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Abstract
Purpose of Review To update on definition, diagnosis, prevalence, patient characteristics, pathophysiology, and treatment of refractory hypertension (RfHTN). Recent Findings Refractory hypertension (RfHTN) is defined as blood pressure (BP) that is uncontrolled despite using ≥ 5 antihypertensive medications of different classes, including a long-acting thiazide diuretic and a mineralocorticoid receptor antagonist (MRA) at maximal or maximally tolerated doses. This new phenotype is different from resistant hypertension (RHTN), defined as BP that is uncontrolled despite using ≥ 3 medications, commonly a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (angiotensin-converting enzyme [ACE] inhibitor or angiotensin receptor blocker [ARB]), and a diuretic. The RHTN phenotype includes controlled RHTN, BP that is controlled on 4 or more medications. RfHTN is largely attributable to increased sympathetic activity, unlike RHTN, which is mainly due to increased intravascular fluid volume frequently caused by hyperaldosteronism and chronic excessive sodium ingestion. Compared to those with controlled RHTN, patients with RfHTN have a higher prevalence of target organ damage and do not have elevated aldosterone levels. Ongoing clinical trials are assessing the safety and efficacy of using devices to aid with BP control in patients with RfHTN. Summary RfHTN is a separate entity from RHTN and is generally attributable to increased sympathetic activity.
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Real-world efficacy and safety of nebivolol in Korean patients with hypertension from the BENEFIT KOREA study. J Hypertens 2020; 38:527-535. [DOI: 10.1097/hjh.0000000000002296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Egan B, Flack J, Patel M, Lombera S. Insights on β-blockers for the treatment of hypertension: A survey of health care practitioners. J Clin Hypertens (Greenwich) 2018; 20:1464-1472. [PMID: 30289609 PMCID: PMC6220865 DOI: 10.1111/jch.13375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/20/2018] [Accepted: 08/03/2018] [Indexed: 01/18/2023]
Abstract
A quantitative survey was completed by 103 primary care physicians (PCPs) and 59 cardiologists who regularly prescribed β-blockers to assess knowledge and use of this heterogeneous drug class for hypertension. More cardiologists than PCPs chose β-blockers as initial antihypertensive therapy (30% vs 17%, P < 0.01). Metoprolol and carvedilol were the most commonly prescribed β-blockers. Cardiologists rated "impact on energy" and "arterial vasodilation" as more important than PCPs (P < 0.05/<0.01, respectively). Awareness of vasodilation was greater for carvedilol (52%) than nebivolol (31%). Association between β-blockers and clinical variables included nebivolol with β1 -selectivity, nebivolol and carvedilol with vasodilation and efficacy in older patients and African Americans, metoprolol with heart rate reduction, and atenolol and metoprolol with weight gain and hyperglycemia. Physicians preferred prescribing β-blockers with lower risk of incident diabetes. Clinical practice guidelines influenced physician prescribing more than formularies or performance metrics. This survey captures physicians' perceptions/use of various β-blockers and clinically relevant knowledge gaps.
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Affiliation(s)
- Brent Egan
- University of South Carolina School of Medicine-Greenville, Greenville, South Carolina
| | - John Flack
- Department of Medicine, Southern Illinois University School of Medicine, Springfield, Illinois
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Thomford NE, Dzobo K, Chimusa E, Andrae-Marobela K, Chirikure S, Wonkam A, Dandara C. Personalized Herbal Medicine? A Roadmap for Convergence of Herbal and Precision Medicine Biomarker Innovations. ACTA ACUST UNITED AC 2018; 22:375-391. [DOI: 10.1089/omi.2018.0074] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Nicholas Ekow Thomford
- Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology and Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- School of Medical Sciences, University of Cape Coast, Cape Coast, PMB, Ghana
| | - Kevin Dzobo
- International Centre for Genetic Engineering and Biotechnology, Cape Town component, University of Cape Town, Cape Town, South Africa
- Department of Integrative Biomedical Science, Division of Medical Biochemistry, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Emile Chimusa
- Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology and Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kerstin Andrae-Marobela
- Molecular Cell Biology, Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Shadreck Chirikure
- Department of Archaeology, University of Cape Town, Cape Town, South Africa
| | - Ambroise Wonkam
- Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology and Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Collet Dandara
- Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology and Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Mann SJ. Redefining beta-blocker use in hypertension: selecting the right beta-blocker and the right patient. ACTA ACUST UNITED AC 2017; 11:54-65. [DOI: 10.1016/j.jash.2016.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 11/29/2016] [Indexed: 01/13/2023]
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Gao S, Malbon C, Wang HY. Probing the stoichiometry of β2-adrenergic receptor phosphorylation by targeted mass spectrometry. J Mol Signal 2014; 9:3. [PMID: 24690384 PMCID: PMC4022239 DOI: 10.1186/1750-2187-9-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/18/2014] [Indexed: 01/21/2023] Open
Abstract
Background Protein phosphorylation of G-protein-coupled receptors (GPCR) is central to the myriad of functions that these ubiquitous receptors perform in biology. Although readily addressable with the use of phospho-specific antibodies, analysis phosphorylation at the level of stoichiometry requires receptor isolation and advanced proteomics. We chose two key sites of potential phosphorylation of human beta2-adrenergic receptor (β2AR residues S355 and S356) to ascertain the feasibility of applying targeted mass spectrometry to establishing the stoichiometry of the phosphorylation. Method We stimulated HEK293 cells stably expressing Flag-tagged β2AR-eGFP with 10 μM beta-adrenergic agonist (isoproterenol) and made use of proteomics and targeted mass spectrometry (MS) to quantify the molar ration of phosphorylation on S355 and S356 versus non-phosphorylated receptor in agonist-treated cells. Results Phosphorylation of either S355 or S356 residue occurred only for agonist-occupied β2AR. The results demonstrated that pS356 is the dominant site of protein phosphorylation. The abundance of the p356 was 8.6-fold more than that of pS355. Calculation of the molar ratio of phosphorylated (pS355 plus pS356) versus non-phosphorylated receptor reveals that at high occupancy of the receptor only 12.4% of the β2AR is phosphorylated at these sites. Conclusions Application of advanced proteomics and use of the most sensitive targeted MS strategy makes possible the detection and quantification of phosphorylation of very low abundance peptide digests of β2AR. Establishing the stoichiometry of two key sites of agonist-stimulated phosphorylation with β2AR is an essential first-step to global analysis of the stoichiometry of GPCR phosphorylation.
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Affiliation(s)
- Shujuan Gao
- Department of Pharmacology, Health Sciences Center, School of Medicine, State University of New York at Stony Brook, Stony Brook, NY 11794-8651, USA.
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Abstract
Objective: To review the pharmacology, pharmacokinetics, and pharmacodynamic properties of commonly used β-blockers (atenolol, carvedilol, metoprolol succinate, metoprolol tartrate, and nebivolol). Data Sources: A MEDLINE literature search (1966-May 2013) was performed using the following key terms: hypertension, β-blockers, atenolol, carvedilol, metoprolol tartrate, metoprolol succinate, nebivolol, pharmacology, pharmacodynamics, pharmacokinetics, blood pressure, metabolic, lipid, central aortic pressure, diabetes, and insulin resistance. References from publications reviewed were included. Study Selection and Data Extraction: English-language articles identified were reviewed. Animal studies and studies in patients for a primary diagnosis of coronary artery disease were excluded. Data Synthesis: β-Blockers are no longer recommended first-line therapy for primary hypertension, based on data showing that β-blockers are inferior to other antihypertensives and no better than placebo, in spite of provision of blood pressure reduction. Because atenolol is the β-blocker used in 75% of these studies, uncertainty about widespread application to all β-blockers exists. Different pharmacological and physiological properties, both within β-blockers and compared with other antihypertensives, may explain divergent effects. Evidence shows that β-blockers have a truncated effect on central aortic pressure, an independent predictor of cardiovascular events, compared with other antihypertensive classes; differences within the class may exist, but the evidence is inconclusive. Metabolic effects differ within the β-blocker class, with evidence that carvedilol causes less metabolic dysregulation. Conclusion: Emerging evidence reveals physiological differences within the β-blocker class and in comparison to other antihypertensives. These differences provide insight into the diverse clinical effects β-blockers provide in cardiovascular disease.
