Around the beta-blockers, one more time

Cardioprotective effects of perioperative β-blockade in vascular surgery patients: fact or fiction?

PURPOSE OF REVIEW

Perioperative β-blockade remains a subject of debate. In this review, recent literature and current guidelines for perioperative β-blockade in vascular surgery patients are discussed.

RECENT FINDINGS

Available evidence suggests that perioperative β-blockade may be beneficial in reducing cardiac events. However, in a recent large study, the incidences of stroke and mortality were increased in patients on perioperative β-blockers. Large systematic reviews failed to demonstrate a net beneficial effect of perioperative β-blockers. The 2009 American and the European guidelines for perioperative β-blockade in vascular surgery disagree on the available evidence but do recommend β-blockade for several indications. Most recent, Wallace and colleagues published a large-sized retrospective study, reporting a beneficial effect of the adoption of a protocol for perioperative β-blockade.

SUMMARY

Perioperative β-blockade reduces cardiac events, but at the expense of increased risk for mortality and stroke. The guidelines seem to be eager to follow positive outcome studies, without considering the effects of β-blockade on other organ systems. Perhaps the main reason for the reported cardioprotective effects of perioperative β-blocker therapy should be sought in failing preoperative β-blocker prophylaxis (irrespective of surgery).

Influence of some beta-adrenoceptor antagonists on the anticonvulsant potency of antiepileptic drugs against audiogenic seizures in DBA/2 mice

The two enantiomers of propranolol antagonize generalized tonic-clonic seizures in DBA/2 mice with the (-)-enantiomer being about 1.5 times more potent than the (+)-enantiomer. Metoprolol was less active and atenolol was unable to affect audiogenic seizures. In combination with conventional antiepileptic drugs, both propranolol enantiomers tested in doses not affecting the occurrence of audiogenic seizures increased the anticonvulsant activity of diazepam, phenobarbital, valproate and lamotrigine and tended to increase that of carbamazepine and phenytoin. The effect was more pronounced with the (-)-enantiomer. This increase was associated with an enhancement of motor impairment, however, the therapeutic index of combined treatment of the antiepileptic drugs with both propranolol enantiomers was more favourable than the combination with saline alone. Metoprolol was also able to decrease the ED(50) values of the antiepileptic drugs, whereas atenolol showed no effects. Since neither enantiomer of propranolol significantly influenced the total and free plasma levels of the antiepileptics, pharmacokinetic interactions are not likely. In addition, (+)- and (-)-propranolol did not significantly affect the hypothermic effects of the antiepileptics tested. In conclusion, both enantiomers of propranolol and metoprolol showed an additive anticonvulsant effect when co-administered with some conventional antiepileptic drugs, most notably diazepam, phenobarbital, lamotrigine and valproate, implicating a possible therapeutic relevance of such drug combinations.

Propranolol and metoprolol enhance the anticonvulsant action of valproate and diazepam against maximal electroshock

The anticonvulsive potential of classical antiepileptics co-administered with beta-adrenergic receptor antagonists against generalized tonic-clonic seizures was evaluated in the model of maximal electroshock (MES)-induced convulsions. Propranolol, acebutolol, metoprolol and atenolol were tested in the doses not affecting the electroconvulsive threshold. Propranolol and metoprolol lowered the ED(50) of valproate and diazepam. Acebutolol reduced valproate's but not diazepam's ED(50) value. In contrast, hydrophilic atenolol, not penetrating via blood-brain barrier, affected neither the action of valproate nor diazepam. None of the studied drugs changed the protective activity of carbamazepine and phenytoin against MES. beta-blockers per se did not alter the motor performance of mice. Moreover, propranolol and metoprolol did not influence diazepam-evoked impairment of locomotor activity. The free plasma and brain levels of antiepileptic drugs were not affected by beta-blockers. In conclusion, the use of certain beta-adrenoceptor antagonists, such as propranolol and metoprolol, might improve the antiepileptic potential of valproate and diazepam.

Antisense inhibition of beta(1)-adrenergic receptor mRNA in a single dose produces a profound and prolonged reduction in high blood pressure in spontaneously hypertensive rats

BACKGROUND

beta-Blockers are the first line of therapy for hypertension. However, they are associated with side effects because of central nervous system (CNS) effects and beta(2)-adrenergic antagonism. To overcome these problems and provide a long-term beta(1)-blockade, antisense oligonucleotides against rat beta(1)-adrenergic receptor (beta(1)-AR) mRNA (beta(1)-AS-ODN) were designed and tested for the ability to inhibit cardiac beta(1)-ARs as well as lower blood pressure in spontaneously hypertensive rats (SHRs).

METHODS AND RESULTS

Radioligand binding assay showed that a single intravenous injection of beta(1)-AS-ODN delivered in cationic liposomes significantly decreased cardiac beta(1)-AR density by 30% to 50% for 18 days (P<0.01), with no effect on beta(2)-ARs. This was accompanied by marked attenuation of beta(1)-AR-mediated positive inotropic response in isolated perfused hearts in vitro (P<0.02) and in conscious SHRs monitored by telemetry in vivo (P<0.02). Furthermore, the blood pressure of SHRs was reduced for 20 days, with a 38 mm Hg maximum drop. Heart rate was not significantly decreased. Quantitative autoradiography was performed to assess beta(1)-AS-ODN effects on the CNS, which demonstrated no changes in beta(1)-ARs in brain, in contrast to a significant reduction in heart and kidney (P<0.05). For comparison with beta-blockers, the effects of atenolol on cardiovascular hemodynamics were examined, which lowered blood pressure for only 10 hours and elicited appreciable bradycardia in SHRs.

CONCLUSIONS

These results indicate that beta(1)-AS-ODN, a novel approach to specific beta(1)-blockade, has advantages over currently used beta-blockers in providing a profound and prolonged reduction in blood pressure without affecting heart rate, beta(2)-ARs, and the CNS. Diminished cardiac contractility resulting from less beta(1)-AR expression contributes to the antihypertensive effect.