Calcium antagonists and low density lipoprotein receptors

Effects of nifedipine, verapamil and diltiazem on serum biochemical parameters and aortic composition of atherosclerotic chickens

Calcium appears to be involved in many of the cellular events, which are thought to be important in atherogenesis. In this study, we examine the effects of three calcium entry blockers (nifedipine, verapamil, and diltiazem at clinical and higher doses) on serum biochemical parameters and aortic calcium, cholesterol and triglyceride concentrations of atherosclerotic egg-fed chickens. All egg-fed chickens (treated and non-treated) showed an increase in serum total cholesterol, LDL-cholesterol and triglycerides without significant effect when calcium entry blockers were used. Increased HDL values were observed in clinical and high-dose nifedipine and clinical dose verapamil groups. The high-dose diltiazem group presented increased zinc values with respect to the clinical dose diltiazem and control groups. The sodium concentrations were significantly decreased in all the groups of animals treated with calcium entry blockers at high-doses and nifedipine at clinical doses. Measurements of aortic calcium concentration showed a significant decrease in the high-dose nifedipine and verapamil groups. Calcium channel blockers had a tendency to decrease total cholesterol in aortas. The values were statistically significant for the high-dose verapamil, and nifedipine groups. Only nifedipine showed a significant decrease for this parameter at clinical dosages. Triglyceride concentrations in aortas were significantly low in animals fed an atherogenic diet and treated with calcium channel blockers, without differences between drugs or dosages used in the experiment. In addition, the chicken atherosclerosis model has proved itself useful and very suitable for in vivo drug intervention studies.

Antiatherosclerotic effects of calcium channel blockers

Over the past 30 years, a considerable body of experimental and clinical evidence has accumulated to support the suggestion that calcium channel blockers (CCBs) have significant antiatherosclerotic effects that are independent of their hypotensive effects. Early research using animal models of atherosclerosis and CCBs in concentrations that exceeded the normal therapeutic dose range showed definite antiatherosclerotic effects, especially in the development of new lesions. Investigations of these effects in humans have used quantitative coronary angiography and B-mode ultrasonography and have demonstrated some antiatherosclerotic effects. This article reviews the currently available evidence of antiatherosclerotic effects of CCBs in animal models and in clinical trials.

Effect of lercanidipine and its (R)-enantiomer on atherosclerotic lesions induced in hypercholesterolemic rabbits

The in vivo antiatherogenic activity of the calcium antagonist lercanidipine and its (R)-enantiomer was investigated in two different types of atherosclerotic lesions (hyperplastic and fatty-streak lesions) in rabbits. Lercanidipine (0.3, 1, and 3 mg kg(-1) week(-1)) as well as its (R)-enantiomer at 3 mg kg(-1) week(-1) were given by subcutaneous injection for 10 weeks to White New Zealand rabbits, with cholesterol feeding beginning at week 2. The hyperplastic lesion was obtained by positioning a hollow silastic collar around one carotid artery, while aortic fatty streak lesions were induced by cholesterol feeding. In untreated animals (n=5), 14 days after collar positioning an intimal hyperplasia was clearly detectable: the arteries without collar showed a intima/media (I/M) ratio of 0.03+/-0.02, whereas in carotids with a collar the ratio was 2+/-0.42. In lercanidipine-treated animals a significant and dose-dependent effect on intimal hyperplasia was observed. I/M ratios were 0.73+/-0.4, 0.42+/-0.1, 0.32+/-0.1 for 0.3, 1, and 3 mg kg(-1) week(-1), respectively (P<0.05). The lercanidipine enantiomer (3 mg kg(-1) week(-1)) was as effective as the racemate (0.41+/-0.11). Proliferation of smooth muscle cells, assessed by incorporation of BrdU into DNA, was reduced by about 50%, 70%, 85%, and 80% by lercanidipine (0.3, 1, and 3 mg kg(-1) week(-1)) and its (R)-enantiomer, respectively. The area of fatty-streaks in the aorta (n = 11-15) was significantly reduced by lercanidipine (3 mg kg(-1) week(-1), 16% vs 27%, P<0.05), a trend was observed also with lower doses. When different segments of the aorta were considered (arch, thoracic, abdominal) a significant and dose-dependent effect in the thoracic and abdominal aorta was observed also at lower doses. The (R)-enantiomer was as effective as lercanidipine. These results suggest a direct antiatherosclerotic effect of lercanidipine, independent of modulation of risk factors such as hypercholesterolemia and/or hypertension as demonstrated by the absence of stereoselectivity.

