Chronic propranolol treatment inhibits sympathetic nerve activity and keeps blood pressure from rising in spontaneously hypertensive rats

European Headache Federation (EHF) critical re-appraisal and meta-analysis of oral drugs in migraine prevention - part 4: propranolol

OBJECTIVE

The aim of this paper is to critically re-appraise the published trials assessing propranolol for migraine prophylaxis.

METHODS

We report methods and results following the Preferred Reporting Items for Systematic Reviews (PRISMA), by searching MEDLINE, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov for randomized trials of pharmacologic treatments for migraine prophylaxis. We included randomized trials that compared propranolol with placebo for migraine prophylaxis in adults. The outcomes of interest were informed by the Core outcome set for preventive intervention trials in chronic and episodic migraine (COSMIG) and include the proportion of patients who experience a 50% or more reduction in monthly migraine days, the reduction of monthly migraine days, and the number of adverse events leading to discontinuation. We assessed risk of bias by using a modified Cochrane RoB (risk of bias) 2.0 tool and the certainty of evidence by using the GRADE approach.

RESULTS

Our search yielded twenty trials (n = 1291 patients) eligible for data synthesis and analysis. The analysis revealed a moderate certainty evidence that propranolol leads to a reduction in monthly migraine days versus placebo (-1.27; 95% CI: -2.25 to -0.3). We found moderate certainty evidence that propranolol increases the proportion of patients who experience a 50% or more reduction in monthly migraine days, compared to placebo with a relative risk of 1.65 (95% CI 1.41 to 1.93); absolute risk difference: 179 more per 1,000 (95% CI 113 to 256). We found high certainty evidence that propranolol increases the proportion of patients who discontinue due to adverse events compared to placebo with a risk difference of 0.02 (95% CI 0.00 to 0.03); absolute risk difference: 20 more per 1,000 (95% CI 0 to 30).

CONCLUSIONS

The present meta-analysis shows that propranolol has a prophylactic role in migraine, with an overall acceptable tolerability profile. Combining these results with its long-standing use and its global availability at a low cost confirms its role as a first line agent in the prophylaxis of migraine.

Antihypertensive and cardioprotective effects of different monotherapies and combination therapies in young spontaneously hypertensive rats - A pilot study

Spontaneously hypertensive rats (SHR) are an established animal model for antihypertensive treatment. The aim of this pilot study was a systematic search for two lines of antihypertensive treatment - a monotherapy and a combination of two drugs - to be applied in a future study on old SHR. Originally, representatives of three drug classes recommended for antihypertensive therapy in humans should be applied, namely captopril (CAP) as an antagonist of the renin-angiotensin-aldosterone system, nifedipine (NIF) as calcium channel blocker and propranolol (PROP) as β-adrenergic blocker. As we observed that PROP had been poorly ingested, all groups with PROP therapy were excluded from the study. CAP (60 mg kg^-1 d^-1), NIF (10 mg kg^-1 d^-1) or both were administered orally to seven-week-old SHR over 3 weeks. A further group of SHR received no treatment (SHR/CTRL). Age-matched normotensive Wistar-Kyoto rats served as normotensive controls. We examined the effect of the antihypertensive therapies on systolic blood pressure, heart weight and on histological and biochemical markers of cardiac hypertrophy and fibrosis. CAP proved to be the most effective treatment reducing blood pressure and relative heart weight significantly compared to SHR/CTRL without reaching normotensive values. Beginning cardiac fibrosis observed in SHR/CTRL was completely abrogated with CAP treatment. Similar effects were achieved with a combination of CAP and NIF. CAP as monotherapy and CAP + NIF as combination therapy were chosen for the forthcoming study on old SHR.

