[Ventricular arrhythmias. A potential risk associated with the use of non-cardiovascular drugs prolonging the QT interval]. / Aritmie ventricolari letali. Possibile rischio associato all'uso di farmaci che prolungano l'intervallo QT.

The electrocardiogram shows a sequence of cardiac electrical events generated by individual electrical currents generated mainly by sodium (Na+), potassium (K+) and calcium (Ca++) ions transiting via specialized transport pathways, such as ion channels, inserted in the membranes of excitable cardiac cells. Na+ and Ca++, entering the cells, are messengers of activating, inward, depolarizing currents (INa, ICa), generating the QRS wave of the electrocardiogram, whereas K+, leaving the cells, carries outward repolarizing currents (e.g. Ito, IKr, IKs and IK1), generating the T wave of the electrocardiogram, which drives the cell to a rest condition. Therefore, a significantly prolonged repolarization process results in a prolonged QT interval which can initiate ectopic cardiac beats that may evolve into a potentially lethal ventricular tachyarrhythmia, called torsades de pointes. This implies that the measurement of QT interval, appropriately corrected (QTc) for heart rate values by applying available algorithms, is a current tool of diagnostic investigation to reveal abnormalities of the cardiac repolarisation process. Numerous non cardiovascular drugs in general clinical use (psychotropics, prokinetics, antimalarials, antibiotics, antihistamines, etc.) can prolong QT interval, often by a mechanism not necessary for their therapeutic effects, which is a reduction of the potassium current IKr conveyed by the HERG channel. The torsadogenic potential of these drugs can be facilitated by factors (female gender, bradycardia, electrolyte imbalances, cardiac diseases, simultaneous use of multiple drugs prolonging QT interval, etc.) known to have the propensity to reduce the redundant cardiac repolarization reserve, characterizing the healthy myocardium. Presently, drug candidates are routinely subjected to preclinical and clinical examination for cardiac safety, a property required by health authorities for any new medicine before allowing marketing authorization. Finally, before prescribing a medicinal product prolonging QT interval, a physician should carefully evaluate not only the disease he wants to treat but also the availability of equally effective, alternative drugs. The golden rule, to which such a prescription has always to abide, requires that the beneficial effects expected from a therapy should for each treated patient outweigh any possible adverse consequence, particularly when the latter one could be of lethal nature.

Frequency-independent blockade of cardiac Na+ channels by riluzole: comparison with established anticonvulsants and class I anti-arrhythmics.

The Na+ channel blocking activity and the antiarrhythmic effects of riluzole, and established anticonvulsants (lamotrigine and lifarizine) and class I antiarrhythmics (lidocaine, flecainide and disopyramide) were studied under in vitro and in vivo conditions. Guinea-pig cardiac Purkinje fibres were superfused with Tyrode solution and electrically driven for recording action potentials with intracellular microelectrodes. In these preparations paced at 1 Hz, all compounds tested produced concentration-dependent (0.3-100 microM) reductions in the maximum rate of depolarization of the action potential (Vmax). For riluzole, phenytoin and carbamazepine this effect was frequency-independent (0.5-6 Hz) but for lamotrigine, lifarizine, lidocaine, flecainide and disopyramide it was frequency-dependent. In anaesthetized rats, riluzole, in contrast to flecainide, did not delay the appearance of aconitine-induced arrhythmias. Riluzole (0.3-3.9 mg/kg, i.v.) also lacked notable cardiac electrophysiological effects in anaesthetized dogs. At an i.v. dose of 3.0 mg/kg riluzole failed to restore a normal sinus rhythm in conscious dogs with polymorphic arrhythmias produced by ligation of the left anterior descending coronary artery 24 h earlier. These results indicate that riluzole, phenytoin and carbamazepine, unlike lamotrigine, lifarizine and flecainide, block cardiac Na+ channels in a frequency-independent manner. This property may account for the lack of antiarrhythmic activity of riluzole, phenytoin and carbamazepine in animal models of arrhythmias that respond to class I antiarrhythmic drugs. It may also account for the clinical observation that riluzole does not seem to cause the unfavourable electrocardiographic changes characteristic of drugs that block cardiac Na+ channels in a frequency-dependent manner.

Drugs that prolong QT interval as an unwanted effect: assessing their likelihood of inducing hazardous cardiac dysrhythmias.

