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Drugs 2010; 70 (1): 41-56 REVIEW ARTICLE 0012-6667/10/0001-0041/$55.55/0 ª 2010 Adis Data Information BV

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Drugs 2010; 70 (1): 41-56 REVIEW ARTICLE 0012-6667/10/0001-0041/$55.55/0 ª 2010 Adis Data Information BV This material is the copyright of the original publisher. Unauthorised copying and distribution is prohibited. Terms and Conditions for Use of PDF The provision of PDFs for authors' personal use is subject to the following Terms & Conditions: The PDF provided is protected by copyright. All rights not specifically granted in these Terms & Conditions are expressly reserved. Printing and storage is for scholarly research and educational and personal use. Any copyright or other notices or disclaimers must not be removed, obscured or modified. The PDF may not be posted on an open-access website (including personal and university sites). The PDF may be used as follows: • to make copies of the article for your own personal use, including for your own classroom teaching use (this includes posting on a closed website for exclusive use by course students); • to make copies and distribute copies (including through e-mail) of the article to research colleagues, for the personal use by such colleagues (but not commercially or systematically, e.g. via an e-mail list or list serve); • to present the article at a meeting or conference and to distribute copies of such paper or article to the delegates attending the meeting; • to include the article in full or in part in a thesis or dissertation (provided that this is not to be published commercially). Drugs 2010; 70 (1): 41-56 REVIEW ARTICLE 0012-6667/10/0001-0041/$55.55/0 ª 2010 Adis Data Information BV. All rights reserved. Nebivolol Haemodynamic Effects and Clinical Significance of Combined b-Blockade and Nitric Oxide Release Otto Kamp,1 Marco Metra,2 Silvia Bugatti,2 Luca Bettari,2 Alessandra Dei Cas,3 Natalia Petrini2 and Livio Dei Cas2 1 DepartmentThis of Cardiology, Institute material for Cardiovascular Research VU, VU University is Medical Center, Amsterdam, the Netherlands 2 Section of Cardiovascular Disease, Department of Experimental and Applied Sciences, University of Brescia, Faculty of Medicine, Brescia, Italy 3 Departmentthe of Internal copyright Medicine and Biomedical Sciences, University of of Parma, Parma,the Italy Contents Abstract.................................................................................. 41 1. Mechanismsoriginal of Action . .publisher. 42 1.1 Differences Between b-Blockers . 42 1.2 b1-Adrenergic Receptor Selectivity . 43 1.3 Nitric Oxide Release . 43 2. Haemodynamic Effects of Nebivolol. 44 2.1 Heart Rate . 44 Unauthorised2.2 Peripheral Vasodilatation and Endothelial Function . .copying . 44 2.3 Coronary Blood Flow . 46 2.4 Left Ventricular (LV) Function. 47 2.4.1 Subjects with Normal LV Function . 47 2.4.2 Patients with Heart Failure and Preserved LV Systolic Function . 48 2.4.3and Patients with LV Systolicdistribution Dysfunction: Short-Term Studies . 48 2.4.4 Patients with LV Systolic Dysfunction: Long-Term Studies . 49 3. Clinical Effects. 50 3.1 Hypertension . 50 3.2 Heart Failure . 52 4. Conclusion . .is . .prohibited. 53 Abstract Nebivolol is a third-generation b-adrenergic receptor antagonist (b-blocker) with high selectivity for b1-adrenergic receptors. In addition, it causes vasodi- latation via interaction with the endothelial L-arginine/nitric oxide (NO) pathway. This dual mechanism of action underlies many of the haemodynamic properties of nebivolol, which include reductions in heart rate and blood pressure (BP), and improvements in systolic and diastolic function. With re- spect to BP lowering, the NO-mediated effects cause a reduction in peripheral vascular resistance and an increase in stroke volume with preservation of car- diac output. Flow-mediated dilatation and coronary flow reserve are also in- creased during nebivolol administration. Other haemodynamic effects include beneficial effects on pulmonary artery pressure, pulmonary wedge pressure, 42 Kamp et al. exercise capacity and left ventricular ejection fraction. In addition, nebivolol does not appear to have adverse effects on lipid metabolism and insulin sen- sitivity like traditional b-blockers. The documented beneficial haemodynamic effects of nebivolol are translated into improved clinical outcomes in patients with hypertension or heart failure. In patients with hypertension, the incidence of bradycardia with nebivolol is often lower than that with other currently available b-blockers. This, along with peripheral vasodilatation and NO-induced benefits such as antioxidant activity and reversal of endothelial dysfunction, should fa- cilitate better protection from cardiovascular events. In addition, nebivolol has shown an improved tolerability profile, particularly with respect to events commonly associated with b-blockers, such