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NEBIVOLOL UNA ALTERNATIVA DIFERENTE EN EL MANEJO DE LA HTA
Y FALLA CARDIACA
DRA. BALKIS ROLONG CAROJefe de Recuperación CV y Rehabilitación Cardiovascular O.Clínica General del Norte
FELLOWSHIP: Insuficiencia Cardiaca –Prevención y Rehabilitación Cardiovascular MD.FAMILIAR
PROFESORA POSTGRADO MD INTERNA Y ANESTESIA FUSM
Hypertension and NO
Haemodynamic progressionof hypertension
• Early hypertension:Increased CO with relative increased SVR
• Established hypertension:Decreased CO and increased SVR
• Late hypertension:Decreased CO (25%) and markedly increased SVR (25%)
Houston MC. Primary Care Clin North Am 1991; 18:713-753.
2
Optimal approach to reduce high blood pressure
• Reduce SVR
• Preserve CO
• Improve arterial compliance
• Maintain organ perfusion
Houston MC. Primary Care Clin North Am 1991; 18:713-753.
3
Haemodynamic effects of mainantihypertensive classes
Calcium channel blockersACE-inhibitorsAngiotensin II (Ang-II) receptor blockers
• reduce SVR, preserve COand improve arterial compliance and perfusion
-blockers• initially they increase SVR, while in chronic therapy they
decrease SVR and riduce CO
Diuretics
• reduce SVR, CO and perfusion, and worsen arterialcompliance
Houston MC. Primary Care Clin North Am 1991; 18:713-753. Rachel RE. Conn’s Current Therapy 2000.
4
Structure of vascular endothelial cells
Transcellular
Junction-associated actinfilament system: actin, myosin and others
Basal lamina
Stress fibre (basal): actin and myosin-containing contractile fibrils
Para-cellular
Focal contact: integrins, talin, vinculin, alpha-actin and others
6
Main functions of endothelium
• Regulation of vasodilation and constriction
• Regulation of vascular permeability
• Regulation of leucocyte and platelet-vessel
wall interaction
• Vascular remodelling
Lüscher TF, Vanhoutte PM. The Endothelium: Modulator of cardiovascular function. CRC Press 1990, Boca Raton.
7
Endothelium-derived vasoactive factors
Adapted from Lüscher and Noll. In: Braunwald E. Heart Disease, 5th ed. Saunders; Philadelpia 1997.
8
Endothelium: physiological condition
Contracting factors:
• Endothelin 1
• Thromboxane A2
• Prostaglandin H2
Cosentino F, Lüscher TF. Eur Heart J 1995; 16:4-12.
Relaxing factors:
• NO
• Prostacyclin
• Endothelium-derivedhyperpolarizing factor
(EDHF)
9
Endothelium: impaired vascular function
Contracting factors:
• Endothelin 1• Thromboxane A2
• Prostaglandin H2
Relaxing factors:
• NO• Prostacyclin
• Endothelium-derivedhyperpolarizing factor
(EDHF)
• Ageing• Menopause
• Hypertension• Diabetes
• Hypercholesterolaemia
Cosentino F, Lüscher TF. Eur Heart J 1995; 16:4-12.
10
L-arginine/NO pathway
Endothelial cell
Vascular smoothmuscle cell
eNOS
L-arginine
NO
citrulline
GTP cGMP
NO
Relaxation (vasodilation)
Guanilatecyclase
Ignarro LJ et al. J Cardiovasc Pharmacol 1999; 34:876-884. Napoli C, Ignarro LJ. Nitric Oxide 2001; 5:88-97.
11
L-arginine/NO pathway inhibition
Endothelial cell
Vascular smoothmuscle cell
Constriction(vasoconstriction)
L-NMMA eNOS
L-arginine
NO (-)
citrulline
(-) NO(-) cGMP
Tousoulis D et al. J Am Coll Cardiol 1997; 25:1256-1262.
12
The NO system in thepathogenesis of hypertension
Decreased NO production; basal and after stimulation
Decreased endothelial vasodilationin response to acetylcholine
Increased vascular resistance
Essential hypertensionCalver A et al. J Hypertension 1992; 10:1025-31.
14
Nebivolol: pharmacological and therapeutic profile
Haemodynamicprofile
1-adrenoceptor antagonism
• Antihypertensive efficacy
• Tolerability profile
NebivololNebivolol
Endothelium-inducedNO-mediated effects
15
Nebivolol and NO release: endothelium induced effects
• Anti-proliferative effectIgnarro, Brehm
• Anti-oxidant activityDe Groot, Troost, Cominacini
• Anti-atherosclerotic activityBrehm, Napoli, Lüscher, Falciani, Kuroedov
• Endothelium-NO-dependent vasodilationIgnarro, Lüscher, Balligand, Broeders
20
Nebivolol: anti-proliferative effect
Arginine
Ornithine
Putrescine
Polyamines for Cell Growth
Spermidine Spermine
arginase
ODC
NO
NO
NebivololNebivolol
NOS
Ignarro LJ. Ann Rev Pharmacol Toxicol 1990; 30:535-560.