Divergent profile between hypothalamic and plasmatic aminopeptidase activities in WKY and SHR. Influence of beta-adrenergic blockade

AIMS

Wistar-Kyoto (WKY) and spontaneously hypertensive rats (SHR) differ in their renin-angiotensin system function and sympathetic tone. The metabolism of angiotensins and vasopressin depends on the action of certain aminopeptidases whose activity may be influenced by the autonomic nervous system. Their regulation may differ between WKY and SHR in hypothalamus and plasma according to the sympathetic tone. We analyzed aminopeptidases responsible for the hydrolysis of certain angiotensins, vasopressin, cholecystokinin or enkephalins in hypothalamus and plasma of WKY and SHR in untreated controls rats and under beta-adrenoceptor blockade. Systolic blood pressure, food intake, water intake and diuresis were measured as parameters modulated by the autonomic nervous system and the above mentioned peptides.

MAIN METHODS

Glutamyl-, aspartyl-, cystinyl- and alanyl-aminopeptidase activities were analyzed fluorimetrically in plasma and hypothalamus of control and propranolol-treated (100mg/kg/day administered in drinking water for 1month) WKY and SHR, using arylamide derivatives as substrates.

KEY FINDINGS

An opposite response of aminopeptidases to propranolol treatment between plasma and hypothalamus was observed in either WKY and SHR. Furthermore, the behavior of aminopeptidases was inversed between WKY and SHR either in hypothalamus and plasma: while the activity increased in hypothalamus and decreased in plasma of WKY, it decreased in hypothalamus and increased in plasma of SHR.

SIGNIFICANCE

These results revealed an inverse response of aminopeptidases between hypothalamus and plasma and also an opposite behavior of these enzymes between WKY and SHR in hypothalamus and plasma. These observations support the involvement of the sympathetic system in the modulation of aminopeptidase activities.

Chronic blockade of phosphatidylinositol 3-kinase in the nucleus tractus solitarii is prohypertensive in the spontaneously hypertensive rat

Phosphatidylinositol 3-kinase (PI3K) within brain stem neurons has been implicated in hypertension in the spontaneously hypertensive rat (SHR). Previously, we demonstrated elevated expression of PI3K subunits in rostral ventrolateral medulla and paraventricular nucleus of SHRs compared with Wistar-Kyoto rats. Here, we considered expression levels of PI3K in the nucleus tractus solitarii, a pivotal region in reflex regulation of arterial pressure, and determined its functional role for arterial pressure homeostasis in SHRs and Wistar-Kyoto rats. We found elevated mRNA levels of p110beta and p110delta catalytic PI3K subunits in the nucleus tractus solitarii of adult (12 to 14 weeks old) SHRs relative to the age-matched Wistar-Kyoto rats (fold differences relative to beta-actin: 1.7+/-0.2 versus 1.01+/-0.08 for p110beta, n=6, P<0.05; 1.62+/-0.15 versus 1.02+/-0.1 for p110delta, n=6, P<0.05). After chronic blockade of PI3K signaling in the nucleus tractus solitarii by lentiviral-mediated expression of a mutant form of p85alpha, systolic pressure increased from 175+/-3 mm Hg to 191+/-6 mm Hg (P<0.01) in SHRs but not in Wistar-Kyoto rats. In addition, heart rate increased (from 331+/-6 to 342+/-6 bpm; P<0.05) and spontaneous baroreflex gain decreased (from 0.7+/-0.07 to 0.5+/-0.04 ms/mm Hg; P<0.001) in the SHRs. Thus, PI3K signaling in the nucleus tractus solitarii of SHR restrains arterial pressure in this animal model of neurogenic hypertension.

Practice-based randomized controlled-comparison clinical trial of chiropractic adjustments and brief massage treatment at sites of subluxation in subjects with essential hypertension: pilot study

OBJECTIVE

To determine the feasibility of conducting a randomized clinical trial in the private practice setting examining short- and long-term effects of chiropractic adjustments for subjects with essential hypertension compared with a brief soft tissue massage, as well as a nontreatment control group.

DESIGN

Randomized controlled-comparison trial with 3 parallel groups.

SETTING

Private practice outpatient chiropractic clinic.

PATIENTS

Twenty-three subjects, aged 24 to 50 years with systolic or diastolic essential hypertension.

