiotensin II after captopril. After placebo, there were no significant changes in splanchnic blood flow, systemic or other regional responses and in biochemical measurements, while supine. 4. Our studies indicate that captopril is a potent dilator of the splanchnic vascular bed and suggest that this action may contribute to its therapeutic effects. The studies indicate a role for angiotensin II in the control of this large vascular bed although other agents (bradykinin, prostacyclin) may contribute.

ACE-inhibitors in coronary artery disease?

Angiotensin converting enzyme (ACE)-inhibitors are established in the treatment of arterial hypertension and heart failure. In recent years ACE-inhibitors have also been used in the treatment of patients with coronary artery disease (CAD), since from experimental data an antiischemic action of these agents is suggested. Antiischemic effects of ACE-inhibitors may be exerted through a reduction of myocardial oxygen demand, by a reduction of angiotensin-mediated coronary vasoconstriction, by an interaction with bradykinin and the prostaglandin system, by a modulation of endothelial control of vascular tone, and by an interaction with the sympathetic nervous system. However, clinical findings on potential beneficial effects of ACE-inhibitors in patients with CAD are inconsistent and controversial. While in hypertensive patients with CAD ACE-inhibitors generally seem to attenuate myocardial ischemia at rest and during exercise, a significant fraction of about 30% of normotensive patients with CAD does not benefit or even deteriorates. Lowering of coronary perfusion pressure and alteration of transmural blood flow distribution may be responsible for this. In patients with left ventricular dysfunction (SOLVD) or congestive heart failure (CONSENSUS, SOLVD) ACE-inhibitors have been proven to prevent progressive deterioration in left ventricular function and to reduce mortality. In patients with asymptomatic left ventricular dysfunction after myocardial infarction (SAVE), long-term administration of captropril was associated with an improvement in survival and reduced morbidity and mortality due to major cardiovascular events. Therefore, from a prognostic viewpoint patients with CAD and left ventricular dysfunction or congestive heart failure should be treated with ACE-inhibitors, although the clinical use of ACE-inhibitors in patients with ongoing angina pectoris may be limited by an aggravation of angina, presumably due to critically lowering coronary perfusion pressure. Finally, ACE-inhibitors failed to prevent restenosis after successful PTCA. In conclusion, from a prognostic viewpoint patients with CAD and congestive heart failure or left ventricular dysfunction should be treated with ACE-inhibitors. In hypertensive patients ACE-inhibitors generally seem to attenuate myocardial ischemia. In normotensive patients with CAD and angina pectoris but without left ventricular dysfunction ACE-inhibitors cannot generally be recommended at present, unless the patients, which may have benefit from ACE-inhibitor treatment can be better defined.

A comparison of the effects of angiotensin II and Bay K 8644 on responses to noradrenaline mediated via postjunctional alpha 1-and alpha 2-adrenoceptors in rabbit isolated blood vessels

1. The effects of angiotensin II (AII) and Bay K 8644 on responses to noradrenaline (NA) mediated via postjunctional alpha 1- and/or alpha 2-adrenoceptors have been compared in three isolated venous preparations from the rabbit, the lateral saphenous vein, the left renal vein and the ear vein. 2. A similar action of AII and Bay K 8644 was observed only in the lateral saphenous vein; each potentiated responses to NA after isolation of a homogeneous population of postjunctional alpha 2- adrenoceptors. However, even in this preparation the mechanism of action for these agents was not identical. The sensitivity of KCl-induced contraction to changes in extracellular calcium ions (reflecting activation of voltage-dependent Ca2+ channels) was enhanced by Bay K 8644 but reduced by AII. 3. All produced a selective facilitation of responses mediated via postjunctional alpha 2-adrenoceptors. In the lateral saphenous vein it reduced the effectiveness of prazosin and facilitated responses after isolation of alpha 2-adrenoceptors with phenoxybenzamine and rauwolscine. It directly enhanced responses to NA in the ear vein, where only alpha 2-adrenoceptors are involved. In contrast, AII did not influence responses mediated via postjunctional alpha 1-adrenoceptors in the left renal vein (even after the receptor reserve had been removed with phenoxybenzamine) nor the 'rauwolscine-resistant' component of responses to NA in the saphenous vein. 4. Bay K 8644 enhanced contractile responses to NA mediated both via alpha 2-adrenoceptors, in the lateral saphenous vein, and via alpha 1-adrenoceptors in the left renal vein. Thus, unlike angiotensin II, no preferential effect was apparent. 5. Bay K 8644 was inactive against responses to NA in the rabbit isolated ear vein. Since the sustained component of responses to NA in this preparation is dependent upon the influx of extracellular Ca2 , these observations suggest that the influx of Ca2+ stimulated by NA is mediated via receptor-operated (1,4-dihydropyridine-resistant) Ca2 + channels.