22
Effect of different -blockers on cell proliferation and metabolic activity
Nebivolol
Carvedilol
Metoprolol
Propranolol
10
30
50
70
90
110
130
150
Co 0.1 1 2 4 6 8 10
Pro
life
rati
on
(% c
on
tro
l)
-blocker (µmol/l)
BrdU-ELISA
0
20
40
60
80
100
120
140
Co 0.1 1 2 4 6 8 10
-blocker (µmol/l)
MTT-TEST
Brehm BR et al. J Cardiovascular Research 2001; 49:430-439.
*** *
**
*
*
**
*
*
*
**
*
*
*****
* p<0.01
(n=6)M
eta
bo
lica
cti
vit
y(%
co
ntr
ol)
23
Nebivolol: vasodilationin healthy volunteers
Effects of nebivolol and atenolol administered intra-arterially in two distinctoccasions, at equimolar doses, for 6 minutes on forearm blood flow
Nebivolol 0 18 88.5 177 354 (g/min)Atenolol 0 10 50.0 100 200 (g/min)
Nebivolol
Incr
ease
in F
BF
(%
)
Atenolol
-20
20
60
100
*
*
*
* p<0.01
Cockroft JR. J Pharmacol Exp Ther 1995; 274(3):1067-1071.
31
Nebivolol: decreases systemicoxidative stress
Troost R et al. Br J Clin Pharmacol 2000; 50:377-379.
8-i
so
-PG
F2
(pm
olm
mo
l-1c
rea
tin
ine
)
0
10
20
30
40
50
60
70
Placebo Nebivolol
55.3
42.3
24% reduction
* p<0.05
*
24
Nebivolol: inhibits in vitrohuman platelet aggregation
Falciani M et al. J Cardiovasc Pharmacol 2001; 38:922-929.
% a
gg
reg
ati
on
100
75
50
25
0
-6 -5 -4
% a
gg
reg
ati
on
120
100
80
60
40
-9 -8 -7 -6 -5 -4
NebivololCarvedilolPropranolol
*††*††
††
Log [antagonist]Nebivolol log [M]
NebivololNebivolol+L-arginineNebivolol+L-NMMA
ADP: aggregating agentValues represent mean ± SEM of n=5 experiments
* p<0.050 * p<0.05 nebivolol vs. propranolol† p<0.05 nebivolol vs. carvedilol† † p<0.01 nebivolol vs. carvedilol
**
*
**
*
26
0
10
20
30
40
50
60
70
80
90
100
Plaque reduction and improvementof endothelial dysfunction
Kuroedov A et al. ESC Vienna 2003.
Surface covered byplaques (% vs control)
Relaxation to 10-4 M acetylcholine (% vs control)
Control
Nebivolol
Atenolol*
* *
*
* p<0.05
27
*p<0.05
**
p<0.001
(n=12)
Tzemos N et al. Circulation 2001; 104:511-514.
Nebivolol: vasodilation inhypertensive patients
Placebo
Nebivolol
Atenolol50
0
40
0
30
0
20
0
10
0
0
Acetylcholine, nmol/min
25 50 100
**
**
*
*
L-NMMA, µ mol/min
0
-10
-20
-30
-40
-50
-60
-70
1 2
4
**
*
*
*
35
0
30
0
25
0
20
0
15
0
10
0
50
0
Sodium Nitroprusside, nmol/min
4.2 12.6 37.8
*
F
BF
%
33
Nebivolol blood lipid profile
Predel HG et al. J Hum Hypertens 2001; 15:715-721.
0
50
100
150
200
250
TotalCholesterol
(mg/dl)
LDLCholesterol
(mg/dl)
HDLCholesterol
(mg/dl)
LDL/HDL Triglycerides(mg/dl)
* p=0.0074
Before treatment at rest
After treatment at rest(Nebivolol 5 mg)
*(n=18)
85
Tolerability:Nebivolol vs Amlodipine
Mazza A. et al. Blood Pressure 2002; 11:182-188.
Nebivolol(n=81)
Amlodipine(n=87)
0
5
10
15
20
25
30
Total AEs Oedema Headache Flushing Dizziness Bradycardia
**
*
*
* p<0.05
** p<0.036
N.
of
dru
g r
elat
ed a
dve
rse
even
ts74
CONCLUSIONES LA DISFUNCION ENDOTELIAL DEBE SER CONSIDERA COMO
UN OBJETIVO EN EL TTO ANTIHIPERTENSIVO
NEBIVOLOL UNICO CON PROPIEDADES BENEFICAS Y DIRECTAS SOBRE ENDOTELIO A TRAVES DE VASODILATACION MEDIADA POR LA VIA DEL OXIDO NITRICO AUN EN PRESENCIA DE DISFUNCION ENDOTELIAL
IMPACTO NEUTRO A NIVEL METABOLICO
BIEN TOLERADO Y EFICAZ COMPORTAMIENTO HEMODINAMICO
DISMINUCION RESISTENCIA VASCULAR SITEMICA SIN AFECTAR GASTO CARDIACO
IMPACTO EN MORBIMORTALIDAD EN FALLA CARDIACA
“Hace 50 años teniamos pocos tratamientos para tratar las
enfermedades cardiovasculares, pero existía la relación Médico-Paciente, ahora
tenemos el conocimiento y existen tratamientos muy
eficaces pero no los utillizamos.Acercar este conocimiento a nuestros pacientes debe ser
una prioridad medica y social.”
Salim Yusuf