Medicinal products that, as an unwanted effect, prolong the QT interval of the electrocardiogram (ECG) can trigger episodes of polymorphic ventricular dysrhythmias, called torsades de pointes, which occasionally culminate in sudden death. The accurate measurement of QT interval requires the adoption of appropriate criteria of recording, measurement and data processing. Traditionally, QT interval is standardised to a reference heart rate of 60 beats/min by using the Bazett algorithm. However, this correction method can bias observed QT intervals in either direction. The ECG reflects cardiac electrical currents generated by ions (Na+, K+ and Ca2+) entering and leaving the cytosol mainly via transmembrane channels. Na+ and Ca2+ carry inward depolarising currents (INa, ICa) whereas K+ carries outward repolarising currents (Ito, IKr, IKS and IK1). Sometimes, a prolonged QT interval is a desired drug effect but, more commonly it is not, and reflects abnormalities in cardiac repolarisation heralding torsades de pointes. Furthermore, the potential torsadogenic activity of drugs is favoured by concurrent cardiac risk factors (old age, female gender, bradycardia, electrolyte imbalances, cardiac diseases etc.) which reduce cardiac repolarisation reserve. The evaluation of the cardiac safety of drug candidates can be started by determining their potency as IKr blockers in cloned Human Ether-a-go-go Related Gene (HERG) channels expressed in mammalian cells. Compounds passing successfully this test (desirable cardiac safety index > 30, calculated as ratio of IC50 against IKr over ED50 determined in an efficacy test) should be further investigated in other relevant human cardiac ion currents, in in vitro animal heart preparations and finally in in vivo pharmacodynamic models. The decision as to whether the potential benefit of a new drug outweighs the cardiac risk inherent in its therapeutic use should be made in the light of the condition that it is expected to treat and with reference to alternative drug therapies. If a drug represents a unique therapeutic advance, non-clinical and clinical signals of unsatisfactory cardiac safety may not constitute sufficient grounds to abandon its development. However, if the drug offers only marginal benefits over existing therapies, decisions concerning its possible development should be taken by corporate policy makers.

Preclinical in vitro cardiac electrophysiology: a method of predicting arrhythmogenic potential of antihistamines in humans?

The cardiac action potential results from a dynamic balance between inward depolarising Na+ and Ca2+ currents and outward K+ repolarising currents. During a cardiac cycle, the resultant of repolarisation phase from all ventricular cells is represented by the QT interval of the surface ECG. Congenital long QT syndrome (LQTS) is characterised by polymorphic ventricular tachycardia sometimes with twisting QRS morphology (torsade de pointes) which, although usually self-limiting, can result in sudden cardiac death. Acquired LQTS can be induced by a variety of drugs, including some nonsedative histamine H1 receptor antagonists (astemizole, terfenadine). The Committee for Proprietary Medicinal Products of the European Union has recently proposed studying the action potential in in vitro heart preparations as a preclinical test for predicting the propensity of noncardiovascular drugs to induce malignant QT prolongation in humans. The effects of several histamine H1 receptor antagonists on the electrically evoked action potential have been evaluated in rabbit Purkinje fibres. In this preparation, astemizole (0.3 to 10 micromol/L) prolongs the duration of the action potential measured at the level where repolarisation is 90% complete (APD90). This effect is dependent on drug concentration, incubation time, pacing frequency and K+ or Mg2+ concentration. Astemizole also markedly depresses the rate of rise of the action potential (Vmax). Terfenadine showed qualitatively similar, but quantitatively smaller, effects in this model. The histamine H1 receptor antagonists cetirizine, ebastine, carebastine, loratadine and fexofenadine do not significantly affect APD90 at 1 micromol/L, but cetirizine and carebastine prolong it slightly at 10 micromol/L. In conclusion, in rabbit Purkinje fibres, astemizole and terfenadine produce adverse electrophysiological effects at concentrations which may be achieved in the human myocardium in certain clinical situations. APD90 lengthening induced by carebastine and cetirizine is minor and occurs at concentrations that are very unlikely to be encountered clinically, since these drugs, in contrast to astemizole and terfenadine, do not accumulate in the myocardium. Direct extrapolation of preclinical results to humans requires great caution, since malignant QT prolongations by terfenadine and astemizole are extremely rare clinical events. However, since prolongation of the QT interval often precedes the development of torsade de pointes, any significant delay in cardiac repolarisation produced by noncardiovascular drugs in preclinical, and particularly in clinical, studies should, in general, be considered to indicate a potential cardiac risk in humans. Its significance should subsequently be evaluated in appropriate studies in patients with conditions known to predispose to arrhythmias.

QT interval prolongation by non-cardiovascular drugs: issues and solutions for novel drug development.