ACE inhibitors for the treatment of myocardial ischemia?

Apart from their established use in the treatment of hypertension and heart failure, ACE inhibitors have been suggested to exert anti-ischemic effects. This article reviews the mechanisms of systemic and intracardiac angiotensin formation, as well as its interaction with the bradykinin, the prostaglandin, and the sympathetic nervous system. While high doses of angiotensin can precipitate myocardial ischemia. experimental data on a potential beneficial effect of ACE inhibitors on ischemic myocardial blood flow and function are inconsistent and controversial. Pooling the few available clinical data, several ACE inhibitors may attenuate myocardial ischemia at rest and during exercise. However, a significant fraction of patients does not benefit or even deteriorates. Recent experimental studies suggest a beneficial role of ACE inhibitors in attenuating reperfusion arrhythmias and postinfarction left ventricular remodeling. Unless the mechanisms and determinants of potential anti-ischemic actions of ACE inhibitors can be better defined, their use for treatment of myocardial ischemia cannot be recommended at present.

The effect of captopril on peripheral hemodynamics in patients with essential hypertension: comparison between oral and sublingual administration

A comparative study of the effects of oral and sublingual captopril on the hemodynamics of the peripheral musculocutaneous vasculature was carried out on ten patients with essential hypertension. Both routes of administration of captopril lead to lower blood pressure and decreased regional resistance, and to an increased arterial blood flow at rest. The first measurable effect and the peak effect on blood pressure and peripheral hemodynamics appear slightly earlier with sublingual administration. The data provided in this study support the usefulness of the sublingual route in clinical situations in which oral administration of captopril is not feasible.

Carotid arterial hemodynamics in hypertension: acute administration of captopril or cadralazine

Arterial diameter, blood flow, and vascular resistance of the common carotid artery were studied together with the carotido-femoral pulse wave velocity in men with sustained essential hypertension before and after acute oral administration of either captopril or a hydralazinelike agent, cadralazine. The two drugs caused similar decreases in mean blood pressure and vascular resistance in the carotid area. While cadralazine did not change arterial diameter and pulse wave velocity, captopril caused a significant increase in arterial diameter and a decrease in pulse wave velocity. The study provided evidence that two drugs causing a similar reduction in blood pressure and dilatation of small arteries have different effects on the large common carotid artery. Only captopril caused an enhancement of arterial diameter and distensibility related to the pharmacologic action of the drug on the vascular wall.