as fatigue and sexual dysfunction. ThisData from SENIORSmaterial (Study of the Effects of Nebivolol is Intervention on Out- comes and Rehospitalization in Seniors with Heart Failure) showed that sig- nificantly fewer nebivolol versus placebo recipients experienced the primary endpoint of all-cause mortality or cardiovascular hospitalization. The benefits of nebivolol therapy were shown to be cost effective. Thus, nebivolol is an effective the copyrightand well tolerated agent with benefits over of and above thosethe of traditional b-blockade because of its effects on NO release, which give it unique haemo- dynamic effects, cardioprotective activity and a good tolerability profile. b-Adrenergicoriginal receptor antagonists (b-block- publisher.pathomimetic activity, selectivity for b1- and/or ers) play an important role in the management of b2-receptors, and additional properties, including cardiovascular disease, including hypertension, peripheral vasodilatation.[14-16] Intrinsic sym- coronary artery disease and chronic heart failure. pathomimetic activity is not considered to be a However, the role of traditional b-blockers in the desirable feature because increased sympathetic Unauthorisedtreatment of hypertension has recently been stimulation copying has adverse effects on the heart. In questioned,[1,2] leading to these agents no longer contrast, receptor selectivity and peripheral vaso- being recommended as first- or second-line ther- dilatation are important properties for a b-blocker. apy for hypertension.[3] Third-generation b- One of the main differences between b-blockers blockers with b1-adrenergic receptor selectivity, is selectivity for b1-adrenergic receptors. b1- such as nebivolol,and have been useddistribution effectively in Selective agents include metoprolol, bisoprolol, patients with hypertension,[4-11] heart failure[12,13] atenolol and, with the greatest degree of selec- [12,13] and left ventricular (LV) dysfunction. tivity, nebivolol. b1-Adrenergic receptors are This review focuses on the haemodynamic ef- most numerous in the heart, and selectivity for fects of nebivolol, along with other ancillary mech- this subtype of b-adrenergic receptor limits ad- anisms of actionis that differentiateprohibited. it from verse effects resulting from blockade of b -adre- 2 traditional b-blockers and may contribute to bene- nergic receptors in the lungs and vascular beds. ficial cardiovascular effects. Haemodynamics and Most, if not all, the negative effects of sympa- other activity are considered in general initially, thetic stimulation are mediated by b1-adrenergic [17,18] then discussed with respect to the use of nebi- receptors, whereas stimulation of b2-adre- volol in the treatment of cardiovascular disease. nergic receptors may have potentially beneficial effects. These include inhibition of apoptosis and LV remodelling as well as other favourable ac- 1. Mechanisms of Action tions on myocardial cell biology.[14,19,20] How- 1.1 Differences Between b-Blockers ever, selectivity is dose dependent, and decreases or disappears when higher dosages are used. On b-Blockers vary with respect to several phar- the other hand, the favourable effects of carvedilol, macological properties, including intrinsic sym- compared with metoprolol, on LV function[21] ª 2010 Adis Data Information BV. All rights reserved. Drugs 2010; 70 (1) Nebivolol 43 and outcomes[22] in patients with heart failure are eral vessels and the heart.[23,28-31] In the periph- probably not explained by differences in receptor eral vessels, b3-adrenergic receptors are expressed selectivity but rather by other characteristics of in the endothelial cells where they stimulate endo- this agent such as its peculiar binding character- thelial NO synthase (eNOS) with increased NO istics to the b1- and b2-adrenergic receptors, release. NO produced at the endocardial level and ancillary antioxidant and anti-proliferative may paracrinally promote cardiomyocyte relaxa- properties.[14,15] tion and improve left ventricular filling. Other Concomitant peripheral vasodilatation is an b3-adrenergic receptors are located in the cardio- important characteristic of third-generation b- myocytes, where they have negative inotropic ef- blockers such as carvedilol and nebivolol. Vaso- fects mediated by G-a-I coupling with NOS and dilatation may be achieved through concomitant NO-mediated inhibition of b1- and b2-adrenergic blockade of aThis-adrenergic receptors material (in the case effects on cardiac muscle. is[31] Thus, b -adrenergic 1 3 of labetalol and carvedilol) or via stimulation receptor stimulation causes NO-mediated peri- of nitric oxide (NO) release (nebivolol).[23] Vaso- pheral vasodilatation, increased myocardial dilatation may allow greater efficacy in the compliance (through the paracrine effects of endo- treatmentthe of cardiovascular copyright diseases, such as cardial NO release)of
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