In 1997, the Committee for Proprietary Medicinal Products (CPMP) issued a document concerning the potential of non-cardiovascular drugs to cause prolongation of the QT interval of the electrocardiogram. This article reviews several aspects of this complex problem, including a preclinical strategy (in vitro electrophysiology in human cardiac cells and in vivo pharmacologically validated conscious dogs) to satisfy the expectations of the CPMP. In particular, the discussion stresses the danger of drugs prolonging the QT interval in patients with concurrent cardiac risk factors and the need for rigorous clinical testing to determine the risk of fatal cardiac events for drugs with the propensity to prolong QT.

Effect of the platelet-activating factor antagonist RP 59227 (Tulopafant) on myocardial ischemia/reperfusion injury and neutrophil function.

The effect of the platelet activating factor antagonist RP 59227 (Tulopafant) on myocardial infarct size was compared to that of a vehicle-treated control group in barbital-anesthetized dogs subjected to 90 min of left circumflex coronary artery occlusion and 5 h of reperfusion. The myocardial region at risk and infarct size were determined by the triphenyltetrazolium histochemical technique and regional myocardial blood flow by radioactive microspheres. Myeloperoxidase (MPO) activity was used as an index of neutrophil infiltration into the ischemic-reperfused area. Vehicle (n = 11) or RP 59227 (n = 12, 2.5 mg/kg i.v.) were administered 15 min prior to occlusion. Hemodynamics and regional myocardial blood flow in the ischemic-reperfused areas did not differ between the two groups throughout the experiment. In contrast, the number of dogs which developed ventricular fibrillation during occlusion and reperfusion was significantly less in RP 59227-treated dogs (8 of 11 in the control group vs. 3 of 12 in the RP 59227-treated group, p < 0.05). Myocardial infarct size expressed as a percent of the area at risk (control, 39.0 +/- 5.0; RP 59227, 24.8 +/- 3.4%) or as a percent of the left ventricle (control, 15.3 +/- 1.9; RP 59227, 9.0 +/- 1.3%) was significantly smaller in the RP 59227-treated group. Infarct size was inversely related to the collateral blood flow in the inner two thirds of the left ventricular wall of the infarct area, and this relationship was shifted downward in the RP 59227-treated group (p < 0.05). MPO activity in the border zone immediately adjacent to infarcted tissue was reduced in the RP 59227-treated dogs (control, 7.4 +/- 0.5 U/g; RP 59227, 4.1 +/- 0.4 U/g). In additional in vitro studies, the addition of PAF was found to elicit a concentration-dependent potentiation in chemiluminescence produced by purified canine neutrophils, a measure of oxygen-derived free radicals, which was stimulated with a low concentration of opsonized zymosan. Preincubation of neutrophils with RP 59227 resulted in a concentration-dependent decrease in chemiluminescence produced by PAF primed cells. Taken together, these data demonstrate that RP 59227 effectively reduces myocardial infarct size and reduces the incidence of ischemia and reperfusion-induced arrhythmias in barbital-anesthetized dogs, and support the concept that PAF plays an important role in the pathogenesis of acute myocardial infarction.

Influence of depolarization on vasorelaxant potency and efficacy of Ca2+ entry blockers, K+ channel openers, nitrate derivatives, salbutamol and papaverine in rat aortic rings.

