Myocardial beta-1 adrenoceptor down-regulation in aging and heart failure: implications for beta-blocker use in older adults with heart failure

Metoprolol Mitigates Ischemic Heart Remodeling and Fibrosis by Increasing the Expression of AKAP5 in Ischemic Heart

The harm of heart failure mainly causes patients to develop dyspnea, fatigue, fluid retention, and other symptoms, which impair patients' activity tolerance and lead to a dramatic decrease in patients' quality of life. The purpose of this study was to verify whether metoprolol regulates AKAP5 expression and test the role of AKAP5 postinjury in mitigating cardiac infarction-associated tissue remodeling and fibrosis. Sprague-Dawley (SD) rats underwent coronary artery ligation (CAL), which was followed immediately with metoprolol daily. And western blot and coimmunoprecipitation experiments were performed to detect the expression of related proteins in the sham-operated group, model group, and drug-treated group. HW/BW ratio and cardiac expression of COL1 and COL3 were increased in rats following CAL compared with shams. Treatment with metoprolol postinjury was associated with a decrease in HW/BW ratio and COL1/COL3 expression compared to uncontrolled rats. CAL resulted in decreased cardiac AKAP5 expression compared to the control group, while metoprolol treatment restored levels compared to baseline shams. Cardiac expression levels of NFATc3/p-NFATc3 and GATA4 were modest at baseline and increased with injury, whereas metoprolol suppressed gene expression to below injury-associated changes. Immunoprecipitation indicated that AKAP5 could bind and regulate PP2B. In summary, we know that metoprolol alleviates ischemic cardiac remodeling and fibrosis, and the mechanism of alleviating remodeling may improve cardiac AKAP5 expression and AKAP5-PP2B interaction.

Beta receptor blocker therapy for the elderly in the COVID-19 era

When the coronavirus disease 2019 (COVID-19) pandemic spread globally from the Hubei region of China in December 2019, the impact on elderly people was particularly unfavorable. The mortality associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was highest in older individuals, in whom frailty and comorbidities increased susceptibility to severe forms of COVID-19. Unfortunately, in older patients, the course of COVID-19 was often characterized by significant cardiovascular complications, such as heart failure decompensation, arrhythmias, pericarditis, and myopericarditis. Ensuring that the elderly have adequate therapeutic coverage against known cardiovascular diseases and risk factors is particularly important in the COVID-19 era. Beta blockers are widely used for the treatment and prevention of cardiovascular disease. The clinical benefits of beta blockers have been confirmed in elderly patients, and in addition to their negative chronotropic effect, sympathetic inhibition and anti-inflammatory activity are theoretically of great benefit for the treatment of COVID-19 infection. Beta blockers have not been clearly shown to prevent SARS-CoV-2 infection, but there is evidence from published studies including elderly patients that beta blockers are associated with a more favorable clinical course of COVID-19 and reduced mortality. In this minireview, we summarize the most important evidence available in the literature on the usefulness of beta blocker therapy for older patients in the context of the COVID-19 pandemic.

A quantitative view on multivalent nanomedicine targeting

Although the concept of selective delivery has been postulated over 100 years ago, no targeted nanomedicine has been clinically approved so far. Nanoparticles modified with targeting ligands to promote the selective delivery of therapeutics towards a specific cell population have been extensively reported. However, the rational design of selective particles is still challenging. One of the main reasons for this is the lack of quantitative theoretical and experimental understanding of the interactions involved in cell targeting. In this review, we discuss new theoretical models and experimental methods that provide a quantitative view of targeting. We show the new advancements in multivalency theory enabling the rational design of super-selective nanoparticles. Furthermore, we present the innovative approaches to obtain key targeting parameters at the single-cell and single molecule level and their role in the design of targeting nanoparticles. We believe that the combination of new theoretical multivalent design and experimental methods to quantify receptors and ligands aids in the rational design and clinical translation of targeted nanomedicines.

Studies of Molecular Mechanisms Underlying Cardioprotective Action of the ALM-802 Compound

The mechanisms underlying cardioprotective activity of compound ALM-802 were studied in experiments on rats with chronic post-infarction heart failure. Real-time PCR showed that compound ALM-802 (daily intraperitoneal injections in a dose of 2 mg/kg for 28 days starting from day 91 after myocardial infarction modeling) restored the expression of genes encoding β1- (p=0.00001) and β2-adrenoreceptors (p=0.01) and type 2 ryanodine receptors (p=0.008) in the myocardium that was reduced in control animals. These effects can serve as the basis for the ability of the compound to reduce the intensity of remodeling and increase the inotropic function of the left heart ventricle shown earlier in this model.

