adrenergico : Ruolo dei βbloccanti di ultima generazione

G. VESCOVO MD G. VESCOVO MD PhDPhD FESCFESCMedicina I VicenzaMedicina I Vicenza

Agonismo ed Antagonismo Agonismo ed Antagonismo ββadrenergicoadrenergico ::

Ruolo dei Ruolo dei ββ bloccanti di ultima bloccanti di ultima generazionegenerazione

ββ11 and and ββ22 adrenoceptorsadrenoceptors whatwhatdo do wewe knowknow??

InotropicInotropic EffectEffectChronotropicChronotropicLusitropic Lusitropic

MC Schaub 2006

0.1mm

MyocyteMyocyte

Isolation ofIsolation of myocytesmyocytes from the ventricle of the heartfrom the ventricle of the heart

©© Dr GiorgioDr Giorgio VescovoVescovo

Philip Poole WilsonPhilip Poole WilsonSianSian HardingHardingMary JonesMary JonesFederica del MonteFederica del MonteGiorgioGiorgio VescovoVescovoPeterPeter O’GaraO’Gara

LONDON NHLI 1985LONDON NHLI 1985

CalciumCalcium and and ContractilityContractility

S Harding, G Vescovo JMCC 1991

LEC Ca++ 10 -3 M

Cytosol Ca++1-2 -7 M diastole

1-6 M systole

AmAm J J PhysiolPhysiol 19911991

The The syndromesyndrome of of HeartHeart FailureFailure

CHFCHFLeft Left VentricularVentricularDysfunctionDysfunction

CongestionCongestionLungsLungsLimbsLimbsGutsGuts

DyspnoeaDyspnoeaFatigueFatigue

ArrhythmiasArrhythmias

JMCC 1991

Rec

epto

r Den

sity

R

ecep

tor D

ensi

ty

(( fmol

fmol

/mg)

/mg)

NonNon--failingfailing

Failing (IDC)Failing (IDC)

* P < 0.05 vs. non* P < 0.05 vs. non--failingfailingIDC = Idiopathic Dilated IDC = Idiopathic Dilated CardiomyopathyCardiomyopathy Bristow MR et al. Bristow MR et al. ClinClin Drug Drug TherTher 19891989

Adrenergic Receptor Densities Adrenergic Receptor Densities in Human LV Myocardiumin Human LV Myocardium

7070

6060

5050

4040

3030

2020

1010

00ββ11 ββ22 αα11

**

**

BroddeBrodde O.E. J O.E. J PharmacolPharmacol Sci 2006Sci 2006

ββ--ARK1 (GRK2) in ARK1 (GRK2) in HeartHeart Failure Failure and and ββ--blockersblockers treatmenttreatment

LONDON NHLI 1985LONDON NHLI 1985

McLEODMcLEOD VESCOVOVESCOVOEurEur HeartHeart J 1991J 1991

A. Marks Circulation 2001

β-AR Desensitisation andβ-Blockers in Heart Failure

LondonLondon 19861986ApoptoticApoptotic MyocyteMyocyte DeathDeath in in RealReal TimeTime

LondonLondon 1886 Jack the 1886 Jack the RipperRipper

IwaiIwai--KanaiKanai E E CirculationCirculation 19991999

RegulationRegulation of of ApoptosisApoptosisbyby αα-- and and ββ adrenergicadrenergicpathwayspathways

CommunalCommunal C. C. CirculationCirculation 19981998

NorepinephrineNorepinephrine producesproduces myocytemyocyte apoptosisapoptosisbyby activationactivation of the of the ββ--receptorreceptor pathwaypathway

ILIL--11ββ

ILIL--66

TNFTNF--αα

MurrayMurray D D CirculationCirculation 20002000

ββ--adrenoceptoradrenoceptorstimulationstimulationAnd And MyocardialMyocardialCytokineCytokineExpressionExpression

MJ MJ LohseLohse 20032003

GradoGrado didi selettivitàselettività didi diverse diverse molecolemolecole ββ bloccantibloccanti

Rapporto di selettività ß1/ß2 valutato attraverso Rapporto di selettività ß1/ß2 valutato attraverso radioliganteradioligante su miocardio umano (ventricolo sinistro)su miocardio umano (ventricolo sinistro)

PrisantPrisant, J. , J. ClinClin. . PharmacolPharmacol. 2008; 48: 225. 2008; 48: 225--239239

BetaBeta--3 3 adrenergicadrenergic receptorreceptor ADRB3ADRB3

BuprenololBuprenololCarvedilolCarvedilol

LL--796568796568CL 316,243CL 316,243LY 368842LY 368842RoRo 4040--21482148BRL 37344BRL 37344NebivololNebivolol

((partialpartial?)?)