We examined the effects of various KCl concentrations on the actions of some vasodilators belonging to different pharmacological classes in rat aortic rings. In some experiments, tissues were precontracted with noradrenaline after blocking voltage-dependent channels to assess the effects of depolarisation unaccompanied by the entry of extracellular Ca2+ into the cytosol. Concentration/response curves for the vasorelaxant effect of calcium entry blockers (e.g. diltiazem), K+ channel openers (e.g. aprikalim), nitrate derivatives (e.g. nitroglycerin), a beta2-adrenergic agonist (salbutamol) and papaverine were obtained by using endothelium-denuded rat aortic rings precontracted with KC1 (20-60 mM) to determine the potencies and efficacies of the drugs. The efficacies and potencies of calcium entry inhibitors were virtually independent of the [KCl]. A reduction in the potency (up to 18-fold) of papaverine occurred without changes in efficacy when the [KCl] was raised from 20 to 60 mM. The decline in potency was even greater for nitrate-like compounds. The potency of K+ channel openers in aortic rings precontracted with 30 mM KCI decreased by three- to sixfold compared with those precontracted with 20 mM KCl. With the exception of pinacidil, the efficacy of these agents already started to decline in preparations precontracted with 25 mM KCI and was virtually zero in preparations precontracted with 60 mM KCI. In contrast to other K+ channel openers, the vasorelaxant action of pinacidil was relatively resistant to glibenclamide. Salbutamol produced only a slight relaxation even in preparations precontracted with 20 mM KCl. In nitrendipine-pretreated, noradrenaline-precontracted aortic rings, the vasorelaxant effects of aprikalim, but not those of linsidomine or papaverine, declined when the [KCl] of the bathing medium was increased. In conclusion, the vasorelaxant potency and efficacy of calcium entry blockers is independent of the [KCI] used to precontract rat aortic rings, and thus, of the degree of membrane depolarisation. In contrast, increasing the [KCl] strongly reduces the potency and the efficacy of K+ channel openers not only in this preparation but also in noradrenaline-precontracted rings in which the entry of extracellular Ca2+ was prevented with nitrendipine. This indicates that, with the exception of pinacidil, the vasorelaxant activity of K+ channel openers depends on the degree of membrane depolarisation. Finally, the vasorelaxant potency and efficacy of nitrate-like compounds and papaverine are independent of depolarisation per se but they are markedly affected by the influx of Ca2+ accompanying elevated [KCI]. Thus, the degree of vessel depolarisation should be taken into consideration when attempting to compare potencies and efficacies among vasorelaxant agents.

Preferential reduction in vascular responses to endothelin-1 in rats with streptozotocin-induced diabetes.

The effects of vasodepressor (acetylcholine and bradykinin) and pressor [electrical stimulation of the spinal sympathetic outflow, norepinephrine and endothelin-1 (ET-1)] stimuli were determined in rats with 2- and 5-week untreated streptozotocin-induced diabetes (blood glucose 400 and >500 mg/dl, respectively). In pentobarbital-anesthetized animals, the hypotensive response to an intravenous dose of acetylcholine or bradykinin was unaffected in animals treated for 2 weeks with streptozotocin but was significantly reduced (22% and 48%, respectively) after 5 weeks. However, the pressor responses to ET-1 were significantly decreased in animals that had been given streptozotocin 2 (38%) and 5 (45%) weeks previously. In contrast, the vasoconstrictor effects of electrical stimulation of the spinal cord outflow and norepinephrine were significantly inhibited (47% and 30%, respectively) at 5 weeks, but not at 2 weeks, after streptozotocin administration. These results indicate that, in untreated streptozotocin diabetes, a substantial impairment of vascular reactivity to ET-1 appears more rapidly than inhibition of the pressor responses to endogenous and exogenous norepinephrine or to vasodilator substances that require integrity of vascular endothelial cell function to produce their normal effects.

Glibenclamide-induced blockade of ischemic preconditioning is time dependent in intact rat heart.

The ATP-sensitive potassium (KATP) channel has been demonstrated to be a potential mediator of ischemic preconditioning (PC) in most species, with the exception of the rat. This conclusion is based on the failure of the KATP channel antagonist glibenclamide (Glib) to block PC in this species. However, previous studies did not take into consideration the kinetic properties of Glib binding to its receptor in the rat myocardium. Therefore, the purpose of the present study was to test the hypothesis that ischemic PC is mediated by the myocardial KATP channel in the rat and that blockade of PC by Glib is a time-dependent phenomenon. Barbiturate-anesthetized, open-chest male Wistar rats were subjected to 30 min of occlusion and 2 h of reperfusion. Ischemic PC was elicited by three 5-min occlusion periods interspersed with 5 min of reperfusion. Infarct size (IS) as a percentage of the area at risk (AAR; IS/AAR) was determined with triphenyltetrazolium staining. PC and the KATP channel opener nicorandil (50 micrograms.kg-1.min-1 i.v.) resulted in marked reductions in IS/AAR from 53 +/- 3% to 8 +/- 1% and 17 +/- 5%, respectively (P < 0.05). Two doses of Glib (1 or 0.3 mg/kg i.v.) given 30 min before PC abolished the protective effect of PC; however, Glib (0.3 mg/kg i.v.) given 5 min before PC failed to block the effect. Glib administered 30 min before the 15-min nicorandil infusion blocked the cardioprotective effect of NC but did not block its transient hypotensive effect. These results demonstrate that the KATP channel is involved in ischemic PC in the intact rat heart and that the inhibitory effect of Glib to block PC is time dependent.

The myocardial lesions produced by the potassium channel opener aprikalim in monkeys and rats are prevented by blockade of cardiac beta-adrenoceptors.