Calcium-channel blockade (nitrendipine) in combination with ACE inhibition (captopril) in the treatment of mild to moderate hypertension

The antihypertensive efficacy of a combination of calcium-channel blockers and angiotensin-converting-enzyme (ACE) inhibitors in severe primary hypertension is well known, but a synergistic action of this drug combination in mild to moderate primary hypertension is still not established. Therefore, the aim of the present study was to evaluate the efficacy and tolerability of monotherapy with nitrendipine (20 mg) or captopril (100 mg), and of their combination (nitrendipine 10 mg plus captopril 50 mg), in patients suffering from mild to moderate primary hypertension, according to a single-blind, randomized, placebo-controlled design. After the first 4-week monotherapy period, both nitrendipine and captopril induced a significant decrease in systolic and diastolic blood pressure (BP) (p less than 0.001). Furthermore, nitrendipine caused a significant increase in heart rate (HR), while no change in HR was observed in patients treated with captopril. Several side effects were observed, both in the nitrendipine-treated patients (facial flushing, headache, malleolar edema) and in the captopril-treated patients (initial hypotension, dizziness, gastrointestinal disorders). However, these side effects were mild and were well tolerated. In the second combined 4-week therapy period, systolic and diastolic BP of patients treated with 10 mg nitrendipine combined with 50 mg captopril continued to decrease to a degree significantly lower (p less than 0.001) than that observed at the end of the monotherapy period. Simultaneously, no change in HR values occurred when compared to basal values. Furthermore, the incidence and intensity of some side effects observed during the combined therapy period were lower than those of the monotherapy period.(ABSTRACT TRUNCATED AT 250 WORDS)

Why are converting enzyme inhibitors vasodilators?

1. The primary action of the converting enzyme inhibitors to prevent the formation of angiotensin II can explain a decrease in peripheral vascular resistance in patients with elevated, but not in those with normal or reduced plasma renin levels. 2. The inhibition of the breakdown of bradykinin will potentiate the vasodilator properties of the endogenously produced peptide. These include direct relaxation of certain vascular smooth muscle, production of vasodilator prostanoids and release of endothelium-derived relaxing factor(s). The greater release of the latter in the kidney could exert a negative feedback on the release of renin. 3. In addition, converting enzyme inhibitors may directly (by a prejunctional effect) and indirectly (by curtailing the production of angiotensin II) reduce the release of noradrenaline in the blood vessel wall. 4. Converting enzyme inhibitors may also directly reduce the responsiveness of vascular smooth muscle to vasoconstrictor stimuli (e.g. alpha-adrenoceptor activation). 5. The different effects of these therapeutic agents may concur to induce peripheral vasodilatation.

Influence of sublingual captopril on plasma catecholamine levels during hypertensive emergencies and cold immersion

Experimental evidence of captopril-induced inhibition of sympathetic activity, mediated by decrease in angiotensin II production, is presented. The blood pressure, plasma catecholamine, plasma renin activity, and plasma aldosterone responses to a single dose of sublingual captopril in 23 patients with hypertensive emergencies were evaluated. The major correlation found was between the captopril-induced decrease in blood pressure and the decrease in plasma norepinephrine levels (r = 0.57, p less than 0.01). In another 11 hypertensive patients with normal or high renin levels, captopril lowered by 65 percent the increase in plasma norepinephrine induced by cold immersion of the forearm. In both circumstances, plasma renin and aldosterone levels changed in accordance with the expected inhibition of angiotensin converting enzyme activity. These data suggest that, in selected circumstances in hypertensive patients, captopril exhibits a depressive influence on sympathetic activity along with the inhibition of the renin-angiotensin system.

The effect of chronic captopril therapy on adrenergic receptors, plasma noradrenaline and the vascular responses to infused noradrenaline

Adrenergic receptors (alpha 2, beta 2), plasma noradrenaline, heart rate and the pressor responsiveness to infused noradrenaline were examined in ten healthy male volunteers before and after 2 weeks of placebo or captopril therapy in a double blind cross-over study. No significant differences in these measurements were observed between the captopril and placebo treated groups. The study shows that in sodium replete normotensive subjects, long-term angiotensin converting enzyme inhibition does not lead to changes in adrenoceptor density. There is also no alteration in plasma noradrenaline levels nor in the pressor responsiveness to infused noradrenaline. These data suggest that the known interaction between the renin-angiotensin system and the sympathetic nervous system observed in animals is probably of little significance in man.