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Affiliation(s)
- Toni L. Ripley
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Joseph J. Saseen
- University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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Briasoulis A, Oliva R, Kalaitzidis R, Flynn C, Lazich I, Schlaffer C, Bakris G. Effects of nebivolol on aortic compliance in patients with diabetes and maximal renin angiotensin system blockade: the EFFORT study. J Clin Hypertens (Greenwich) 2013; 15:473-9. [PMID: 23815535 PMCID: PMC8033810 DOI: 10.1111/jch.12118] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 03/18/2013] [Accepted: 03/21/2013] [Indexed: 08/30/2023]
Abstract
The beneficial effects of nebivolol on arterial stiffness and endothelial dysfunction are well documented in untreated hypertensive patients and differ from nonvasodilatory β-blockers. This study tests the hypothesis that the addition of nebivolol in predominantly African American patients with type 2 diabetes already receiving maximally tolerated doses of renin-angiotensin system (RAS) blockers will further improve large artery compliance. Patients with type 2 diabetes and hypertension on maximal RAS blockade (n=70) were randomized to nebivolol or metoprolol succinate daily. Doses were titrated until systolic blood pressure (SBP) was <130 mm Hg. Radial artery applanation tonometry and pulse wave velocity (PWV) analysis were used to derive central aortic pressures and hemodynamic indices at repeated visits at intervals during a 6-month period. Both metoprolol succinate and nebivolol groups demonstrated reductions in brachial SBP (-8.2±4.3 mm Hg [P=.01] and -7.8±3.7 [P=.002], respectively) and aortic DBP (-2.4±1.8 [P=.039] and -4.0±2.9 mm Hg [P=.013], respectively). Aortic SBP decreased in the nebivolol group only (125.3±8 to 121.6±8.2, P=.025). There were no between group differences in aortic SBP, DBP, augmentation index, or PWV reduction. A significant increase in hemoglobin A1c was observed only in the metoprolol group. In patients with well-controlled type 2 diabetes and hypertension treated with maximally tolerated RAS blockade, nebivolol does not offer significant reductions in aortic BP over metoprolol succinate but maintains a stable metabolic profile.
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Affiliation(s)
- Alexandros Briasoulis
- Section of Endocrinology, Diabetes and MetabolismDepartment of MedicineASH Comprehensive Hypertension CenterThe University of Chicago MedicineChicagoIL
| | - Raymond Oliva
- Section of Endocrinology, Diabetes and MetabolismDepartment of MedicineASH Comprehensive Hypertension CenterThe University of Chicago MedicineChicagoIL
| | - Rigas Kalaitzidis
- Section of Endocrinology, Diabetes and MetabolismDepartment of MedicineASH Comprehensive Hypertension CenterThe University of Chicago MedicineChicagoIL
| | - Colleen Flynn
- Section of Endocrinology, Diabetes and MetabolismDepartment of MedicineASH Comprehensive Hypertension CenterThe University of Chicago MedicineChicagoIL
| | - Ivana Lazich
- Section of Endocrinology, Diabetes and MetabolismDepartment of MedicineASH Comprehensive Hypertension CenterThe University of Chicago MedicineChicagoIL
| | - Carrie Schlaffer
- Section of Endocrinology, Diabetes and MetabolismDepartment of MedicineASH Comprehensive Hypertension CenterThe University of Chicago MedicineChicagoIL
| | - George Bakris
- Section of Endocrinology, Diabetes and MetabolismDepartment of MedicineASH Comprehensive Hypertension CenterThe University of Chicago MedicineChicagoIL
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Efficacy and Tolerability of Nebivolol in Stage I–II Hypertension: A Pooled Analysis of Data From Three Randomized, Placebo-Controlled Monotherapy Trials. Clin Ther 2011; 33:1150-61. [DOI: 10.1016/j.clinthera.2011.07.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2011] [Indexed: 01/12/2023]
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Kitchlu A, Clemens K, Gomes T, Hackam DG, Juurlink DN, Mamdani M, Manno M, Oliver MJ, Quinn RR, Suri RS, Wald R, Yan AT, Garg AX. Beta-blockers and cardiovascular outcomes in dialysis patients: a cohort study in Ontario, Canada. Nephrol Dial Transplant 2011; 27:1591-8. [PMID: 21873621 DOI: 10.1093/ndt/gfr460] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Beta-blockers may be cardioprotective in patients receiving chronic dialysis. We examined cardiovascular outcomes among incident dialysis patients receiving beta-blocker therapy. METHODS We conducted a retrospective cohort study employing linked healthcare databases in Ontario, Canada. We studied all consecutive chronic dialysis patients aged≥66 years who initiated dialysis between 1 July 1991 and 31 July 2007. Patients were divided into three groups according to new medication use after the initiation of chronic dialysis. The three groups were patients initiated on beta-blockers, calcium channel blockers and statins only. Patients in the beta-blocker and calcium channel blocker groups could also be concurrently receiving a statin. The primary outcome was time to a composite endpoint of death, myocardial infarction, stroke or coronary revascularization. RESULTS There were a total of 1836 patients (504 beta-blocker, 570 calcium channel blocker and 762 statin-only users). Compared to statin-only use, beta-blocker use was not associated with improved cardiovascular outcomes [adjusted hazard ratio (aHR) 1.07, 95% confidence interval (CI) 0.92-1.23]. As expected, calcium channel blocker use was also not associated with improved cardiovascular outcomes (aHR 0.91, 95% CI 0.79-1.06). Among all subgroup analyses by beta-blocker attributes, only high-dose beta-blocker therapy was associated with better cardiovascular outcomes as compared to low-dose beta-blockers (aHR 0.50, 95% CI 0.29-0.88). CONCLUSIONS We observed no beneficial effect of beta-blocker use among patients receiving chronic dialysis relative to our comparator groups. Given current uncertainty around the cardioprotective benefits of beta-blockers in patients receiving dialysis, a large randomized clinical trial is warranted.
