Calcium-channel antagonists for prevention of atherosclerosis

Ginsenoside-Rd, a purified component from panax notoginseng saponins, prevents atherosclerosis in apoE knockout mice

Recently, it was revealed that the dysfunction of transmembrane Ca(2+) transport, results in an increase in intracellular Ca(2+)[Ca(2+)](i), which is involved in the process of atherosclerosis. We previously demonstrated that ginsenoside-Rd, a purified component from panax notoginseng, is a voltage-independent Ca(2+) channels blocker. In this study, we investigated the effects of ginsenoside-Rd on atherosclerosis and the underlying mechanisms in apolipoprotein E deficient (apoE(-/-)) mice and RAW264.7 cells. Atherosclerotic plaques were stained by Red oil O staining. Ca(2+) influx was measured by Fura-2 dyed Mn(2+) quenching. Intracellular cholesterol and uptake of lipid was assayed by enzymatic, fluorometric method and DiI-labeled Ox-LDL. Western blot was used to determine protein expression. We found that Ginsenoside-Rd (20mg/kg/day. i.p.) significantly reduced the atherosclerotic plaque areas, oxidized low-density lipoprotein (ox-LDL) uptake and thapsigargin and l-oleoyl-2-acetyl-glycerol (OAG, membrane-permeable diacylglycerol analog)-induced Ca(2+) influx in macrophages from high-fat diet apoE(-/-) mice. In vitro, 20μM ginsenoside-Rd significantly inhibited ox-LDL-induced foam cell formation and the increase of thapsigargin- and OAG-induced Ca(2+) influx. Ox-LDL induced an increase in scavenger receptor A (SR-A) expression, and ginsenoside-Rd inhibited this effect of ox-LDL significantly. The results suggest that ginsenoside-Rd prevents the development of atherosclerosis. The underlying mechanism may be related to the inhibition of Ca(2+) influx through voltage-independent Ca(2+) channels, resulting in the inhibition of SR-A activity and expression, followed by reductions of ox-LDL uptake and cholesterol accumulation in macrophages.

Contribution of vasoconstriction to the origin of atherosclerosis: a conceptual study

Research during the past century has clearly shown that endothelial injury (EI) and/or endothelial dysfunction (ED) are among the major events determining the onset of atherosclerosis. Included in the events that may elicit endothelial damage, vasoconstriction (VC) has received relatively little attention. This conceptual review attempts to show that in elastic and conduit arteries, VC is not only capable of producing EI/ED, but is also closely associated with many recognized proatherogenic stimuli. Of related interest is the observation that a number of suspected antiatherogenic stimuli oppose VC by their vasodilatory effects, lending further support to this relationship. In addition, recent developments in the knowledge of the molecular basis of VC (including the role of specific inhibitors) are discussed, and their potential for preventing lesion formation and thus becoming novel therapeutic alternatives against the onset of atherosclerosis are highlighted.

Vasospasm, vascular injury, and atherogenesis: a perspective

It is generally believed that injury of the vessel wall is an important condition for the development of atherosclerosis. The nature of this injury and its relationship to lesion origin, however, are not clearly understood. Based on early work by the author and a selective review of the literature, evidence is presented to show how a common cardiovascular event, vasospasm, may be one of the factors responsible for this tissue damage, because it produces a substantial arteriopathy in the very vessel in which it occurs.

Vascular smooth muscle cell migration, atherosclerosis, and calcium channel blockers

Calcium channel blockers have been studied widely for their potential ability to retard or even reverse atherosclerosis. Several potential cellular mechanisms have been proposed, including interactions with vascular smooth muscle cells: migration, inhibition of proliferation, or both. This paper reviews some of the signaling events involved in smooth muscle cell migration, including changes in intracellular calcium, and the inhibition of cell migration by calcium channel blockers. Finally, there is a discussion of preliminary experiments on human vascular smooth muscle cell migration using amlodipine.

The pathogenesis of atherosclerosis

The hypothesis that atherosclerosis is a 'response to injury' is now generally accepted. This paper briefly reviews factors that can damage the vascular endothelium plus the formation of fatty streak lesions, thrombogenic surfaces, fibrous plaques and complex advanced lesions of atherosclerosis.

Calcium antagonists and atherosclerosis

Calcium channel blockers (CCBs) have several properties which may have beneficial effects on the development of atherosclerosis. These include inhibition of vascular smooth muscle cell (SMC) proliferation and migration; inhibition of calcium influx into the vascular wall; reduction of extracellular matrix synthesis; promotion of uptake and breakdown of low-density lipoproteins; protection of lipoproteins from oxidative modification; maintenance of endothelial cell function; inhibition of platelet activation; and reduction of blood pressure. Although some of these effects are only seen at high drug concentrations, the great majority of reports indicate that CCBs can attenuate atherogenesis in animal models, notably the cholesterol-fed rabbit. Several clinical trials have now attempted to determine the efficacy of these drugs in human atheromatous disease. The outcome of these studies, including the International Nifedipine Trial of Antiatherosclerotic Therapy (INTACT), the Montreal Nicardipine Trial, and the Multicenter Isradipine/Diuretic Atherosclerosis Study (MIDAS), are summarized in this review, in the context of trials currently in progress. The emerging evidence suggests that an antiatherosclerotic action can be demonstrated in patients but the extent and clinical importance of this effect have yet to be fully established.