Captopril modifies the hemodynamic and neuroendocrine responses to sodium nitroprusside in hypertensive patients

To determine if clinically effective doses of the antihypertensive agent captopril affected the neuronal release of norepinephrine or baroreflex sensitivity, changes in plasma norepinephrine concentration and heart rate were related to the changes in mean arterial pressure seen during the intravenous infusion of stepwise incremental doses of sodium nitroprusside before and during captopril treatment in eight hypertensive men with normal or low plasma renin activity. At all times, significant linear correlations were found between the decrease in mean arterial pressure and the dose of sodium nitroprusside, the increase in heart rate and the decrease in mean arterial pressure, and the increase in plasma norepinephrine concentration and the decrease in mean arterial pressure. When the subjects were treated with captopril (25 mg t.i.d.) for 2 to 4 weeks, supine mean arterial pressure decreased from 130 to 114 mm Hg (-12%; p less than 0.05), heart rate did not change, supine and upright plasma renin activity increased, while supine plasma norepinephrine and epinephrine concentration decreased slightly. Therapy with captopril (25 mg t.i.d.) increased baroreflex sensitivity, as assessed by the slope of the regression line relating the increase in heart rate to the decrease in mean arterial pressure, and increased the responsiveness of the sympathetic nervous system, as assessed by the slope of the regression line relating the increase in plasma norepinephrine concentration to the decrease in mean arterial pressure. These increases were accompanied by a decrease in the slope of the regression line relating the decrease in mean arterial pressure to the dose of sodium nitroprusside and thus were associated with a decreased sensitivity to the vasodepressor effects of sodium nitroprusside.(ABSTRACT TRUNCATED AT 250 WORDS)

Dietary and pharmacological alterations in endogenous angiotensin II: effect on noradrenaline pressor responsiveness in the rat

Rats were placed on either a low sodium intake (low sodium diet 0.025% dry weight, tap water for drinking) or a high sodium intake (normal sodium diet 0.45% dry weight, 0.9% saline for drinking) for 10 days. The pressor-response curve to angiotensin II in rats previously on a high sodium intake was shifted to the left of that found in rats previously on a low sodium intake. Suppression of endogenous angiotensin II formation with captopril (0.3 mg kg-1) or acute volume repletion (3% body wt per 30 min) resulted in a significant parallel shift of the pressor-response curve for angiotensin II to the left in the low salt group. In the high salt group captopril produced a similar but smaller parallel shift of the dose-response curve to the left. Similar manipulation of endogenous angiotensin II concentrations with high and low salt intake plus captopril treatment or acute volume repletion, produced no alterations in the pressor response for noradrenaline. The attenuated in vivo response to angiotensin II in the low salt intake group may be explained in part by the suppressed vascular sensitivity to angiotensin II in this group, as measured in the isolated perfused kidney of the rat. In kidneys from rats previously on a low sodium intake, an enhanced maximal vasoconstrictor response to noradrenaline was observed as compared to kidneys from high sodium intake rats. These results indicate that, whereas alterations in endogenous angiotensin II concentrations within physiological limits affects the response to exogenous angiotensin, there is little if any effect on the pressor response to noradrenaline.

Effect of pithing on the postjunctional sympatho-inhibitory action of captopril in cats

Pithing of anaesthetized normotensive cats significantly lowered the arterial blood pressure and augmented plasma renin activity (PRA). Captopril dose-dependently diminished mean arterial blood pressure in both pithed and intact anaesthetized normotensive cats. The hypotensive effectiveness of captopril was most pronounced in pithed cats. Captopril inhibited the hypertensive response to intravenously administered noradrenaline in pithed cats, but did not attenuate the hypertensive response to noradrenaline in intact cats. The results do not exclude that the hypotensive activity of captopril in intact cats may be causally independent of the attenuating effect of converting enzyme inhibition on the postjunctional alpha-adrenoceptor mediated vasoconstriction as observed in pithed animals.