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Affiliation(s)
- Abhijat Kitchlu
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
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Sekine T, Kodama T, Kondo T, Fujimoto S, Matsutani H, Arai T, Morita H, Sano T, Saito Y, Takase S. [Usefulness and safety of propranolol injection into vein for acquisition of coronary multidetector-row computed tomography]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2010; 66:1539-47. [PMID: 21282909 DOI: 10.6009/jjrt.66.1539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND A low heart rate (HR), associated with a prolonged slow filling phase (SF), is necessary to obtain a high quality coronary CT at a low radiation dose with conventional 64 multidetector-row computed tomography (MDCT). The purpose of our study was to confirm the safety of injecting propranolol (2-10 mg) into the vein for lowering heart rate in patients requiring MDCT and to document the effect of the drug on HR, PQ and SF. METHOD Of 1290 consecutive patients who were initially considered for enrollment in the coronary MDCT study, 40 patients with atrial fibrillations, 3 with atrial flutters, and 13 with artificial pacemakers were excluded. Of the remaining 1234 patients (M/F=714/520), 331 had already taken an oral beta-blocker before the CT examination, and were included in the study. In patients with no contraindications, propranolol was aggressively injected (2-10 mg) into the vein to reduce the HR. RESULT In patients not taking an oral beta blocker, 2 mg propranolol reduced the HR by -10±5 bpm and 10 mg, by -20±7 bpm. However, in patients taking an oral beta-blocker, the decrease in HR by propranolol was minimal (2 mg, -6±4 bpm; 10 mg, -10±6 bpm). Propranolol significantly prolonged the PQ interval (from 169±27 to 179±29 ms, P<0.0001), and SF (from 125±69 to 264±79 ms, P<0.0001). Adverse effects of propranolol injection were observed in only 3 [2 mild hypotension and 1 paroxysmal atrial fibrillation (recovered to sinus rhythm by DC counter shock)] of 3212 patients. All 3 patients became stable after 1 or 2 hours of rest and could return home. CONCLUSION Propranolol injection was a relatively safe and useful method to reduce HR and prolong SF, necessary for obtaining high quality coronary MDCT with a low radiation dose.
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Affiliation(s)
- Takako Sekine
- Department of Radiological Technology, Takase Clinic, Japan
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Kalra S, Kalra B, Agrawal N. Combination therapy in hypertension: An update. Diabetol Metab Syndr 2010; 2:44. [PMID: 20576135 PMCID: PMC2901246 DOI: 10.1186/1758-5996-2-44] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2009] [Accepted: 06/24/2010] [Indexed: 12/19/2022] Open
Abstract
Meticulous control of blood pressure is required in patients with hypertension to produce the maximum reduction in clinical cardiovascular end points, especially in patients with comorbidities like diabetes mellitus where more aggressive blood pressure lowering might be beneficial. Recent clinical trials suggest that the approach of using monotherapy for the control of hypertension is not likely to be successful in most patients. Combination therapy may be theoretically favored by the fact that multiple factors contribute to hypertension, and achieving control of blood pressure with single agent acting through one particular mechanism may not be possible. Regimens can either be fixed dose combinations or drugs added sequentially one after other. Combining the drugs makes them available in a convenient dosing format, lower the dose of individual component, thus, reducing the side effects and improving compliance. Classes of antihypertensive agents which have been commonly used are angiotensin receptor blockers, thiazide diuretics, beta and alpha blockers, calcium antagonists and angiotensin-converting enzyme inhibitors. Thiazide diuretics and calcium channel blockers are effective, as well as combinations that include renin-angiotensin-aldosterone system blockers, in reducing BP. The majority of currently available fixed-dose combinations are diuretic-based. Combinations may be individualized according to the presence of comorbidities like diabetes mellitus, chronic renal failure, heart failure, thyroid disorders and for special population groups like elderly and pregnant females.
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Affiliation(s)
- Sanjay Kalra
- Dept of Endocrinology, Bharti Hospital, Karnal, India
| | - Bharti Kalra
- Dept of Gynaecology, Bharti Hospital, Karnal, India
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