Aprikalim is a potent, specific, and selective opener of ATP-sensitive K+ (KATP) channels. By virtue of this pharmacological property, aprikalim affords cardioprotection in experimental models of ischemia/reperfusion injury, and, at higher doses, also causes peripheral or coronary vasodilatation. Direct-acting peripheral vasodilators can cause myocardial lesions, particularly in rats and dogs. However, unexpectedly, aprikalim produced this effect also in monkeys. Thus, the primary aim of this investigation was to assess whether in monkeys these myocardial lesions were the direct or indirect consequence of the vascular effects of aprikalim. Cynomologus monkeys were given the beta-adrenoceptor antagonist nadolol (2 mg/kg p.o., twice daily) for 4 consecutive days. On the third and fourth day of the experiment, they received aprikalim (1 mg/kg p.o.). In another series, two monkeys carrying telemetry transmitters for blood pressure and heart rate measurements were also given aprikalim or its vehicle. Finally, aprikalim (1 mg/kg p.o. for 2 days) or its vehicle was administered to rats which were concurrently treated with the beta-adrenoceptor antagonist atenolol (5 mg/kg s.c.) or its vehicle. In cynomologus monkeys, aprikalim produced focal and multifocal myocardial necrosis of minimal to moderate intensity in or near the papillary muscles of the left ventricle. These effects were abrogated by nadolol. Similarly, necrotic lesions were caused by aprikalim only in those rats which had not been pretreated with atenolol. In monkeys, aprikalim produced a marked and long-lasting decrease in aortic blood pressure, accompanied by an even more prolonged tachycardia. These results demonstrate that aprikalim can produce myocardial necrosis not only in rats but also in monkeys. To our knowledge, this is the first time that such adverse effects are reported for a vasodilator in monkeys. More importantly, these effects were prevented by blocking cardiac beta-adrenoceptors. Thus, the myocardial lesions produced by aprikalim may be attributed to its profound and prolonged hemodynamic effects.

Pharmacological evidence that NK-2 tachykinin receptors mediate hypotension in the guinea pig but not in the rat.

Vascular NK-1 and NK-2 tachykinin receptors in the rat and the guinea pig were characterized pharmacologically by using available agonists and antagonists exhibiting varying degrees of selectivity for these receptors. Because the anesthetized guinea pig has unusually low blood pressure, these animals were pithed and vagotomized and infused, throughout the experimental procedure, with norepinephrine (6 micrograms/kg/min). This treatment raised their blood pressure to a level appropriate for the determination of dose-hypotensive response curves. The NK-1 receptor agonists substance P (SP) and septide (0.004 to 1 microgram/kg iv) decreased carotid artery blood pressure in a dose-dependent manner in both species, but they were more potent (13- and 33-fold, respectively) in guinea pigs than in rats. The NK-2 receptor agonist [beta Ala8]-NKA(4-10) (0.06 to 1 microgram/kg) also dose-dependently lowered blood pressure in the pithed guinea pig with noradrenaline-supported blood pressure, although it failed to do so in the same rat preparation. RP 67580, a selective NK-1 antagonist, antagonized the SP- or septide-induced hypotensive response in rats, but not in guinea pigs. Conversely, RPR 100893, a novel NK-1 receptor antagonist chemically related to RP 67580, dose-dependently inhibited hypotension induced by SP, and even more, that induced by septide only in guinea pigs. In the latter species, neither RP 67580 nor RPR 100893 affected decreases in blood pressure induced by [beta Ala8]-NKA(4-10). These decreases were, however, inhibited by the NK-2 receptor antagonist SR 48968. The selectivity of this compound for the latter receptor was confirmed by its failure to affect SP- or septide-induced hypotension in either guinea pigs or rats. These results confirm that the hypotensive responses to SP and septide are mediated by NK-1 receptors in the two species studied. However, functional NK-2 receptors appear to be present in the vascular bed of the guinea pig but not that of the rat, since in the former species the hypotensive responses induced [beta Ala8]-NKA(4-10) were inhibited by SR 48968 but not by the NK-1 receptor antagonists studied. This conclusion is, to our knowledge, drawn here for the first time from clear-cut pharmacological results.

The arterial wall: a new pharmacological and therapeutic target.