INTERVENTIONS

Two months of full-spine chiropractic care (ie, Gonstead) consisting primarily of specific-contact, short-lever-arm adjustments delivered at motion segments exhibiting signs of subluxation. The massage group had a brief effleurage procedure delivered at localized regions of the spine believed to be exhibiting signs of subluxation. The nontreatment control group rested alone for a period of approximately 5 minutes in an adjustment room.

MAIN OUTCOME MEASURES

Cost per enrolled subject, as well as systolic and diastolic blood pressure (BP) measured with a random-0 sphygmomanometer and patient reported health status (SF-36). Pilot study outcome measures also included an assessment of cooperation of subjects to randomization procedures and drop-out rates, recruitment effectiveness, analysis of temporal stability of BPs at the beginning of care, and the effects of inclusion/exclusion criteria on the subject pool.

RESULTS

Thirty subjects enrolled, yielding a cost of $161 per enrolled subject. One subject was later determined to be ineligible, and 6 others dropped out. In both the chiropractic and massage therapy groups, all subjects were classified as either overweight or obese; in the control group there were only 2 classified as such. SF-36 profiles for the groups were similar to that of a normal population. The mean change in diastolic BP was -4 (95% confidence interval [CI]: -8.6, 0.5) in the chiropractic care group, 0.5 (95% CI: -3.5, 4.5) in the brief massage treatment group, and -4.9 (95% CI: -9.7, -0.1) in the no treatment control group. At the end of the study period, this change was -6.3 (95% CI: 13.1, 0.4), -1.0 (95% CI: -7.5, 15.6), -7.2 (95% CI: -13.3, -1.1) in the 3 study groups. The mean improvements in the chiropractic care and no treatment control groups remained consistent over the follow-up period.

CONCLUSIONS

This pilot study elucidated several procedural issues that should be addressed before undertaking a full-scale clinical trial on the effects of chiropractic adjustments in patients with essential hypertension. A multidisciplinary approach to recruitment may need to be used in any future efforts because of the limited subject pool of patients who have hypertensive disease but are not taking medications for its control. Measures need to be used to assure comparable groups regarding prognostic variables such as weight. Studies such as these demonstrate the feasibility of conducting a full-scale 3-group randomized clinical trial in the private practice setting.

Age-related delay in recovery of beta-adrenergic sensitivity after abrupt propranolol withdrawal in rats

We compared cardiovascular responses to various adrenergic agonists in conscious 3-month and 12-month old rats that had been treated with propranolol daily for 7 days, to determine whether changes in beta-adrenergic hypersensitivity induced by abrupt propranolol withdrawal would differ with age. Depressor and tachycardic responses elicited by beta-adrenergic stimulation with isoproterenol were still reduced during the first 3 days following propranolol withdrawal, but were restored to pretreatment levels, more slowly in 12-month than in 3-month-old rats. Opposite pressor and bradycardic responses to alpha-adrenergic stimulation with phenylephrine did not differ between age groups, either before or after propranolol withdrawal. By contrast, pressor and bradycardic responses produced by combined alpha- and beta-adrenergic stimulation with epinephrine after propranolol withdrawal, though unaltered in 3-month-old rats, were enhanced in 12-month-old rats. Hence after sudden propranolol withdrawal beta-adrenergic sensitivity in conscious rats was gradually restored, rather than being enhanced, but more slowly at 12 than at 3 months of age. These results suggest that following abrupt cessation of prolonged propranolol treatment, restoration of normal beta-adrenergic sensitivity becomes delayed in older rats.

Excitation of rostral medullary pacemaker neurons with putative sympathoexcitatory function by cyclic AMP and beta-adrenoceptor agonists 'in vitro'