The Influence of β-Adrenergic Receptor Kinase-1 on Stroke-induced Immunodeficiency Syndrome

BACKGROUND

Immunodeficiency in acute ischemic stroke (AIS) is thought to be a result of norepinephrine suppression of the lymphoid tissue. The possible differences in the distribution of lymphocytes after stroke may be due to differences in responsiveness of lymphocyte β-adrenergic receptors to their kinase (BARK-1).

OBJECTIVE

The objective was to quantify the influence of lymphocyte BARK-1 on stroke-induced immunodeficiency in AIS patients.

METHODS

A prospective clinical cohort study was conducted (N = 44). Measures included age, gender, race, risk factors for stroke, stroke severity, comorbidities, presence of infection, white blood cell counts and differential proportions, and lymphocyte BARK-1. Student t tests, effect sizes, and linear and logistic regressions were conducted to test the study objective. The study was approved by the Oregon Health & Science University Institutional Review Board.

RESULTS

There were significant changes in all white blood cells and differential proportions and in the National Institutes of Health Stroke Scale from admission to 48 hours after onset of stroke deficits. Higher BARK-1 influenced the lower lymphocyte proportion at 48 hours, independent of age, P < .0001. Furthermore, BARK-1 also was associated with an increase in the likelihood of having sustained or stroke-induced immunodeficiency at 48 hours: odds ratio, 2.41; 95% confidence interval, 1.10-5.25; P = .027, and odds ratio, 2.79; 95% confidence interval, 1.03-7.52; P = .043, respectively. In all backward stepwise selection of factors, BARK-1 was the only factor consistently retained in the models.

CONCLUSIONS

β-Adrenergic receptor kinase-1 has a significant quantifiable influence on lymphocyte proportion at 48 hours and on the classification of sustained stroke-induced immunodeficiency.

CLINICAL IMPLICATIONS

β-Adrenergic stimulation influences immunodeficiency in AIS.

Adrenergic Downregulation in Critical Care: Molecular Mechanisms and Therapeutic Evidence

Catecholamines remain the mainstay of therapy for acute cardiovascular dysfunction. However, adrenergic receptors quickly undergo desensitization and downregulation after prolonged stimulation. Moreover, prolonged exposure to high circulating catecholamines levels is associated with several adverse effects on different organ systems. Unfortunately, in critically ill patients, adrenergic downregulation translates into progressive reduction of cardiovascular response to exogenous catecholamine administration, leading to refractory shock. Accordingly, there has been a growing interest in recent years toward use of noncatecholaminergic inotropes and vasopressors. Several studies investigating a wide variety of catecholamine-sparing strategies (eg, levosimendan, vasopressin, β-blockers, steroids, and use of mechanical circulatory support) have been published recently. Use of these agents was associated with improvement in hemodynamics and decreased catecholamine use but without a clear beneficial effect on major clinical outcomes. Accordingly, additional research is needed to define the optimal management of catecholamine-resistant shock.

Atorvastatin prevents sepsis-induced downregulation of myocardial β1-adrenoceptors and decreased cAMP response in mice

Impaired cardiac β-adrenoceptor signaling is an important cause of sepsis-induced myocardial depression in man and experimental animals. We examined the effect of atorvastatin (ATR) pretreatment on myocardial β1-adrenoceptor (β1-AR) expressions and post-receptor signaling in a mouse model of sepsis (cecal ligation and puncture [CLP]). After 20 ± 2 h of surgery, hearts were isolated for the measurement of left ventricular functions (left ventricular developed pressure, dp/dt(max) and dp/dt(min)) using Langendorff setup. Western blot was used to determine β1-AR and G protein-coupled receptor kinase 2 protein expressions. Real-time polymerase chain reaction was done to determine β1-AR mRNA expression. Atorvastatin prevented sepsis-induced decrease in left ventricular functions, such as left ventricular developed pressure (CLP 75.90 ± 0.53 vs. ATR 100.24 ± 1.64 mmHg), dp/dtmax (CLP 3,742 ± 71 vs. ATR 4,291 ± 88 mmHg/s), and dp/dt(min) (CLP -1,010 ± 24 vs. ATR -1,346 ± 84 mmHg/s). Associated with functional impairments, sepsis decreased both myocardial β1-AR protein and mRNA expressions by 52% ± 9% and 62% ± 7%, respectively. However, ATR treatment of CLP mice (ATR) preserved β1-AR protein (96% ± 11%) and mRNA (88% ± 14%) expressions comparable to sham-operated level. Furthermore, it not only attenuated sepsis-induced decrease in basal cardiac adenosine 3',5'-cyclic monophosphate content (CLP 1.30 ± 0.27 vs. ATR 6.30 ± 0.67 pmol/mg protein), but also prevented its refractoriness to dobutamine stimulation (CLP 1.72 ± 0.27 vs. ATR 10.83 ± 1.37 pmol/mg protein). Atorvastatin also inhibited sepsis-induced increase in cardiac G protein-coupled receptor kinase 2 protein expression (CLP 1.73 ± 0.18-fold vs. ATR 1.10 ± 0.18-fold), protein kinase A activity (CLP 1.12 ± 0.14 vs. ATR 0.66 ± 0.08 U/mg protein) and plasma catecholamines (CLP 138 ± 22 vs. ATR 59 ± 2 pg/mL). In conclusion, ATR seems to improve left ventricular functions in vitro through the preservation of β(1)-AR signaling in sepsis.