In recent years, two key concepts having numerous interrelationships were advanced for the understanding of various cardiovascular diseases: the "endothelial dysfunction" and the "arterial remodelling". Both endothelial dysfunction and arterial remodelling occur in various pathologies including essential hypertension, heart failure, atherosclerosis, restenosis after angioplasty, and pulmonary hypertension, and have modified the therapeutic approach by offering new pharmacological targets: specific receptors not only at the site of the vascular smooth muscle cells but also on the endothelial cells, growth factors that stimulate proliferation of smooth muscle, and receptors and enzymes of the extra-cellular matrix. Among the various substances under research, the present review will discuss angiotensin II receptor antagonists, endothelin receptor antagonists, nitrates-NO donors, potassium channel activators, and substances interfering with proteoglycans and other components of the extra-cellular matrix.

Intervessel (arteries and veins) and heart/vessel selectivities of therapeutically used calcium entry blockers: variable, vessel-dependent indexes.

The intervessel selectivity indexes of the calcium entry blockers amlodipine, felodipine, isradipine, nicardipine, nifedipine, nitrendipine, diltiazem and verapamil were assessed by determining the potency of these compounds [concentration decreasing tension developed by KCl in blood vessels by 50% (bvlC50)] to relax several KCl-precontracted blood vessels (femoral, jugular and saphenous veins and left anterior descending and left circumflex coronary and renal arteries) precontracted with KCl. The concentrations of KCl (25 mM for arteries and 50 mM for veins) used gave a similar response in these vessels. Intervessel selectivity indexes are the ratios of the bvlC50 determined in two different vessels. The negative inotropic potency (hlC50) was ascertained in paced (2 Hz), isoproterenol-(10 nM) supported atrial strips, and for three of the compounds, in papillary muscles. This allowed calculation of heart/vessel selectivity or vasoselectivity (ratio of hlC50 and bvlC50). All compounds overcame almost entirely (85-100%) the vessel contractile response to KCl and strongly reduced (65-90%) the tension developed by myocardial preparations. The rank order for vasorelaxant potency (bvlC50 from approximately 1 to approximately 700 nM) was generally as follows: isradipine > or = nifedipine > or = nitrendipine > or = amlodipine > or = verapamil > or = felodipine > or = nicardipine > or = diltiazem. However, the rank order for negative inotropic potency (hlC50 spanning from approximately 200 to approximately 6000 nM) was isradipine > or = nifedipine > or = verapamil > or = diltiazem > or = amlodipine > or = nitrendipine > or = felodipine > or = nicardipine. All compounds were generally more potent in relaxing capacitance than conductance vessels. Furthermore, of the capacitance vessels, the jugular vein was the least susceptible to relaxation; among the conductance vessels, five of the eight compounds relaxed renal arteries with greater potency than coronary arteries. Consequently, the value of the heart/vessel selectivity index is intrinsically dependent on the vessel used to calculate it. Overall, nitrendipine was the most vasoselective calcium entry blocker studied, with selectivity indexes ranging from 28 to 523. In conclusion, 1,4-dihydropyridine calcium entry blockers generally have a much greater affinity for calcium channels present in micropig veins than in heart muscle myocytes. This is possibly due to tissue-specific features of L-type calcium channels. Finally, comparing the vasoselectivity index of various compounds has validity only if this index is calculated by using the same experimental procedure applied to the same vascular tissue and the same heart preparation taken from the same species.

[Arterial wall: a new pharmacological and therapeutic target?]. / La paroi artérielle: une nouvelle cible pharmacologique et thérapeutique?

In recent years, endothelial dysfunction and arterial remodelling in various cardiovascular diseases have emerged as two key concepts, with numerous interrelationships. Both endothelial dysfunction and arterial remodelling occur in various pathologies including heart failure, atherosclerosis, restenosis after angioplasty, and pulmonary hypertension, and have modified the therapeutic approach by offering new pharmacological targets: specific receptors not only at the site of the vascular smooth muscle cells but also on the endothelial cells, growth factors that stimulate proliferation of smooth muscle, and receptors and enzymes of the extracellular matrix. Among the various substances under research, the present review will discuss angiotensin II receptor antagonists, endothelin receptor antagonists, nitrates-NO donors, potassium channel activators, and substances interfering with proteoglycans and other components of the extracellular matrix.

Time-dependent fading of the activation of KATP channels, induced by aprikalim and nucleotides, in excised membrane patches from cardiac myocytes.