Bioequivalence of controlled-release calcium antagonists

In this review, several deficiencies of published bioequivalence studies for controlled-release calcium antagonists have become apparent. As a consequence, some of the published conclusions based on such studies must be viewed with care. A proper statistical analysis of bioequivalence is not frequently reported. A proper statistical analysis of the pharmacokinetic variables involves the calculation of 90% confidence intervals (CI) for the test: reference ratio of the means of the pharmacokinetic variables of the test and reference product. The CI must fall completely within the predetermined bioequivalence range (usually 0.8 to 1.25) for the products to be declared bioequivalent. Serious methodological errors, such as a conclusion of bioequivalence based on a lack of statistically significant difference between products, and conversely, a conclusion of bioequivalence because of a statistically significant difference, or because of a mere failure to show bioequivalence, are still made. With calcium antagonists in particular, an assessment of the rate of absorption and of the maximum concentration is important, as those characteristics may have implications for the safety profile with this class of drugs. As a minimum, in single doses studies the maximum concentration (Cmax), and the time to the maximum concentration (tmax), and in multiple-dose studies the Cmax, and the peak-trough fluctuation (%PTF) must be considered. Some bioequivalence studies of calcium antagonists are deficient in this respect. To show bioequivalence for controlled-release formulations, multiple-dose studies are required but some published bioequivalence studies contain only single-dose assessments. Similarly, bioequivalence studies under fed conditions are rarely published, although food may have a significant effect on the absorption rate of these drugs. Some calcium antagonists, such as verpamil, show stereo-selective pharmacokinetics, so that enantiomers may have to be investigated. Unfortunately, few of the published studies of controlled-release calcium antagonists satisfy all requirements. One would expect that data submitted to regulatory authorities for approval of generic formulations are more complete; published data are in many cases not satisfactory.

So much writing, so little science: a review of 37 years of literature on edetate sodium chelation therapy

OBJECTIVE

To determine the safety and efficacy of edetate sodium (ethylenediamine tetraacetic acid; EDTA) chelation therapy for atherosclerosis.

METHODS

Literature search using MEDLINE, encompassing 1966 through May 1993. Further references were obtained from articles and books, and from citations obtained from the American Academy of Medical Preventics.

RESULTS

16 case reports or case series, 2 longitudinal studies, and 3 clinical trials were reviewed, along with testimonials cited in 19 books.

CONCLUSIONS

Little valid scientific evidence is available. Although the postulated mechanisms of action for EDTA are biologically plausible and EDTA appears to be safe, it has not been proven effective. Indeed, the best evidence shows it to be ineffective. Therefore, EDTA chelation therapy should not be used in clinical practice to treat atherosclerosis.

Use of calcium channel antagonists for cardiovascular disease

Until recently, only three calcium channel antagonists--verapamil, diltiazem and nifedipine--were available for managing cardiovascular disorders such as hypertension and ischemic heart disease. In the past few years, however, several dihydropyridine calcium channel antagonists, including nicardipine, isradipine, felodipine, nimodipine, and amlodipine, have been marketed. Others are currently awaiting FDA approval. In addition, bepridil, which belongs to a new class of calcium channel antagonists, has recently been marketed for refractory angina pectoris. Clinical uses of calcium channel antagonists have been expanded since the 1970s to include management of cardiovascular disorders such as supraventricular arrhythmias, CHF secondary to diastolic dysfunction, and myocardial reinfarction in selected patients. Calcium channel antagonists are also being investigated for prevention of atherosclerosis. Calcium channel antagonists are a heterogeneous group of pharmacologic agents. Differences in tissue selectivity are largely responsible for the variations in hemodynamic and electrophysiologic properties of these agents. Thus, their clinical uses and side effect profiles differ. These differences must be taken into consideration in the selection of the most appropriate agent for a specific indication. Potential advantages of some of the newer dihydropyridine calcium channel antagonists include less frequent dosing (amlodipine and isradipine) and little or no negative inotropic effect (nicardipine, felodipine, amlodipine, isradipine) compared with the prototype calcium channel antagonists. Additional clinical experience with these newer agents is required, however, before their role in the management of cardiovascular disorders can be fully delineated. The availability of sustained-release formulations of verapamil, diltiazem, nifedipine, felodipine, and nicardipine, as well as the recent marketing of calcium channel antagonists with relatively long half-lives (amlodipine and isradipine), makes once- or twice-daily dosing possible with most calcium channel blockers. However, selection of a particular agent will depend on several factors, including clinical efficacy, side effect profile, cost, and patient characteristics such as concomitant disease states and baseline hemodynamic status.