Rapid quantification of live cell receptors using bioluminescence in a flow-based microfluidic device

The number of receptors expressed by cells plays an important role in controlling cell signaling events, thus determining its behaviour, state and fate. Current methods of quantifying receptors on cells are either laborious or do not maintain the cells in their native form. Here, a method integrating highly sensitive bioluminescence, high precision microfluidics and small footprint of lensfree optics is developed to quantify cell surface receptors. This method is safe to use, less laborious, and faster than the conventional radiolabelling and near field scanning methods. It is also more sensitive than fluorescence based assays and is ideal for high throughput screening. In quantifying β(1) adrenergic receptors expressed on the surface of H9c2 cardiomyocytes, this method yields receptor numbers from 3.12 × 10(5) to 9.36 × 10(5) receptors/cell which are comparable with current methods. This can serve as a very good platform for rapid quantification of receptor numbers in ligand/drug binding and receptor characterization studies, which is an important part of pharmaceutical and biological research.

Impact of prescribed medications on patient safety in older people

Appropriate prescribing for older adults presents unique challenges to the prescriber. An understanding of the scale of the problems and contributing factors is essential when designing interventions to improve patient safety. The altered pharmacology of ageing, the existence of multiple medical conditions and the exclusion of elderly patients from many trials render this subgroup of the population particularly vulnerable to underprescribing and overprescribing. Adverse drug events are common, causing significant morbidity and mortality as well as having economic implications. 'High-risk' medications such as opioids, anticoagulants and antipsychotics can have benefits in this group of patients but strategies to optimize their safety are required. Tools exist that help to identify those at risk of adverse drug reactions and to screen for inappropriate prescribing. Developments in information technology are ongoing, and it is hoped that these may enhance the process of medication reconciliation across healthcare transitions and alert the prescriber to potential adverse drug events. This review addresses commonly encountered issues when prescribing for older people, considers strategies to improve medication safety and offers a list of 'top tips' to aid the clinician.

Prevention of cardiac events caused by surgical stress in aged rats: simultaneously activating β2-adrenoceptor and inhibiting β1-adrenoceptor

Increased plasma catecholamine levels are associated with a high risk of perioperative cardiac events in aged individuals undergoing non-cardiac surgical interventions. Given the different effects of β1-adrenoreceptor (β1AR) and β2-adrenoreceptor (β2AR) stimulation by catecholamine in cardiomyocytes, this study evaluated whether simultaneous inhibition of β1AR and activation of β2AR is better than separate application in reducing the risk of perioperative cardiac events in aged rats undergoing non-cardiac surgery. Male aged Sprague-Dawley (SD) rats were divided into five groups. Normal group received no treatment. Surgery group received an abdominal surgery with hypoxia. β1- group, β2+ group, β2+ group and β1+β2+ group received surgery and hypoxia with metoprolol (100 mg/kg·d), fenoterol (250 μg/kg·d) or both, respectively. The drugs were given three days before surgery with treatment continued through post-surgical day 7. The results showed that simultaneous activation of β2AR with a β2AR agonist and inhibition of β1AR with a selective β1AR blocker normalized myocardial oxygen consumption, decreased myocardial damage, augmented cardiomyocyte survival, improved cardiac function, reduced the incidence of arrhythmia, thus decreasing the occurrence of cardiac events in perioperative aged rats undergoing non-cardiac surgery. The results demonstrated that combined use of β2AR agonist and β1AR blocker achieved better general effects than use of either one alone. Our results provide a new insight into preventing perioperative cardiac events for elderly patients undergoing surgical stress.