1. The effects of the potassium channel opener (KCO) aprikalim (RP 52891) on the nucleotide-induced modulation of ATP-sensitive K+ (KATP) channels in freshly dissociated ventricular myocytes of guinea-pig heart, were studied by use of the inside-out patch-clamp technique. The internal surface of the excised membrane patch was initially bathed with a standard solution (Mg(2+)-free with EDTA), then sequentially superfused with solutions containing nucleoside diphosphates (NDPs: 200 microM ADP and 50 microM GDP) and NDPs plus 1 mM MgCl2 (with EGTA; referred to as Mg-NDP solution). 2. The normalized concentration-response (channel closing) relationship to ATP was shifted to the right when the standard solution was replaced by the Mg-NDP solution. Hence, the internal concentration of ATP ([ATP]i) inhibiting the channel activity by half (Ki) increased from 56 microM to 180 microM, with an apparently constant slope factor (s = 2.37). NDPs in the absence of Mg2+ did not decrease the sensitivity of the channels to ATP. 3. In standard solution, aprikalim (100 microM) activated KATP channels in the presence of a maximally inhibitory [ATP]i (500 microM). This effect was strongly enhanced when aprikalim was applied to patches exposed to Mg-NDP solution, as demonstrated by the 9 fold increase in Ki for [ATP]i (from 180 microM to 1.5 mM and s = 2.37). 4. The ability of aprikalim to overcome the channel closing effects of ATP in Mg-NDP solution waned rapidly. Similarly, the NDP-induced activation of ATP-blocked channels was also time-dependent. Both activation processes disappeared before the channel run-down phenomenon appeared in ATP-free conditions. 5. In conclusion, aprikalim is much more potent in opening KATP channels in membrane patches bathed in Mg-NDP solution than in standard solution. However, under the former experimental conditions, the effect of aprikalim waned rapidly. It is proposed that the waning phenomenon results from changes in the intrinsic enzymatic activity of the KATP channel protein (possibly linked to the experimental conditions) which lead to the channel closure.

Effects of beta 2-adrenoceptor agonists on anti-IgE-induced contraction and smooth muscle reactivity in human airways.

1. The beta 2-adrenoceptor agonists, salbutamol, salmeterol and RP 58802 relaxed basal tone of human isolated bronchial smooth muscle. Salmeterol- and RP 58802-induced relaxations persisted for more than 4 h when the medium was constantly renewed after treatment. 2. Salbutamol, salmeterol and RP 58802 reversed histamine-induced contractions in human airways (pD2 values: 6.15 +/- 0.21, 6.00 +/- 0.19 and 6.56 +/- 0.12, respectively). 3. Anti-IgE-induced contractions were significantly inhibited immediately after pretreatment of preparations with beta 2-adrenoceptor agonists (10 microM). However, when tissues were treated with beta 2-agonists and then washed for a period of 4 h, salmeterol was the only agonist which significantly inhibited the anti-IgE response. 4. Histamine response curves were shifted to the right immediately after pretreatment of tissues with the beta 2-adrenoceptor agonists (10 microM; 20 min), but maximal contractions were not affected. After a 4 h washing period, the histamine curves were not significantly different from controls. Concentration-effect curves to acetylcholine (ACh) or leukotriene C4 (LTC4) were not significantly modified after beta 2-agonist pretreatment. 5. These results suggest that beta 2-adrenoceptor agonists may prevent anti-IgE-induced contraction by inhibition of mediator release rather than alterations of those mechanisms involved in airway smooth muscle contraction.

Ischemic myocardial cell protection conferred by the opening of ATP-sensitive potassium channels.

The responses of the cardiac myocyte to a potentially injurious ischemic stress are multiple. The opening of the ATP-sensitive K+ channels may constitute one such response. These channels are present in the plasmalemma at very elevated density and have a large unitary conductance. Consequently, the opening of a small fraction (0.01-0.1%) of these channels during ischemia can help to drive the myocyte into an "emergency" state, in which its syncytial functions become rapidly downregulated and strategies appropriate to preserving cell viability are implemented. Thus, ATP-sensitive K+ channels in cardiac myocytes would appear to be an efficient and apparently redundant natural means of defense against metabolic stress. These channels can undergo physiologic modulation, as occurs during cardiac ischemic preconditioning in several species, including humans. The term cardioprotection refers to an endogenous cardioprotective strategy, whereby the myocardium slows its energy demands, produces fewer toxic glycolytic products, and exhibits reduced injury following a potentially lethal ischemic stress. Openers of cardiac ATP-sensitive K+ channels, a class of drugs that includes, in particular, aprikalim and nicorandil, also afford cardioprotection by reducing the functional and biochemical damage produced by ischemia. Hence, these compounds can improve the recovery of cardiac contractility, reduce the extracellular leakage of intracellular enzymes, delay the loss of ATP, and preserve the cell ultrastructure in isolated heart preparations subjected to transient ischemic conditions. Furthermore, when segmental contractility has been strongly depressed by a stunning insult, nicorandil and aprikalim can accelerate recovery at the reperfusion. Finally, nicorandil and aprikalim decrease substantially the size of the necrotic region that results from a prolonged ischemic insult followed by reperfusion. All of these desirable effects of K(+)-channel openers can be abolished by blockers of ATP-sensitive K+ channels, such as glibenclamide. The fundamental mechanism of the myocyte viability protection conferred by K(+)-channel openers is not yet clear. It may exploit some of the same pathways that mediate cardiac ischemic preconditioning. If this suggestion holds true, drugs opening cardiac ATP-sensitive K+ channels would mimic, exploit, or intensify those cardioprotective means that are naturally available to the cardiac myocyte for overcoming metabolic stress.