Verapamil enhances the uptake and the photocytotoxic effect of PII, but not that of tetra(4-sulfonatophenyl)porphine

The influence of the calcium channel blocker verapamil on the sensitivity of mouse fibrosarcoma cells of the line EMT-6 to treatment with Photofrin II (PII) or tetra(4-sulfonatophenyl)porphine (TPPS4) and light has been assessed. Cells were treated with 1.5 microg/ml PII or 75 microg/ml TPPS4 overnight in the absence or presence of 50 microg/ml verapamil and subsequently exposed to light. Verapamil increased the sensitivity of the EMT-6 cells to PII-induced photoinactivation by a factor of 2. In contrast, verapamil decreased the sensitivity of the cells to TPPS4-induced photoinactivation by 50-60%. Both sensitizers were found to be located to a large extent in lysosomes as revealed by fluorescence microscopy and by photochemical inactivation of the lysosomal marker enzyme beta-N-acetyl-D-glucosaminidase. Verapamil increased the uptake of PII by 30% and reduced the uptake of TPPS4 by 20%. Furthermore, verapamil enhanced the binding and uptake of LDL by about 40%. In conclusion, the effects of verapamil-induced sensitization of EMT-6 cells treated with PII or TPPS4 and light can to a large extent be attributed to the modulatory effects of verapamil on endocytosis.

Accelerated arteriosclerosis after transplantation: the possible role of calcium channel blockers

The major factor limiting the long-term success of cardiac transplantation is the development of accelerated arteriosclerosis that occurs in the coronary arteries of the cardiac allograft. Transplant arteriosclerosis is characterized by diffuse, uniform, concentric narrowing of the artery by a proliferative, fibrocellular intima. The etiology of transplant arteriosclerosis is thought to be immune-mediated, and endothelial cells, smooth muscle cells, and inflammatory cells participate in the progression. Based on data derived from studies of conventional atherosclerosis, in which calcium channel blockers (CCBs) have demonstrated beneficial effects, preliminary studies designed to determine if CCBs might affect transplant arteriosclerosis similarly have been performed in animal models as well as in a limited number of cardiac transplant patients. Amlodipine suppressed transplant arteriosclerosis in one animal study, while diltiazem preserved vasodilatory responses in another animal study. Small prospective trials and retrospective studies in humans have shown that CCBs have a favorable effect on the development of transplant arteriosclerosis. While no work has been directed specifically at determining the mechanisms by which CCBs might prevent transplant arteriosclerosis, there are several likely candidates. These include preservation of endothelial function, suppression of smooth muscle cell migration and proliferation, production of extracellular matrix, and regulation of lipid metabolism and certain components of the immune system.

Direct antiatherogenic activity of isradipine and lacidipine on neointimal lesions induced by perivascular manipulation in rabbits

The in vivo antiatherogenic activity of two calcium antagonists of the dihydropyridine class (isradipine and lacidipine) was investigated in a new experimental model. The proliferative lesion induced in the rabbit carotid artery was obtained by positioning a hollow silastic collar around the vessel. The neointimal formation was determined by measuring cross sectional thickness of intimal (I) and medial (M) tissue of fixed arteries obtained 14 days after collar placement. The effectiveness in inhibiting neointimal formation was assessed for isradipine (0.5, 1 and 4 mg kg-1 day-1) in normocholesterolemic (NC) animals and for lacidipine (1, 3, and 10 mg kg-1 day-1) in hypercholesterolemic (HC) rabbits. In NC control animals a neointimal formation was clearly detectable (I/M 0.53 +/- 0.18, n = 5). In isradipine-treated groups I/M ratios were significantly decreased (0.15 +/- 0.03, 0.12 +/- 0.02, 0.1 +/- 0.02 for the 0.5, 1 and 4 mg kg-1 day-1 doses respectively). In HC rabbits the administration of cholesterol 1% mixed with food and drug treatment started either 60 days before collar insertion (pretreated group, HC60) or on the same day (non pretreated group, HC15) of the collar placement. Only the pharmacological pretreatment was effective in reducing neointimal formation (0.47 +/- 0.02, 0.4 +/- 0.09, and 0.32 +/- 0.02 for dose 1, 3 and 10 mg kg-1 day-1 vs 1.1 +/- 0.14 in control animals). The inhibition of neointimal hyperplasia was much less evident in nonpretreated animals (0.7 +/- 0.15, 0.6 +/- 0.18 and 0.43 +/- 0.08 for dose 1, 3, and 10 mg kg-1 day-1 vs 0.72 +/- 0.2 in control animals). These results suggest a direct antiatherosclerotic effect of isradipine and lacidipine on neointimal hyperplasia induced in NC and HC pretreated rabbits independently of modulation of risk factors such as hypercholesterolemia and/or hypertension.

