Magnitude and mechanisms of the antihypertensive action of labetalol, including ambulatory assessment

Labetalol. A reappraisal of its pharmacology, pharmacokinetics and therapeutic use in hypertension and ischaemic heart disease

Since labetalol was first reviewed in the Journal (1978), its scope of therapeutic use has expanded and become better defined. Labetalol is an adrenoceptor blocking drug with combined alpha- and beta-blocking properties. These result in a more favourable haemodynamic profile for labetalol compared with 'pure' beta-blockers or pure alpha-blockers, but also contribute to a wider range, but not an overall increased incidence, of adverse effects. The drug is effective and well-tolerated in patients with all grades of hypertension, but is of particular value in special subgroups such as Black patients, the elderly and patients with renal hypertension. While comparative studies are not extensive, available data show that the drug reduces blood pressure to a similar extent, and in a similar proportion of patients, as 'pure' beta-blockers such as propranolol, pure alpha-blockers such as prazosin, calcium antagonists (nifedipine, verapamil), and centrally acting drugs (clonidine and methyldopa). Labetalol is very effective in hypertensive pregnant women and in hypertensive crises, where it provides good control of blood pressure without serious adverse effects, and where few therapeutic options exist. Few controlled studies have investigated the use of labetalol in deliberate induction of hypotension or prevention of hypertension during anaesthesia, and also in patients with ischaemic heart disease. However, available evidence suggests a role for labetalol in these indications and further studies should aid in clarification of its efficacy in these areas. Thus, with its broad scope of therapeutic use in hypertension labetalol remains an important therapeutic option, and the drug may well find an additional place in the treatment of myocardial ischaemia if further evidence confirms encouraging preliminary findings.

Computerized evaluation of Valsalva's Maneuver before and during alpha-adrenoceptor blockade with alfuzosin

Methodological differences exist in the evaluation of Valsalva's Maneuver. Linear and nonlinear mathematical models were described for beat-to-beat changes in blood pressure and R-R intervals occurring during the strain and release phases of Valsalva's Maneuver. This study indicated that the strain phase is linear, whereas the release phase is nonlinear; the release phase consists of a "lag phase," a "breakpoint," and an "overshoot phase." The alpha-adrenoceptor antagonist, alfuzosin, reduced baroreflex-mediated tachycardia during the strain phase and prolonged the "time lag" and "pressure lag" during the release phase; the latter change was due entirely to the reduced systolic pressure that occurred with alfuzosin at the end of the strain phase.

Real time detection of significant blood pressure events in ambulant subjects

A typical twenty-four hour continuous ambulatory blood pressure (BP) record demonstrates many marked, apparently spontaneous blood pressure spikes. Awareness of such BP fluctuations may help determine their causative mechanisms and lead to improved applications of conscious learned control of BP (Biofeedback). A microprocessor device has been constructed to monitor direct arterial blood pressure in real time and to compile a profile history of the BP and heart rate (HR). When the BP level exceeds a threshold based on the BP history, an audio signal prompts the subject, who is then able to record the current physical and emotional status. Alternatively, a combination of the parameters (SBP,DBP,HR) may be used to determine the threshold criteria. A decision table determines whether each parameter should lie above, below or within the threshold region. Triggering will occur only if a predefined relationship has occurred. The device will aid in the detection and interpretation of significant BP events occurring during a 24 hour recording as well as in the application and assessment of biofeedback control of blood pressure.

Combined alpha- and beta-receptor inhibition in the treatment of hypertension

Both beta- and alpha-adrenergic mechanisms are important in the control of blood pressure; alpha-mediated vasoconstriction is responsible for the regulation of vascular tone, and beta-mediated responses stimulate the heart directly and indirectly by liberating renin and affecting vascular smooth muscle tone. beta-Adrenergic blocking drugs have long been established in the treatment of hypertension. The development of drugs which combine this action with an alpha-blocking effect represents an additional mode of action to lower the blood pressure. Numerous studies have demonstrated that labetalol intravenously or orally gives a rapid fall of blood pressure in essential and renal hypertension. It has also been used intravenously in phaeochromocytoma, tetanus, clonidine withdrawal, and as an adjunct to halothane to produce hypotensive anaesthesia. Intravenously, labetalol is probably best given as a graded infusion or as repeated small bolus injections to assure a smooth fall of blood pressure. Many long term studies have shown it to be effective orally in prolonged treatment of hypertension with studies of over 5 years, showing that tolerance does not develop. Labetalol can be used in combination with diuretics and other drugs when necessary. It can be employed to control the blood pressure in all grades of hypertension. A dosage of 100mg twice daily will often be adequate to control mild hypertension and the use of even lower doses has been reported. However, the dosage can be markedly increased in severe hypertension and while such doses are relatively exceptional, several trials have employed over 2 g per day for the more resistant cases. Studies have demonstrated that blood pressure control with labetalol is equivalent to that with beta-adrenoceptor blocking drugs plus vasodilators, or methyldopa. Labetalol has been used in patients with severe renal impairment and a number of studies suggest that it may now be the drug of choice in raised blood pressure of pregnancy. Side effects can be divided into those related to beta-blockade, those related to alpha-blockade and those not clearly related to either effect. It has been suggested that the side effects attributable to the beta-blocking component are less obtrusive than those seen with pure beta-blocking drugs without alpha-activity because the alpha-blockade modifies the consequences of beta-blockade. Heart failure has been reported, but for haemodynamic reasons would be expected to be less common; careful patient selection should avoid any risk. Similarly labetalol may worsen asthma even if the risks are probably less than with non-selective beta-blockade alone.(ABSTRACT TRUNCATED AT 400 WORDS)