Angiotensin-converting enzyme inhibitors: biochemical properties and biological actions

The review will cover the chemistry and biochemistry of angiotensin-converting enzyme inhibitors with emphasis on data published since the publication of previous reviews. The relative merits of each contribution will be evaluated, as well as their potential for leading to new discoveries. The biology of angiotensin-converting enzyme inhibitors will be brought up-to-date to give the reader an appreciation of the medical implications of this new type of antihypertensive agent.

"Pertussis toxin induces tachycardia and impairs the increase in blood pressure produced by alpha 2-adrenergic agonists"

Administration of purified pertussis toxin to rats induced persistent tachycardia, (observed in conscious rats but not after pithing); as little as 0.05 microgram/100 g produced a significant effect. Pertussis toxin-treatment did not affected the pressor response produced in the pithed rats by the alpha 2-adrenergic agonist methoxamine but markedly diminished the pressor effect of the alpha 2-adrenergic agonists clonidine and azepexole. A role of adenylate cyclase inhibition in the action of postsynaptic vascular alpha 2-adrenergic receptors is suggested.

Sgd 101/75 is distinguished from other selective alpha 1-adrenoceptor agonists by the inhibition of its pressor responses by calcium entry blockade and vasodilatation in pithed rats and cats

The vasopressor effects of the selective alpha 1-adrenoceptor agonist Sgd 101/75 (2-[2-methylindazol-4-imino]-imidazolidine HCl) were analyzed in pithed rats and cats. Vasodilatation by the beta 2-adrenoceptor agonist salbutamol (1 mg/kg i.v.) or by the converting enzyme inhibitor captopril (5 mg/kg i.v.) antagonized the vasoconstriction by Sgd 101/75 in pithed rats. The effect of salbutamol was abolished by restoration of the baseline diastolic pressure by infusion of vasopressin. Calcium entry blockade by nifedipine (0.1-3 mg/kg i.v.) and (-)-verapamil (0.3 and 1 mg/kg i.v.) dose dependently inhibited the rise in the diastolic pressure induced by Sgd 101/75 pithed rats. This inhibition could not be attenuated by an infusion of vasopressin. In pithed cats, nifedipine most effectively antagonized the pressor effects of Sgd 101/75. In this respect, Sgd 101/75 is different from other alpha 1-adrenoceptor agonists, which are known to elicit a vasoconstriction which is virtually insensitive to vasodilatory measures and calcium entry blockade. These findings may be explained on the basis of a further subdivision of vascular postjunctional alpha 1-adrenoceptors.

Pharmacological characterization of alpha-adrenoreceptor subtypes in rat isolated thoracic aorta

The subtype of alpha-adrenoreceptor mediating contraction in rat isolated thoracic aorta was classified pharmacologically using preferential agonists and antagonists, and by utilizing mixed agonist and antagonist interactions. Noradrenaline was 8 to 10-times more potent at contracting the aorta than phenylephrine and both agonists were about 1000 and 10,000-fold respectively more potent than azepexole (a preferential alpha 2-agonist). Prazosin (a preferential alpha 1-antagonist) inhibited the dose-response curves to noradrenaline and phenylephrine 100 and 1000-times respectively more effectively than either phentolamine or rauwolscine (a preferential alpha 2-antagonist). Furthermore, prazosin (5 x 10(-9) M) completely abolished contractions elicited by a single concentration of azepexole (3 x 10(-4) M). In mixed antagonist studies, rauwolscine (5 x 10(-7) M) failed to shift the dose-response curves to noradrenaline and phenylephrine obtained in the presence of prazosin (5 x 10(-9) M). In mixed agonist experiments, azepexole (3 x 10(-4) M) acted as a partial antagonist toward phenylephrine-induced contractions. The results suggest that the alpha-adrenoreceptor of the rat thoracic aorta is predominantly, if not exclusively, of the alpha 1-subtype.