Comparative effect of ursodeoxycholic acid and calcium antagonists on the binding, uptake and degradation of LDL in isolated hamster hepatocytes

We have shown that ursodeoxycholic acid (UDCA) stimulates low density lipoprotein (LDL) metabolism (Biochem. J. 280 (1991) 589), as well as calcium mobilization (Am. J. Physiol. 264 (1993) G243) in isolated hepatocytes. Therefore, the effect of UDCA and that of different calcium antagonists on hepatic LDL metabolism was compared. Isolated hamster hepatocytes were incubated at 37 degrees C for 60 min in the presence of 125I-labelled hamster LDL, increasing concentrations (25-100 microM) of verapamil, nifedipine, and diltiazem, respectively, and with or without 700 microM ursodeoxycholic acid (UDCA). At concentrations up to 100 microM, neither verapamil nor nifedipine significantly affected cell associated LDL, but both agents decreased LDL degradation in a dose-dependent manner, with almost total inhibition with 100 microM of either agent. In contrast, 25 microM diltiazem stimulated LDL binding and uptake, with a maximum increase of 15-20% of control, while 50 and 100 microM diltiazem stimulated LDL degradation by 50 and 100%, respectively. UDCA increased native LDL binding and uptake by 20%, and degradation by 50%. None of the agents tested had any effect on the binding, uptake and degradation of methylated LDL. The increased hepatic LDL uptake induced by UDCA was not altered in the presence of calcium antagonists, while the increased degradation of LDL by UDCA was abolished by the addition of 50 microM of either verapamil or nifedipine. However, 100 microM diltiazem and 700 microM UDCA stimulated LDL degradation without any additive effect. These studies show that different calcium antagonists have differential effects on hepatic LDL metabolism. The similarities between the effect of diltiazem and UDCA on LDL metabolism and the absence of any additive effect, suggest that these two agents have a similar mechanism of action, which may involve the integration of both agents into the plasma membrane lipid bilayer.

Effect of lacidipine on fatty and proliferative lesions induced in hypercholesterolaemic rabbits

1. The in vivo antiatherogenic activity of the calcium antagonist, lacidipine, was investigated in two different types of atherosclerotic lesions (proliferative and fatty lesions) induced in rabbits. 2. The proliferative lesion was obtained by positioning a hollow silastic collar around one carotid artery, while aortic fatty lesions were induced by cholesterol feeding. Cholesterol (1%) and lacidipine (1, 3, and 10 mg kg-1) were given daily mixed with standard diet for 8 weeks to White New Zealand rabbits. The intimal hyperplasia (proliferative lesion) was induced 6 weeks after dietary and drug treatment started. 3. The neointimal formation was determined by measuring cross sectional thickness of intimal (I) and medial (M) tissue of fixed arteries. In untreated animals (n = 5), 14 days after collar positioning an intimal hyperplasia was clearly detectable: the arteries with no collar (sham) showed an I/M tissue ratio of 0.03 +/- 0.02, whereas in the carotid with collar the ratio was 0.62 +/- 0.12. In lacidipine-treated animals a significant and dose-dependent effect on proliferative lesions at all three doses tested, was observed. I/M ratios were 0.47 +/- 0.02, 0.40 +/- 0.09, 0.32 +/- 0.02 for doses 1, 3, and 10 mg kg-1 day-1, respectively (P < 0.05). 4. The fatty lesion extent was significantly reduced by lacidipine at the 10 mg kg-1 day-1 dose, although a trend was also observed with lower dosage. 5. These results suggest a direct antiatherosclerotic effect of lacidipine, independent of modulation of risk factors such as hypercholesterolaemia and/or hypertension. Furthermore, the proliferative lesions are apparently more sensitive to lacidipine than are lipid-rich lesions.