Array data extractor (ADE): a LabVIEW program to extract and merge gene array data

Background

Large data sets from gene expression array studies are publicly available offering information highly valuable for research across many disciplines ranging from fundamental to clinical research. Highly advanced bioinformatics tools have been made available to researchers, but a demand for user-friendly software allowing researchers to quickly extract expression information for multiple genes from multiple studies persists.

Findings

Here, we present a user-friendly LabVIEW program to automatically extract gene expression data for a list of genes from multiple normalized microarray datasets. Functionality was tested for 288 class A G protein-coupled receptors (GPCRs) and expression data from 12 studies comparing normal and diseased human hearts. Results confirmed known regulation of a beta 1 adrenergic receptor and further indicate novel research targets.

Conclusions

Although existing software allows for complex data analyses, the LabVIEW based program presented here, “Array Data Extractor (ADE)”, provides users with a tool to retrieve meaningful information from multiple normalized gene expression datasets in a fast and easy way. Further, the graphical programming language used in LabVIEW allows applying changes to the program without the need of advanced programming knowledge.

Pinpointing beta adrenergic receptor in ageing pathophysiology: victim or executioner? Evidence from crime scenes

G protein-coupled receptors (GPCRs) play a key role in cellular communication, allowing human cells to sense external cues or to talk each other through hormones or neurotransmitters. Research in this field has been recently awarded with the Nobel Prize in chemistry to Robert J. Lefkowitz and Brian K. Kobilka, for their pioneering work on beta adrenergic receptors (βARs), a prototype GPCR. Such receptors, and β2AR in particular, which is extensively distributed throughout the body, are involved in a number of pathophysiological processes. Moreover, a large amount of studies has demonstrated their participation in ageing process. Reciprocally, age-related changes in regulation of receptor responses have been observed in numerous tissues and include modifications of βAR responses. Impaired sympathetic nervous system function has been indeed evoked as at least a partial explanation for several modifications that occur with ageing. This article represents an updated presentation of the current knowledge in the field, summarizing in a systematic way the major findings of research on ageing in several organs and tissues (crime scenes) expressing βARs: heart, vessels, skeletal muscle, respiratory system, brain, immune system, pancreatic islets, liver, kidney and bone.

[Cardioprotection]

The demographic change is associated with an increasing number of elderly patients with serious comorbidities. The prevalence of coronary heart disease in particular increases with age and raises the risk of perioperative myocardial ischemia. In the last few years various interventions have been evaluated to lower the perioperative risk for serious cardiovascular events. This includes cardioprotective medical interventions, for example with β-receptor blockers and statins. Current guidelines recommend that patients who are on β-receptor blockers or statins for chronic treatment of cardiovascular diseases should continue this medication throughout the perioperative period. Myocardial conditioning has been assessed to be effective under numerous experimental conditions and clinical trials have also provided evidence for myocardial protection by conditioning. Besides ischemic and anesthetic-induced preconditioning the noninvasive technique of remote preconditioning offers interesting possibilities, especially for patients with serious comorbidities; however, large scale randomized clinical multicentre trials are still needed. Regarding cardioprotective effectiveness, the clinical data for regional anesthesia are very heterogeneous; nevertheless regional anesthesia is very effective in postoperative pain therapy. Therefore regional anesthesia should be used as a part of multimodal therapy concepts to lower the risk of perioperative cardiovascular events.

Chronic social stress induces cardiomyocyte contractile dysfunction and intracellular Ca2+ derangement in rats

Chronic psychosocial stress triggers cardiovascular diseases although underlying mechanisms are still elusive. This study examined the effect of social stress on cardiomyocyte contractile function and pathological changes in myocardium using the visible burrow system (VBS) model. Chronic social stress was induced using a mixed-sex VBS housing in adult Sprague-Dawley (SD) rats. Contractile and intracellular Ca(2+) properties were evaluated in isolated cardiomyocytes including peak shortening (PS), time-to-PS (TPS), time-to-90% relengthening (TR(90)), maximal velocity of shortening/relengthening (± dL/dt), Fura-2 fluorescence intensity, and intracellular Ca(2+) decay. Myocardial histology was evaluated using Masson trichrome staining. Social stress led to depressed PS, ± dL/dt, shortened TPS and prolonged TR(90) compared with the unstressed controls. Baseline and electrically-stimulated rise in Ca(2+) were reduced whereas intracellular Ca(2+) decay was delayed in stressed rats. Histological analyses exhibited overt interstitial fibrosis and cardiomyocyte hypertrophy in stressed rats. The GSH/GSSG ratio (indicative of oxidative stress status) was reduced whereas oxidative protein carbonyl formation was elevated in stressed rats. Western blot analysis showed unchanged expression of superoxide dismutase 1 (SOD1), β(1)-adrenoceptor (β(1)-AR) levels, reduced sarco(endo)plasmic reticulum Ca(2+)-ATPase (SERCA2a) levels, and elevated phosphorylation of the stress signaling protein kinase JNK but not ERK in myocardium from stressed rats. Short-term in vitro treatment of cardiomyocytes with the stress inducer phenylephrine mimicked cell damage and intracellular Ca(2+) mishandling, the effects of which were mitigated by antioxidant, JNK inhibition, carvedilol and SERCA2a adenovirus. These findings indicate that chronic social stress is detrimental to cardiac structure and function possibly via mechanisms associated with oxidative injury and intracellular Ca(2+) mishandling.