Inhibitors of the angiotensin I converting enzyme as antihypertensive drugs

Inhibitors of the angiotensin I converting enzyme (captopril, enalapril) offer a new principle in the drug treatment of hypertension and congestive heart failure. The present survey deals with the mode of action of the converting enzyme inhibitors, including possible interference with the renin-angiotensin systems in the kidney, the vascular wall and the brain, with the kallikrein--bradykinin system and with the sympathetic nervous system, at both pre- and postjunctional sites. Furthermore, the haemodynamic pattern as well as the therapeutic applications are discussed, including the most important side-effects, contra-indications, interactions and clinical pharmacokinetic properties.

Calcium entry blocking drugs, 'calcium antagonists' and vascular smooth muscle function

The group of drugs known as "calcium antagonists' is under extensive investigation in experimental animals and man and a re-evaluation of their pharmacological properties is overdue. Recent proposals to adopt the more specific nomenclature of calcium entry blockers for some of these compounds (Vanhoutte & Bohr, 1981) should be supported since there is much confusion in the literature with this class of compound. In this review, which concentrates on vascular smooth muscle, only nifedipine, verapamil, their close chemical analogues and diltiazem are recognised as being relatively selective calcium entry blocking drugs. Whilst definitive evidence for calcium entry blockade must include the demonstration of a selective inhibition of Ca2+-influx into a tissue over a range of concentrations also inhibiting contraction, it is nevertheless possible to define several simple pharmacological criteria which may aid in the identification of such activity. These criteria include the selective antagonism of K+ and Ca2+-induced contractions, relative to those of noradrenaline in suitable vascular smooth muscle preparations and a selective inhibition of alpha 2- as opposed to alpha 1-adrenoreceptor mediated pressor responses in, for example, pithed rat preparations. Recent pharmacological and biochemical studies have identified 3 major subgroups of "calcium antagonist' drugs but the compounds within each subgroup varies with the technique adopted. It is therefore suggested that a combination of both pharmacological and ligand-binding studies be used for purposes of classification. Which mechanism, if any, of inhibiting calcium entry is therapeutically most desirable remains an important question for future research.

Attenuation by captopril of pressor responses to sympathetic stimuli: effects of procedures reducing activity of the renin-angiotensin system

Low doses (0.1-1.0 mg/kg) of the converting enzyme inhibitor captopril given intravenously to pithed rats were followed by long lasting falls in systolic and diastolic arterial blood pressures. Concomitantly pressor responses were reduced to either electrical stimulation of the thoraco-lumbar sympathetic outflow or intravenous injection of the ganglion stimulant McNeil-A-343. Positive chronotropic responses of the heart to cardiac nerve stimulation were unchanged after relatively large doses of the drug (3.0 mg/kg). The reductions in arterial blood pressure and pressor responses to McNeil-A-343 caused by captopril persisted following beta-adrenoreceptor blockade, renal sympathectomy or unilateral nephrectomy, but did not occur after acute bilateral nephrectomy nor during sodium and water retention due to unilateral nephrectomy plus subacute administration of desoxycorticosterone and saline. Pressor responses to noradrenaline were reduced after 1.0 mg/kg captopril i.v. whereas those to methoxamine or vasopressin were unaltered after 5.0 mg/kg. It is concluded that in the rat, after elimination of sympathetic tone by pithing, the level of the arterial blood pressure and the magnitude of pressor responses to peripheral sympathetic nerve activation depend on the basal activity of the renin-angiotensin system. This maintains sufficient angiotensin II production to ensure retention of some tone in resistance vessels together with presynaptic augmentation of noradrenaline output at a sympathetic postganglionic nerve endings. The latter effects are abolished after converting enzyme inhibition with captopril, consequent to reduced tissue levels of angiotensin II and perhaps potentiation of the actions of bradykinin.