This study explores the mechanism of action of catecholamines on rostral medullary pacemaker neurons with putative sympathoexcitatory function, in tissue slices. The firing rate of the pacemaker neurons of nucleus reticularis rostroventrolateralis (RVL pacemakers) was reversibly increased by agents which elevate intracellular levels of cAMP (forskolin and 8-br-cAMP). Forskolin dideoxy, an analog without action on adenylate cyclase, was ineffective and adenosine, a potential degradation product of 8-br cAMP produced inhibition exclusively and only in high doses (0.1-1 mM). The firing rate of these cells was uniformly increased by epinephrine and isoproterenol (10 microM) but unaffected by both phenylephrine (100 microM) and clonidine (up to 1 microM). These effects were abolished by pretreatment with the beta-adrenoceptor antagonist propranolol (10 microM) but they were unaffected by the alpha-antagonist phentolamine (100 microM). The indirectly-acting sympathomimetic amine tyramine (0.1-1 mM) activated all the cells tested. The effect of tyramine was antagonized by the beta-blocker pindolol and was absent 7 days after microinjection of the neurotoxin 6-hydroxydopamine into the lateral aspect of the RVL. Intracellular recordings indicated that both isoproterenol and tyramine enhanced the rate of depolarization of the pacemaker neurons during the interspike interval and produced a decrease in input resistance. After tetrodotoxin (TTX) pretreatment, isoproterenol produced a depolarization also associated with a reduction in input resistance. Three conclusions are proposed. First, RVL pacemakers have functional beta-adrenergic receptors whose activation increases their discharge rate via the intracellular production of cAMP. The effect of cAMP is due at least in part to the activation of an inward current which may be carried by a cation. Secondly, RVL neurons are in close proximity to a releasable pool of catecholamines which is susceptible to destruction by the cytotoxic agent 6-hydroxydopamine (6-OHDA). Finally it is tentatively suggested that the reduction in sympathetic tone produced by centrally acting beta-blockers could be due, at least in part, to an action of these agents on RVL pacemaker cells.

Propranolol-induced changes in the catecholamine-containing cells and vesicles of SHR sympathetic ganglia

The ultrastructural effects of long-term propranolol administration on the catecholamine-containing (CC) cells of cervical sympathetic ganglia were studied in spontaneously hypertensive rats. After 2 months of propranolol administration, there were hydrops of mitochondria, together with swelling and vesiculation of Golgi complex and rough endoplasmic reticulum. Such swollen organelles seemed to coalesce with each other, resulting in transformation of major parts of the cytoplasm into large membrane bound saccules. In that group of animals, the number of CC vesicles showed a significant decrease (P less than 0.025) compared to the control. Moreover, such vesicles looked more electron dense, with decreased electron-lucent haloes compared to the control. Blood pressure recording via rat tail cuff showed a significant drop (P less than 0.0001) of the mean systolic blood pressure in the treated animals. One month after stopping propranolol administration, resorption of the cytoplasmic saccules occurred, but the cytoplasm looked lighter and lost its granular appearance. The mitochondria regained their normal shape, though they appeared fewer in number. The CC vesicles were significantly reduced in number (P less than 0.001) and were less electron dense compared to the control. The possible implications of these findings on the mechanism of action of propranolol as an antihypertensive agent are discussed.

Effects of colchicine on hexokinase activity in the paraventricular and supraoptic nuclei of spontaneously hypertensive and normotensive rats

The effects of intracerebroventricular (ICV) colchicine (70 micrograms per rat) on systolic pressures and levels of hexokinase activity in the hypothalamic paraventricular (PVH) and supraoptic (SON) nuclei were investigated in adult normotensive and spontaneously hypertensive rats (SHR). One day after colchicine injection, systolic pressures had dropped significantly in Sprague-Dawley (SD) rats, Wistar-Kyoto (WKY) rats, and SHR; the largest decrease was seen in SHR. Postinjection pressures in SHR were within the normotensive range. No further decreases were observed two days after injections. Quantitative analysis of hexokinase activity in control animals verified that the parvo- and magnocellular PVH (but not SON) of SHR contained significantly lower levels of hexokinase than in WKY or SD rats. Two days after colchicine injection, hexokinase activities in pPVH and mPVH were similar in all three strains. Activity had decreased significantly in SD and WKY rats. In SHR, no differences between control and postinjection values were found. Hexokinase activity in SON was significantly decreased to the same extent in all strains. As metabolic activity in the pPVH, mPVH, and SON decreased after colchicine injection in normotensive rats whereas no such decreases occurred in the pPVH and mPVH of SHR, the findings suggest that colchicine may have differential effects on the metabolic activity of specific cell groups in brain depending on the physiological state of the animal.