Role of the excessive amounts of circulating catecholamines and glucocorticoids in stress-induced heart disease

Various stressful stimuli are known to activate the sympathetic nervous system to release catecholamines and the hypothalamic-pituitary-adrenal axis to release glucocorticoids in the circulation. Although initial actions of both catecholamines and glucocorticoids are beneficial for the function of the cardiovascular system, their delayed effects on the heart are deleterious. Glucocorticoids not only increase plasma levels of catecholamines by inhibiting their extraneuronal uptake, but they have also been shown to induce supersensitivity to catecholamines in the heart by upregulating different components of the betta-adrenoceptor signal transduction system. Low concentrations of catecholamines stimulate the heart by promoting Ca2+ movements, whereas excessive amounts of catecholamines produce cardiac dysfunction by inducing intracellular Ca2+ overload in cardiomyocytes. Several studies have shown, however, that under stressful conditions high concentrations of catecholamines become oxidized to form aminolutins and generate oxyradicals. These oxidation products of catecholamines have been demonstrated to produce coronary spasm, arrhythmias, and cardiac dysfunction by inducing Ca2+-handling abnormalities in both sarcolemmal and sarcoplasmic reticulum, defects in energy production by mitochondria, and myocardial cell damage. In this article we have focused the discussion to highlight the interrelationship between catecholamines and glucocorticoids and to emphasize the role of oxidation products of catecholamines in the development of stress-induced heart disease.

DEFEAT heart failure: assessment and management of heart failure in nursing homes made easy

Heart failure (HF) in older adults presents challenges that are different in many ways than those for younger adults. Diagnosis of HF in older adults can be delayed due to attributing early symptoms to normal changes of aging or, in the setting of a normal ejection fraction, failing to appreciate diastolic heart failure. Moreover, treatment of HF in the elderly is often complicated by comorbidities and polypharmacy. The long-term care setting can present even more challenges, yet can be made easy by following a simple mnemonic DEFEAT-HF. After making a clinical Diagnosis and determining the Etiology, Fluid volume must be assessed to achieve euvolemia, and Ejection frAction must be determined to guide Therapy.

Analyses of dynamic beat-to-beat QT-TQ interval (ECG restitution) changes in humans under normal sinus rhythm and prior to an event of torsades de pointes during QT prolongation caused by sotalol

BACKGROUND

Restitution through intracardiac pacing has been used to assess arrhythmia vulnerability. We examined whether analyses of sequential beat-to-beat QT and TQ interval measures can be used to quantify ECG restitution changes under normal sinus rhythm.

METHODS

The QT, R-R and TQ intervals were examined 22.5 hour Holter monitoring before and after oral sotalol in normal male and female volunteers. Additionally, comparisons were made to those observed in the time-matched dataset prior to torsades de pointes in a heart diseased patient that received a single dose of sotalol.

RESULTS

Sotalol increased QT, R-R and TQ intervals 71, 101, and 125 ms after 160 mg (n = 38) and 194, 235, and 135 ms after 320 mg (n = 19) during maximum plasma concentrations, respectively. The percentage of beats with a QT/TQ ratio >1 was reduced 25% over the entire 22.5 hours after sotalol and the lower TQ interval boundary (5th quantile) was increased 22-30%. In contrast, 99% of the beats prior to torsades de pointes had a QT/TQ ratio > 1 and the median TQ interval was below the lower 98% confidence bounds of normals before and after sotalol.

CONCLUSIONS

ECG restitution changes are quantifiable under varying states (nocturnally, beta-adrenergic blockade, QT prolongation) in healthy subjects.