Postjunctional alpha-adrenoceptors in the isolated saphenous vein of the rabbit. Characterization and influence of angiotensin

Experiments on the isolated saphenous vein of the rabbit have been performed in order to determine whether a coexistence of postjunctional alpha 1- and alpha 2-adrenoceptor subtypes can be demonstrated also under in vitro conditions. Prazosin, selective for alpha 1-receptors, and rauwolscine, selective for alpha 2-receptors, were used to antagonize the contractile response of the agonists phenylephrine (alpha 1), B-HT 920 (alpha 2) and noradrenaline (alpha 1/alpha 2). Each of the antagonists was equipotent against all three agonists; the effect of neither antagonist fulfilled the criteria for a competitive antagonism. The preferential alpha 1-receptor antagonist phenoxybenzamine, applied for irreversible blockade of alpha-receptors, reduced the effect of phenylephrine and B-HT 920 to the same degree. Thus, the results obtained with alpha-receptor antagonists cannot be reconciled with the coexistence of alpha 1- and alpha 2-receptors or the existence of only one of them. Contractile responses induced by alpha 1- and alpha 2-receptor agonists, respectively, could be differentiated by the calcium entry blocker nitrendipine. The effect of B-HT 920 was decreased whereas that of phenylephrine was hardly affected. Furthermore, we investigated the influence of angiotensin II on the effects of the alpha-adrenoceptor agonists as well as the antagonists. We observed firstly, that angiotensin, acting postsynaptically, potentiates the contractile response of certain alpha 2-receptor agonists and secondly, that in the presence of angiotensin the characteristics of the receptors as revealed by B-HT 920 are converted to typical alpha 2-adrenoceptors. It is concluded that the postjunctional alpha 2-receptors of the saphenous vein require the blood borne substance angiotensin for their expression.

Attenuation by captopril of pressor responses to peripheral sympathetic nerve stimulation in rats is abolished after bilateral nephrectomy and during mineralocorticoid hypertension

Intravenous administration of captopril (0.1-0.3 mg/kg) to normotensive pithed rats, with or without unilateral nephrectomy, was followed by a sustained fall in arterial blood pressure. Concomitantly pressor responses to electrical stimulation of the spinal sympathetic outflow (T11-L3), ganglion stimulation with McNeil-A-343 (4-(m-chlorophenylcarbamoyloxy)-2-butynyl-trimethylammonium chloride) or intravenous injection of noradrenaline were reduced. Attenuation by captopril (1 mg/kg) of pressor responses to McNeil-A-343 persisted after intravenous propranolol (1 mg/kg). Tachycardia caused by electrical stimulation of the spinal sympathetic nerves (C7-T2) was unchanged after 3.0 mg/kg captopril. After procedures reducing the activity of the renin angiotensin system, bilateral nephrectomy or induction of mineralocorticoid hypertension by unilateral nephrectomy and administration of desoxycorticosterone acetate, pressor responses to McNeil-A-343 or noradrenaline were unchanged after 1 mg/kg captopril. It is concluded that in the pithed rat, basal arterial blood pressure and the height of pressor responses to either postganglionic sympathetic nerve activation or intravenous noradrenaline depend on converting enzyme activity maintaining circulating angiotensin II levels.

Pharmacology of converting enzyme inhibitors: new aspects

The antihypertensive mechanism of CEI cannot be solely explained by an inhibition of the plasma RAS with reduced vasoconstrictor action of circulating ANG II. Inhibition of Kininase II with an increase of endogenous bradykinin does not appear to play a major role. Within the dose range used therapeutically, captopril and other CEI inhibit the facilitatory action of ANG II on neurogenic vasoconstriction, leading to a reduced sympathetic tone. CEI may also interfere with sympathetic reflexes. Doses above the therapeutic range seem to inhibit the sympathetic nervous system through mechanisms unrelated to CE inhibition. A reduced local generation of ANG II within tissues such as vascular wall, kidney or brain appears to contribute sympathetic tone. The type of hypertension (e.g. with or without stimulated plasma RAS or sympathetic tone) and the chemical characteristics of the CEI used (e.g. lipid solubility governing penetration into tissues) may determine the relative importance of the different mechanisms and sites of action for the reduction of blood pressure.