Cellular pharmacology of potassium channel openers in vascular smooth muscle.

Potassium channel opening is a physiological mechanism which excitable cells exploit to maintain or restore their resting state. Thus drugs that open vascular potassium channels have the potential to restrain or prevent contractile responses to excitatory stimuli or clamp the vessel in a relaxed condition. Hence, potassium channel openers, such as aprikalim and levcromakalim, relax agonist precontracted vascular preparations in vitro and lower systemic and regional vascular resistances in intact animals. Glibenclamide, a blocker of ATP sensitive potassium (KATP) channels, antagonises these effects. The main vasorelaxant mechanism of the potassium channel openers is to increase the potassium efflux through opening plasmalemmal potassium channels, which repolarises and/or hyperpolarises the membrane. This effect lowers the opening probability of voltage dependent calcium channels, restrains agonist induced calcium release from intracellular sources through inhibition of inositol trisphosphate formation, decreases the sensitivity of intracellular contractile elements to calcium, and accelerates the clearance of intracellular calcium via the Na+/Ca+ exchanger. Experimental evidence indicates that mechanisms not linked to potassium channel opening may also contribute to the potassium channel opener induced vasorelaxation; these remain to be clearly defined (for example, inhibition of the refilling of intracellular calcium stores). Potassium channel openers displace the binding of 3H-P1075, a potent potassium channel opener, in myocytes and intact rings from the rat aorta. In patches from vascular myocytes, potassium channel openers primarily open a small conductance (10-20 pS) KATP channel which is gated by [ATP]i and particularly by nucleotide diphosphates and magnesium.(ABSTRACT TRUNCATED AT 250 WORDS)

The contribution of guanylate cyclase stimulation and K+ channel opening to nicorandil-induced vasorelaxation depends on the conduit vessel and on the nature of the spasmogen.

Nicorandil, the specific K+ channel opener aprikalim, and the stimulant of guanylate cyclase, nitroglycerin, overcame in a concentration-dependent manner the sustained contractile responses evoked by KCl (10-25 mM) and norepinephrine (25-300 nM) in endothelium-denuded rings from rabbit aorta and pulmonary and mesenteric arteries. Nicorandil exhibited similar vasorelaxant potency (EC50, 1.6-3.1 microM) in all preparations investigated. The responses to nicorandil or nitroglycerin for pulmonary artery rings contracted with the two spasmogens and for aorta rings contracted with norepinephrine were not substantially modified by the K+ channel blocker glibenclamide at a concentration (1 microM) that displaced to the right the concentration-response curve to aprikalim obtained with these preparations. However, glibenclamide shifted to the right 2- to 3-fold the concentration-response curve obtained with nicorandil in aorta rings contracted with KCl and in mesenteric artery rings contracted with either KCl or norepinephrine, but not that obtained with nitroglycerin. Methylene blue (5-10 microM), an inhibitor of guanylate cyclase, displaced to the right the control concentration-response curves to nitroglycerin 3- to 21-fold and those to nicorandil 1.5- to 11-fold, but not those to aprikalim. In rabbit mesenteric artery rings, nicorandil both stimulated guanylate cyclase and opened K+ channels, regardless of whether KCl or norepinephrine was used to contract the vessels. However, nicorandil-induced relaxation of the pulmonary artery contracted with these spasmogens and the aorta contracted with norepinephrine was mediated almost entirely by the stimulation of guanylate cyclase, whereas the dual mechanism of action was again demonstrable when the latter vessel was contracted with KCl.(ABSTRACT TRUNCATED AT 250 WORDS)