DEFEAT heart failure: clinical manifestations, diagnostic assessment, and etiology of geriatric heart failure

Aging is characterized by heterogeneity, both in health and in disease. Older adults who have heart failure (HF) often have atypical and delayed clinical manifestations and many have diastolic HF. The assessment and management of HF in older adults may be simplified by a 5-step process called DEFEAT HF: (1) establish a clinical Diagnosis of HF; (2) establish an Etiology for HF, preferably in collaboration with a cardiologist; (3) determine Fluid status and achieve euvolemia; (4) determine left ventricular Ejection frAction; and (5) provide evidence-based Therapy.

Beta-blocker contraindications: Are there patients or situations where use is inappropriate?

beta-blockers have been conclusively proven to increase survival and improve symptoms of heart failure, yet there is underutilization of these agents most commonly because of misunderstandings of the relative contraindications and adverse events during treatment. In this manuscript, we discuss the potential contraindications to beta-blockers in heart failure and compare the true risks against the significant benefits.

Changes in the in vitro pharmacodynamic properties of metoprolol in atria isolated from spontaneously hypertensive rats

1. The present study addressed possible changes in the dissociation constant of metoprolol and its inverse agonist activity in spontaneously hypertensive rats (SHR). In addition, a possible correlation between cardiac hypertrophy and the inverse agonist activity of metoprolol was explored. 2. In order to determine the dissociation constant (expressed as the pKb) of metoprolol, a cumulative concentration-response curve to noradrenaline was constructed in the absence or presence of metoprolol (0.1, 1 or 10 micromol/L). In a second experiment, a cumulative concentration-response curve to metoprolol was constructed to determine its inverse agonist activity. 3. The ventricular weight of SHR was significantly greater compared with Wistar-Kyoto (WKY) rats. A rightward shift of the concentration-response curve to noradrenaline was observed in SHR compared with WKY rats. The pKb of metoprolol was smaller in SHR compared with WKY rats (6.35 +/- 0.14 vs 6.99 +/- 0.12, respectively; P < 0.05). No difference was observed in the maximal response (Emax) of the concentration-time effect of metoprolol in WKY rats and SHR (-29.1 +/- 7.1 vs-28.2 +/- 8.5%, respectively; n = 6 for both). However, the concentration of metoprolol eliciting a half-maximal effect (expressed as the pEC50) was significantly smaller in SHR compared with WKY rats (4.82 +/- 0.07 vs 5.29 +/- 0.13, respectively; n = 6; P < 0.05). Although a significant correlation (r = -0.876) between the ventricular weight/bodyweight (VW/BW) ratio and the pEC50 of the chronotropic effect of metoprolol was found, no relationship (r = -0.257) was found between the VW/BW ratio and Emax. 4. In summary, the present study provides the first evidence of a change in the in vitro pharmacodynamic properties of metoprolol in SHR. The sympathetic overactivity present in SHR not only reduces the positive chronotropic effect of noradrenaline, but also diminishes the constant dissociation of metoprolol from atrial beta1-adrenoceptors and its inverse agonist activity. A significant correlation between the VW/BW ratio and the inverse agonist potency of metoprolol was found, suggesting a possible link between cardiac hypertrophy and the reduction of the inverse agonist activity of metoprolol.

Clinical manifestations, diagnostic assessment, and etiology of heart failure in older adults

Aging is characterized by heterogeneity, both in health and in dis-ease. Older adults who have heart failure (HF) often have a typical and delayed clinical manifestations and many have diastolic HF. The assessment and management of HF in older adults may be simplified by a 5-step process called DEFEAT HF: (1) Establish a clinical Diagnosis of HF; (2) Establish an Etiology for HF, preferably in collaboration with a cardiologist; (3) Determine Fluid status and achieve euvolemia; (4) Determine left ventricular Ejection frAction; and (5) Provide evidence-based Therapy.

Effects of carvedilol on M2 receptors and cholinesterase-positive nerves in adriamycin-induced rat failing heart

Heart failure is correlated with attenuation of parasympathetic nervous function and enhanced sympathetic activity. Carvedilol, a third-generation beta-blocker, may improve the prognosis of heart failure better than selective beta(1)-blockers. Not all of its effects, however, can be explained by direct actions on the sympathetic nervous system. This study was therefore performed to investigate the possible alterations of muscarinic cholinergic (M)(2) receptors and cholinesterase-positive nerves in different regions of the adriamycin-induced failing rat heart, and the potential effects of carvedilol on these M(2) receptors and cholinesterase-positive nerves. Karnovsky-Roots histochemical staining combined with point counting methods, and immunochemical streptavidin-biotin complex staining and image analysis were used to test the distribution of cholinesterase-positive nerves and the expression of M(2) receptors, respectively. Our results show that the cholinesterase-positive nerve system was downregulated in the adriamycin-induced failing heart group, while the density of M(2) receptors was increased in the carvedilol 3- and 10-mg/kg body weight groups, especially in the endocardial tissues of the left-ventricular free wall. It is concluded that upregulation of M(2) receptors may be one of the potential mechanisms by which carvedilol exert its action on heart failure.