Interference by inhibitors of the renin-angiotensin system with neurogenic vasoconstriction

In the pithed rat preparation captopril, enalapril, teprotide and saralasin given intravenously attenuated pressor responses to both spinal sympathetic nerve stimulation and exogenous noradrenaline, indicating that angiotensin has a potent adrenergic facilitating action. Bi-lateral nephrectomy abolished the effects of captopril on nerve stimulation but responses to noradrenaline were still inhibited following nephrectomy, indicating that part of the post-junctional actions of captopril might not be angiotensin dependent. Both phenylephrine and clonidine are also inhibited by captopril in the pithed rat. It is thus not clear whether captopril is interacting with post-junctional alpha 1- or alpha 2-adrenoceptors. Vasoconstrictor responses to nerve stimulation are greater in SHR than WKY and captopril is more effective at inhibiting responses in the SHR than it is in WKY. These interactions between captopril and the sympathetic nervous system could explain the effectiveness of ACE inhibitors as antihypertensive agents.

Hypotensive action of captopril in spontaneously hypertensive and normotensive rats. Interference with neurogenic vasoconstriction

The effects of captopril and angiotensin II on adrenergic neurotransmission have been studied in spontaneously hypertensive rats (SHR) and Wistar-Kyoto rats (WKY). In a pithed rat preparation, vasoconstrictor responses evoked by spinal stimulation were greater in SHR than WKY (p less than 0.01). Captopril reduced responses to electrical stimulation and this reduction was greater in the SHR (p less than 0.001). Bilateral nephrectomy reduced the vasoconstrictor responses to nerve stimulation in both strains of rat and abolished the effects of captopril. In an isolated perfused mesenteric artery WKY (p less than 0.05). Angiotensin II potentiated responses from both strains of rat, however the amplitude of the potentiation was greater in preparations from the SHR than those from WKY (p less than 0.002). Captopril (30 mg/kg by mouth) reduced blood pressure in conscious SHR over a 5-day dosing period. In WKY rats, no hypertensive action of captopril was observed. However, in another normotensive strain, the Alderley Park Wistar rat (APW), captopril lowered blood pressure. Plasma renin activity was not significantly different among these three strains of rat. The APW have previously been shown to be very sensitive to the adrenergic potentiating actions of angiotensin II. Captopril thus lowers blood pressure in SHR and APW, and both these strains are sensitive to the adrenergic potentiating actions of angiotensin II. It does not lower blood pressure in WKY, which is relatively insensitive to these actions of the octapeptide. Therefore, the hypotensive action of captopril in the rat may be due to its interference with the adrenergic potentiating effect of angiotensin II.

Captopril and atenolol combined with hydrochlorothiazide in essential hypertension

1 Fifty-seven patients with mild or moderate essential hypertension, mean age 50 (range 31-69) were randomised to treatment with either captopril or atenolol. Twenty-six patients in each group completed the study. 2 Captopril (25-50 mg three times daily) and atenolol (50-100 mg once daily) caused a highly significant fall in blood pressure both supine and standing. 3 When hydrochlorothiazide (25-50 mg once daily) was added a further fall in blood pressure was observed in both groups. 4 Captopril as single drug caused no significant change in heart rate, while atenolol significantly reduced heart rate both supine and standing. 5 Two patients were excluded from the captopril group, one because of a reversible loss of taste and the other because of dizziness. Three patients were excluded from the atenolol group, two because of bradyarrhythmias and one because of inadequate blood pressure response. 6 Both captopril and atenolol were found to be effective antihypertensive agents, suitable for the treatment of essential hypertension.