Differential and interactive effects of calcium channel blockers and cholesterol content of the diet on jejunal uptake of lipids in rabbits

The present study was undertaken to determine the effects of two classes of calcium channel blockers (CCB), nisoldipine (N) and verapamil (V), on the jejunal uptake of lipids in rabbits. The uptake of cholesterol and long-chain fatty acids into rabbit jejunum was examined after 6 and 36 min of exposure to N or V in vitro ("acute" studies), and after 3-wk feeding of N or V ("chronic" studies). Animals were fed either a low (0.08%) cholesterol diet (LCD) or a high (2.8%) cholesterol diet (HCD), with or without N or V added. Acute in vitro exposure of the jejunum to N or V did not affect the uptake of cholesterol or palmitic acid in rabbits fed LCD or HCD. The effect of N or V feeding depended upon the cholesterol content of the diet; adding N or V to LCD increased cholesterol uptake while adding N or V to HCD enhanced or lowered cholesterol uptake, respectively. Both N and V increased the uptake of stearic acid in LCD. N in HCD had no effect on fatty acid uptake, whereas V lowered the uptake of stearic and linoleic acids and increased the uptake of oleic acid. These changes in lipid uptake were not due to variation in the animals' food intake, body weight gain, or intestinal mucosal surface area. The chronic administration of N or V results in an intestinal adaptative process that alters the jejunal uptake of lipids, the direction of which is influenced by the class of CCB, and by the cholesterol content of the diet. (ABSTRACT TRUNCATED AT 250 WORDS)

A preliminary study of diltiazem in the prevention of coronary artery disease in heart-transplant recipients

BACKGROUND

Accelerated coronary artery disease is a major cause of late morbidity and mortality among heart-transplant recipients. Because calcium-channel blockers can suppress diet-induced atherosclerosis in laboratory animals, we assessed the efficacy of diltiazem in preventing coronary artery disease in transplanted hearts.

METHODS

Consecutive eligible cardiac-transplant recipients were randomly assigned to receive diltiazem (n = 52) or no calcium-channel blocker (n = 54). Coronary angiograms obtained early after cardiac transplantation and annually thereafter were used for the visual assessment of the extent of coronary artery disease. The average diameters of identical coronary artery segments were measured on the angiograms obtained at base line and at the first and second follow-up examinations.

RESULTS

In the 57 patients who had all three angiograms, the average coronary artery diameter (+/- SD) 0.27 decreased in the group that received no calcium-channel blocker from 2.41 +/- 0.27 mm at base line to 2.19 +/- 0.28 mm at one year, and to 2.22 +/- 0.26 mm at two years (P < 0.001 for both years). The average diameter in the diltiazem group changed little from the base-line value of 2.32 +/- 0.22 mm (2.32 +/- 0.27 mm at one year and 2.36 +/- 0.22 mm at two years). The average change in the diameter of the segment differed significantly between the two treatment groups (P < 0.001), and the estimated effect of treatment changed only negligibly after adjustment for other relevant clinical variables. New angiographic evidence of coronary artery disease developed in 14 patients not given calcium-channel blockers, as compared with 5 diltiazem-treated patients (P = 0.082). Coronary stenoses greater than 50 percent of the luminal diameter developed in seven patients not given calcium-channel blockers, as compared with two patients given diltiazem; death due to coronary artery disease or retransplantation occurred in five patients in the group that did not receive calcium-channel blockers and none of those who received diltiazem.

CONCLUSIONS

Our preliminary results suggest that diltiazem can prevent the usual reduction in the diameter of the coronary artery in cardiac-transplant recipients, but further follow-up will be required to determine whether diltiazem can decrease the long-term incidence of symptomatic coronary artery disease.

Focus on anti-atherosclerotic therapy

Calcium antagonists (CA) exert an anti-atherosclerotic effect in cholesterol-fed rabbits through reduction of cholesterol accumulation in the arterial wall. Further studies in our Institute indicate that verapamil-like compounds and diltiazem stimulate receptor-mediated LDL uptake by human fibroblasts in culture, while nifedipine-like compounds and flunarizine are inactive. Verapamil and diltiazem stimulated LDL-receptor activity also in cells from a heterozygous FH patient, while they were inactive in a receptor defective homozygous FH patient. A basic group needs to be present on the CA molecule to modulate the LDL receptor expression. Preliminary data in our laboratory suggest that some CA can achieve concentrations in the aortic wall likely to exert effects on LDL receptors. This stimulatory activity may improve lipid metabolism in the arterial wall.