Age-related changes in sympathetic neurotransmission in rat retina and choroid

While age-related night vision loss and age-related macular degeneration are well characterized, less is known about the normal aging process in the retina and choroid. The purpose of this study was to ascertain whether dopamine beta-hydroxylase (DBH), beta1- and beta2-adrenergic receptor gene and protein expression are altered in the retina and choroid with age. The retina and choroid were dissected from F344xBNF1 hybrid rats aged 8, 22, and 32 months. Real-time PCR and Western blot analysis were conducted to determine steady-state mRNA and protein expression. Immunohistochemistry (IHC) was conducted to localize DBH protein expression in the retina. DBH protein expression was substantially decreased with age in the retina, particularly in the outer nuclear layer, with no changes in DBH expression noted in the choroid. There was a significant increase in beta1-adrenergic receptor protein expression in retinal samples at 22 months, while beta2-adrenergic receptor protein expression was not affected by age. Decreased expression of DBH with age in the retina could lead to reduced production of norepinephrine, potentially resulting in an increase of beta1-adrenergic receptor expression due to denervation supersensitivity. Gene expression for DBH, beta1- and beta2-adrenergic receptors were observed to peak at 22 months and return to baseline levels by 32 months of age in the choroid. Our findings suggest that the retina may be more sensitive to age-related loss of sympathetic neurotransmission than the choroid, which may partially explain normal age-related vision loss in the elderly.

The role of adrenergic receptor polymorphisms in heart failure

The main function of the cardiac adrenergic system is to regulate cardiac work both in physiologic and pathologic states. A better understanding of this system has permitted the elucidation of its role in the development and progression of heart failure. Regardless of the initial insult, depressed cardiac output results in sympathetic activation. Adrenergic receptors provide a limiting step to this activation and their sustained recruitment in chronic heart failure has proven to be deleterious to the failing heart. This concept has been confirmed by examining the effect of beta-blockers on the progression of heart failure. Studies of adrenergic receptor polymorphisms have recently focused on their impact on the adrenergic system regarding its adaptive mechanisms, susceptibilities and pharmacological responses. In this article, we review the function of the adrenergic system and its maladaptive responses in heart failure. Next, we discuss major adrenergic receptor polymorphisms and their consequences for heart failure risk, progression and prognosis. Finally, we discuss possible therapeutic implications resulting from the understanding of polymorphisms and the identification of individual genetic characteristics.

Intravenous Esmolol is Well Tolerated in Elderly Patients with Heart Failure in the Early Phase of Non-ST Elevation Myocardial Infarction

AIM

To investigate the haemodynamic response to and clinical safety and tolerability of intravenous esmolol (Brevibloc), Baxter Healthcare Corporation, Deerfield, Illinois, USA) in elderly and younger patients with acute non-ST elevation myocardial infarction (NSTEMI) and heart failure.

PATIENTS AND METHODS

We studied 24 consecutive patients, 12 of them elderly (> or =75 years old) and 12 younger (32-74 years old), with NSTEMI and symptoms of heart failure on presentation. After stabilisation of the patient's condition with standard therapy, intravenous esmolol was administered. An infusion rate of 0.05 mg/kg/min for 30 minutes was instituted and, if no adverse effects developed, this was increased to 0.20 mg/kg/min. All haemodynamic parameters were measured before and at the end of each administration using a Swan-Ganz catheter.

RESULTS

Only one patient in the elderly subgroup did not tolerate the augmented infusion rate (because of severe bradycardia) and so had to return to the initial lower infusion rate. The cardiac index (mean +/- SD) was 2.4 +/- 0.9 L/min/m(2) at baseline and decreased to 1.9 +/- 0.4 L/min/m(2) (p < 0.05 vs baseline) at the end of the administration of the second dose of esmolol in the elderly patients and 2.6 +/- 0.5 L/min/m(2) and 2.2 +/- 0.5 L/min/m(2) (p < 0.05 vs baseline), respectively, in the younger patients. Mean pulmonary wedge pressure was 17 +/- 6mm Hg at baseline and increased to 19 +/- 4mm Hg (p < 0.05 vs baseline) at the end of the second dose of esmolol in the elderly patients and 16 +/- 10mm Hg and 18 +/- 10mm Hg (p < 0.05 vs baseline), respectively, in the younger patients. The response of both age groups to esmolol was the same for all of the parameters examined.