Accelerated development of cardiac sympathetic responses in spontaneously hypertensive (SHR) rats

The functional development of cardiac and adrenal medullary responses to reflex activation of the sympathetic nervous system was studied in preweanling spontaneously hypertensive (SHR) and Wistar-Kyoto (WKY) normotensive rats. Pups of the two strains received injections of insulin or saline at 2, 4, 8, 12, or 16 days of age and were sacrificed 3 h later. Insulin administration produces a significant decrease in circulating levels of glucose which in turn results in a centrally mediated increase in sympathetic outflow. The induction of ornithine decarboxylase (ODC) in heart and the depletion of epinephrine from the adrenal medulla served as tissue markers of functional sympathetic neurotransmission. WKY and SHR pups had comparable levels of ODC activity in heart under basal conditions. In contrast, levels of catecholamines in the adrenals were greater in SHR pups at 2 and 4 days of age. Following insulin administration, SHR pups exhibited a greater induction of cardiac ODC activity at 2, 4, and 8 days of age compared to age-matched WKY controls. However, there were no differences between SHR and WKY pups in the magnitude of the adrenal medullary response to insulin-induced hypoglycemia. These alterations in sympathetic-target tissue development during the first postnatal week of life may contribute in part to the higher arterial pressures maintained by SHRs throughout the lifespan.

Increase of renal sympathetic nerve activity by metoprolol or propranolol in conscious spontaneously hypertensive rats

1 Mean arterial pressure (MAP), heart rate (HR) and renal sympathetic nerve activity (RSNA) were recorded in conscious spontaneously hypertensive rats (SHR). 2 Infusion of metoprolol (4 mumol kg-1 h-1) or propranolol (1.5 mumol kg-1 h-1) reduced HR and significantly increased RSNA. 3 Administration of metoprolol caused a sustained decrease of MAP starting in the third hour of infusion. In contrast, administration of propranolol induced a biphasic response in MAP. It is suggested that the increase of RSNA after both beta-adrenoceptor blocking drugs is due to a decrease in arterial baroreceptor activity.

Further evidence that a beta-adrenergic mechanism regulates water intake: role of the subfornical organ

The daily water intake was reduced in rats by subcutaneous administration of propranolol. The fluid intake after 24 h of dehydration in nephrectomized animals was decreased by propranolol. In intact rats diazepam did not modify the postdehydration water intake. Propranolol injected into subfornical organ decreased water consumption after 24 h of fluid deprivation but did not change the dipsogenic response to carbachol given in the same structure. These results suggest that a beta-adrenoceptor mechanism participates in the regulation of the daily water intake. After a stimulus such as dehydration, beta-blockade modifies water consumption by a non-renal mechanism. This mechanism involves neither a general depressant nervous activity nor a local anesthetic action and could be located in a periventricular structure, the subfornical organ.

Attenuation of alpha-adrenergic responsiveness in hypoxic SHR

Chronic exposure to hypoxia reduces the severity of hypertension in SHR. This study explored the possibility that hypoxic moderation of spontaneous hypertension is caused by a decrease in vascular responsiveness. In vitro studies were conducted with thoracic aortic rings obtained from SHR and Wistar-Kyoto (WKY) rats maintained under hypoxic (H; simulated altitude = 3658 m) and normoxic (N; laboratory altitude = 1520 m) conditions. Vessels were removed prior to the rapid development of hypertension (5 weeks of age; 3 days of altitude exposure), during the rapid hypertension-development stage (10 weeks of age; 5 weeks of altitude exposure), and during the established hypertension stage (18 to 20 weeks of age; 11 to 13 weeks of altitude exposure). Dose-response curves were obtained using a non-specific vasoconstrictor (KCl) and an alpha-adrenergic agonist, phenylephrine. At all ages, WKY vessels developed greater maximal contraction to vasoconstrictor stimuli, whereas vessels from the two older groups of SHR were more sensitive (more responsive at lower dosages) to KCl. Hypoxia caused significant (p less than 0.05) attenuation of the contractile responses to phenylephrine in young "pre-hypertensive" SHR, while similar, though less marked, attenuation of phenylephrine responsiveness was evident in young WKY-H. Chronically-reduced responsiveness to phenylephrine was found in vessels from SHR-H but not WKY-H. The lack of hypoxia-induced changes in vessel response to the non-specific vasoconstrictor, KCl, suggests a specific hypoxic attenuation of adrenergic vascular responsiveness. Thus, hypoxia may protect against the development of spontaneous hypertension through attenuation of alpha-adrenergic vasoconstrictor mechanisms.