Dihydropyridine calcium antagonist modulates cholesterol metabolism and eicosanoid biosynthesis in vascular cells

Recent clinical studies have shown that calcium channel blockers can retard and possibly reduce the angiographic progression of coronary artery disease. Calcium channel blockers also inhibit dietary-induced atherosclerosis in animal models of this disease. In this study, we delineate potential cellular and molecular mechanisms by which nicardipine, a dihydropyridine calcium antagonist, may alter lipoprotein and cholesterol trafficking, affect the regulatory signal transduction pathways involved in accelerating cholesteryl ester (CE) catabolism in vascular smooth muscle cells, and modulate cell-cell interactions of vascular and inflammatory cells. We demonstrate in arterial smooth muscle cells that nicardipine increases 1) LDL binding, uptake, and degradation, 2) RNA transcript levels for the LDL receptor, 3) CE catabolic activity, 4) PGI2 release, and 5) RNA transcript levels for cyclooxygenase. Furthermore, nicardipine blocked cytokine-induced monocyte adhesion to endothelial cells and smooth muscle cells. Taken together, these findings support the hypothesis that nicardipine may function as an anti-atherosclerotic agent by promoting CE catabolism and cholesterol clearance and by reducing monocyte adhesion to the activated endothelium.

Cellular processes in atherogenesis: potential targets of Ca2+ channel blockers

Atherosclerosis is characterized by increased endothelial permeability, monocyte infiltration, intimal smooth muscle cell (SMC) proliferation, platelet aggregation and the accumulation of lipids, calcium and extracellular matrix components in the vessel wall. In various animal studies and recently in humans it could be established that Ca2+ channel blockers delayed the progression of the atherosclerotic process at the stage of early lesions. This review surveys the interaction of Ca2+ channel blockers with various membrane proteins (purinergic receptors, nucleoside transporter, peripheral benzodiazepine receptors, multi-drug resistance protein) which are involved in signal transduction and their potential impact on the observed antiatherosclerotic effects. Although the precise mechanisms have yet to be fully elucidated, it has been clearly shown that these drugs inhibit smooth muscle cell proliferation and migration, improve cellular lipoprotein metabolism in vascular cells, alter phospholipid turnover, decrease platelet adhesion in the vessel wall, reduce extracellular matrix synthesis and protect against radical induced cell damage. Most of these effects are independent of Ca2+ flux across voltage-operated Ca2+ channels. However, all these processes are relevant to the pathogenesis of atherosclerosis and therefore the elucidation of the antiatherogenic mechanisms of Ca2+ channel blockers at the cellular level is of great interest. The future development of Ca2+ channel blockers with altered molecular structures optimized for their antiatherosclerotic targets may provide a useful tool in the therapy of atherosclerosis and risk factor intervention. The protective mechanisms are related to a stabilization of cell membrane integrity, the modulation of secretory activities and cell/cell communication processes rather than to a lowering of plasma lipoprotein levels.

Cholesterol stimulation of HDL binding to human endothelial cells EAhy 926 and skin fibroblasts: evidence for a mechanism independent of cellular metabolism

The properties of the HDL binding site on the permanent human cell line EAhy 926 were studied. This cell line presents with highly differentiated functions of vascular endothelium. EAhy 926 cells possess HDL3 saturable binding sites with a Kd of about 20 micrograms/ml, which were up-regulated by cholesterol and were pronase- and EDTA-insensitive. Furthermore, HDL3 promoted cholesterol efflux from EAhy 926 cells in a dose-dependent manner. Thus, the HDL-binding site in EAhy 926 cells is similar to that present in fibroblasts, smooth muscle cells and endothelial cells. Up-regulation of HDL binding by cholesterol did not require de novo synthesis of HDL 'receptor' protein, as shown by the lack of effect of cycloheximide and alpha-amanitin and also occurred in fixed, non-living cells. Similar results were obtained using human skin fibroblasts. From these data we conclude that: (a) EAhy 926 cells are a good model for studying the HDL interaction with endothelial cells; (b) a mechanism independent of cellular metabolism is involved in the cholesterol-mediated up-regulation of HDL binding sites in EAhy 926 cells and human skin fibroblasts.