CONCLUSION

Intravenous esmolol was safe and well tolerated in the early phase of NSTEMI in patients presenting with symptoms of heart failure and ongoing ischaemia, regardless of their age.

Use of Beta-Blockers in Older Adults with Chronic Heart Failure

Most heart failure patients are older adults. Angiotensin-converting enzyme (ACE) inhibitors reduce mortality and morbidity in patients with systolic heart failure. However, the annual mortality rate in patients with systolic heart failure receiving ACE inhibitors is about 12%. Beta-blockers further reduce mortality rate by an additional 35% to 65%. Because of potential adverse effects, the rate of beta-blocker use is likely to be low in older adults with systolic heart failure. In this article, we review the findings of the major beta-blocker trials in systolic heart failure and discuss the potential benefits and adverse effects of beta-blockers, along with various practical aspects of their use in older adults with systolic heart failure. Subgroup analyses of these trials suggest that the survival benefits of beta-blockers observed in the main trials are also observed in persons 65 years of age and older. However, data are limited for heart failure patients 85 years of age and older. About half of the older adults with heart failure do not have systolic heart failure, and currently there is no evidence that beta-blockers also improve survival in these patients. Beta-blockers might play a beneficial role in heart failure patients without systolic heart failure by reducing high blood pressure, high heart rate, or myocardial ischemia, conditions known to impair ventricular relaxation. Adequate knowledge of the commonly used beta-blockers, along with careful patient selection and close monitoring for adverse effects will allow safe initiation and continuation of beta-blocker use for older adults with systolic heart failure. It is likely that lower doses of beta-blockers are as effective as higher doses.

Impaired muscle metaboreflex-induced increases in ventricular function in heart failure

We investigated to what extent heart failure alters the ability of the muscle metaboreflex to improve ventricular function. Dogs were chronically instrumented to monitor mean arterial pressure (MAP), cardiac output (CO), heart rate (HR), stroke volume (SV), and central venous pressure (CVP) at rest and during mild treadmill exercise (3.2 km/h) before and during reductions in hindlimb blood flow imposed to activate the muscle metaboreflex. These control experiments were repeated at constant heart rate (ventricular pacing 225 beats/min) and at constant heart rate coupled with a beta-adrenergic blockade (atenolol, 2 mg/kg iv) in normal animals and in the same animals after the induction of heart failure (HF, induced via rapid ventricular pacing). In control experiments in normal animals, metaboreflex activation caused tachycardia with no change in SV, resulting in large increases in CO and MAP. At constant HR, large increases in CO still occurred via significant increases in SV. Inasmuch as CVP did not change in this setting and that beta-adrenergic blockade abolished the reflex increase in SV at constant HR, this increase in SV likely reflects increased ventricular contractility. In contrast, after the induction of HF, much smaller increases in CO occurred with metaboreflex activation because, although increases in HR still occurred, SV decreased thereby limiting any increase in CO. At constant HR, no increase in CO occurred with metaboreflex activation even though CVP increased significantly. After beta-adrenergic blockade, CO and SV decreased with metaboreflex activation. We conclude that in HF, the ability of the muscle metaboreflex to increase ventricular function via both increases in contractility as well as increases in filling pressure are markedly impaired.

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Diabetes mellitus is associated with a distinct cardiomyopathy. Whether cardiac myofilament function is altered in human diabetes mellitus is unknown. Myocardial biopsies were obtained from seven diabetic patients and five control, nondiabetic patients undergoing coronary artery bypass surgery. Myofilament function was assessed by determination of the developed force-Ca2+ concentration relation in skinned cardiac cells from flash-frozen human biopsies. Separate control experiments revealed that flash freezing of biopsy specimens did not affect myofilament function. All patients in the diabetes mellitus cohort were classified as Type 2 diabetes mellitus patients, and most showed signs of diastolic dysfunction. Diabetes mellitus was associated with depressed myofilament function, that is, decreased Ca2+ sensitivity (29%, P < 0.05 vs. control) and a trend toward reduction of maximum Ca2+-saturated force (29%, P = 0.08 vs. control). The slope of the force-Ca2+ concentration relation (Hill coefficient) was not affected by diabetes, however. We conclude that human diabetes mellitus is associated with decreased cardiac myofilament function. Depressed cardiac myofilament Ca2+ responsiveness may underlie the decreased ventricular function characteristic of human diabetic cardiomyopathy.