Cytochrome oxidase activity in the hypothalamus of SHR and normotensive rats before and after fasting

The metabolic activity in the brains of adult spontaneously hypertensive rats (SHR) and Wistar-Kyoto (WKY), and Wistar (W) rats was assessed before and after fasting using cytochrome oxidase (COX) histochemistry. Before fasting, metabolic activity in the paraventricular (PVH) and supraoptic (SON) nuclei of the hypothalamus in SHR was greater than in control rats. Fasting elicited a decrease in arterial pressure (AP) in SHR and WKY; in SHR the decrease in AP was accompanied by a decrease of metabolic activity in the PVH and SON. The findings of this study support the hypothesis that the PVH and SON are involved in the hypertension and in the increased levels of sympathetic nervous activity and vasopressin production known to occur in SHR. In addition, the PVH and possibly the SON may be involved in the suppression of sympathetic nervous system activity and the lowering of arterial pressure which are associated with fasting.

Neural and non-neural components of the developing hypertension in genetically hypertensive rats

Blood pressures of Otago genetically hypertensive (GH) rats are higher than those of genetically related normotensive (N) rats as early as 35 days after birth. At this age, the elevation of blood pressure is entirely neurogenic, as both GH and N animals have similar blood pressures following ganglion blockade; however, by age 45 days an additional non-neural component of the hypertension has appeared, and this persists into adulthood. Chronic treatment with propranolol or atenolol (1 mg/kg/day) over days 28-90 does not attenuate the development of hypertension. Neonatal sympathectomy with guanethidine almost abolishes resting sympathetic tone even in adult (GH) animals, but does not prevent the appearance of the non-neural component of the hypertension. It is concluded that although sympathetic nervous tone contributes to the absolute level of blood pressure in GH rats, it is not a causative factor in the development of hypertension.

Sympathetic nervous system response to graded exercise: effect of beta-blockade

This study compares the sympathetic nervous system response to graded exercise in normotensive and essential hypertensive subjects with and without beta-adrenergic blockade. Blood pressure (BP), heart rate, and plasma norepinephrine (NE), epinephrine (E), and dopamine (DA) were measured just before starting the exercise (Pre-Ex), in the submaximal exercise (Sub-max),and after 8 minutes rest (Post-Ex). On placebo, Sub-max induced in both normotensives and hypertensives a similar increase in NE and E plasma levels. Plasma DA remained unchanged. Propranolol in controls and propranolol or mepindolol in hypertensives didn't modify significantly: 1) Pre-Ex plasma levels of E, NE, and DA; 2) response at Sub-max in controls; 3) plasma E and DA in hypertensive patients. In hypertensives on beta-blockade, submaximal exercise elicited a greater increase in plasma NE. Values for plasma NE in patients on propranolol were 1135 +/- 229 pg/ml higher than those obtained in the same patients on placebo (p less than 0.001). On mepindolol, the plasma NE increment was higher than that on placebo (p less than 0.05), but lower than that on propranolol (p less than 0.01). In controls, propranolol did not significantly modify BP at Pre-Ex or its response to exercise, whereas systolic and diastolic BP were significantly lower at Pre-Ex, Sub-max, and Post-Ex in hypertensives. On beta-blockade, heart rate decrease in Pre-Ex, Sub-max, and Post-Ex were not different in controls and hypertensives. The differences found on beta blockade would indicate that the effects of beta blockers are not identical in normotensive and hypertensive subjects.