A new generation of calcium antagonists and their role in atherosclerosis

A new generation of calcium antagonists is being developed in an attempt to improve the already widespread therapeutic applications of this class of drugs. In this report the effect of these new calcium antagonists on those processes involved in atherogenesis that occur in the cellular component of the arterial wall is reviewed. The new generation of calcium antagonists appears to possess many of the antiatherosclerotic properties demonstrated by their prototypes. Moreover, these new compounds may have unique mechanisms of action and may be more potent than their first-generation counterparts.

Calcium antagonists and intimal cell proliferation in atherogenesis

Smooth muscle cell (SMC) migration and intimal proliferation are major events in the formation of the atherosclerotic lesions. Among other processes, calcium may participate in atherogenesis by affecting SMC proliferation. Calcium antagonists, which possess antiatherosclerotic properties in animal models, are effective in inhibiting SMC proliferation. This effect has been demonstrated both in vitro in cell culture and in vivo in balloon-catheterised rats and rabbits. Such an effect, indicates a possible mechanism involved in the antiatherosclerotic activity elicited by this category of drugs.

In vitro inhibition of arterial myocyte growth and stimulation of low density lipoprotein metabolism by SIM 6080, a new calcium antagonist

We have investigated the in vitro effect of the new calcium antagonist SIM 6080 on proliferation of rat aortic smooth muscle cells and on LDL receptor-mediated catabolism in human fibroblasts. Verapamil was used as the reference compound. SIM 6080 inhibited the proliferation of rat aortic myocytes in concentrations ranging between 1 and 20 microM. The inhibition, evaluated as cell number and nuclear incorporation of [3H]thymidine, was dose and time dependent; the cell doubling time increased with drug concentrations up to 69 h versus 20 h for controls. Similar results on both LDL pathway and smooth muscle cell proliferation were achieved with verapamil, but higher concentrations were needed. The specific uptake and degradation of 125I-LDL was evaluated in human fibroblasts after 48 h incubation with SIM 6080 (1-10 microM). The compound dose dependently enhanced the receptor-mediated 125I-LDL uptake, with a fourfold increase as a maximal effect (10 microM); LDL degradation was less sensitive to the drug. The present results provide evidence that the new calcium antagonist SIM 6080 interferes in vitro with processes involved in atherogenesis.

Effects of calcium antagonists on lipids and atherosclerosis

The arterial accumulation of cholesterol and calcium is a hallmark of atherosclerosis. Calcium antagonists (CAs) lessen the severity of experimentally induced atherosclerosis in cholesterol-fed animals. The reduction of aortic cholesterol is one of the most striking findings. This effect is achieved without a reduction of plasma lipid or blood pressure, and is probably related to an interference of CAs with lipid metabolism in the arterial wall. To what extent these properties of CAs are due to their ability to block calcium channels still remains to be addressed. This report briefly discusses the available in vivo and in vitro evidence for the antiatherosclerotic properties of CAs, and outlines the possible mechanisms by which these compounds affect cellular lipid metabolism.

Cellular calcium and atherosclerosis: a brief review

Evidence for and against the theory that cell calcium is causally involved in the pathogenesis of atherosclerosis is presented and evaluated. In particular, it is argued that: (1) arterial calcium is increased in atherosclerosis; (2) this increase in tissue calcium content is largely intracellular; (3) this increased intracellular calcium content is caused by increased plasma membrane calcium permeability; (4) the increased calcium content is causally related to atherogenesis; (5) many of the cell physiological, cell biological, biochemical, and molecular biological processes, known to function abnormally in atherosclerosis, are also known to be calcium regulated; and (6) these processes are activated or inactivated in atherosclerosis in a manner consistent with increased cell calcium. It is concluded that the calcium-atherogenesis hypothesis has the potential to unify macroscopic clinical risk factors in terms of intracellular mechanisms that are controlled by cell calcium, and that this hypothesis deserves further experimental tests.

Calcium antagonists as antiatherogenic agents

Pharmacological manipulations of calcium metabolism in animals fed high-fat diets may slow the progression of atherosclerosis. Agents with calcium-chelating (diphosphonic acid and thiophene carboxylic acid derivatives) or calcium-channel-blocking properties (dihydropyridine derivatives, verapamil and its derivatives, diltiazem) have been demonstrated to suppress atherogenesis in rabbits and monkeys. The antiatherosclerotic effects appear to occur in the absence of hypolipidemic effects. The mechanisms of action of the structurally unrelated drugs remain to be elucidated.