GsGsadenylateadenylatecyclasecyclase

cAMPcAMP

LipolysisLipolysisArrestinArrestin

mediatedmediateddesensitdesensit

NANA--A A mediatedmediatedvasodilatvasodilat

+ + regulatregulatMAPK MAPK cascadecascade

Negative Negative inotropicinotropic and and lusitropiclusitropicefffectefffect

cNOScNOSiNOSiNOS

ISO=NA>AISO=NA>Aββ33

AntagonistAntagonistAgonistAgonistMechanismMechanismActionActionAgonistAgonistPotencyPotency

ReceptorReceptorTypeType

ββ33 RECEPTORS IN RECEPTORS IN MYOCARDIAL CELLSMYOCARDIAL CELLS

C C GauthierGauthier J J ClinClin InvestInvest 19931993

ββ11 ββ2 2 stimulationstimulation

ββ3 3 agonistsagonists

H Le Marec J Clin Invest 1998

G Lembo G Lembo CirculationCirculation 20072007

ββ22 antagonistantagonist

ββ33 antagonistantagonist

? ? ββ33 partialpartial agonistagonist

G Lembo G Lembo CirculationCirculation 20072007

D. Bers Circulation 2001

iNOSiNOS CaCa--releasereleaseLPS LPS iNOSiNOS

In LPS In LPS myocytesmyocytes

AG lAG l--aminoamino--guanidineguanidineiNOS antagonistiNOS antagonist

RJ Lefkowitz PNAS 2007

ββ--arrestin stimulates arrestin stimulates MAPKMAPKIP3K AKT IP3K AKT cJun kinase cJun kinase ERKERK

A A MorimotoMorimoto AmAm J J PhysiolPhysiol 20052005

S S MoniotteMoniotte CirculationCirculation 20012001

S S MoniotteMoniotte CirculationCirculation 20012001

JL JL BalligandBalligand CirculationCirculation 20052005

ββ33AR AR eNOSeNOS iNOSiNOS

ββ33

contractilitycontractility

eNOSeNOS

agonistagonist

NormalNormal HeartHeart FailureFailureUpregulationUpregulation

AgonistAgonist

ββ33

eNOSeNOS

?? iNOSiNOS

ContractilityContractility

HeartHeart FailureFailureBetaBeta--blockerblocker ββ33 activeactive

ββ33 blockerblocker

ββ33

eNOSeNOS

? ? iNOSiNOS

ContractilityContractility

β1 desensit

ββ33 RECEPTORS IN THE RECEPTORS IN THE VASCULAR CELLSVASCULAR CELLS

C. Gauthier Br J Pharmacol 2006

MAW MAW BroedersBroeders CirculationCirculation 20002000

β1 ARSer or Glyβ1 ARSer or Gly

β2 ARArg or Glyβ2 ARArg or Gly

β2 ARGln or Glu

β2 ARGln or Glu

β2 ARMet or Valβ2 ARMet or Val β2 AR

Thr or Ileβ2 ARThr or Ile

β1 ARGly

or Arg

β1 ARGly

or Arg

16164949

27273434

164164

389389

Gln27GluC79Gbetabeta 22

Gly16ArgG46Abetabeta 22

Gly389ArgG1165Cbetabeta 11

Ser49GlyA145Gbetabeta 11

Arg492CysC1441Talphaalpha 1A1A

EffectEffectPolymorphismPolymorphismARAR--subtypesubtype

αα-- and and ββ--receptorsreceptors polymorphismpolymorphism

RathzRathz DA JBC 2002DA JBC 2002

ββ11((GlyGly--Arg389)Arg389)--ββ22 ((ThrThr--Ill164) Ill164) adrenoceptoradrenoceptorpolymorphismpolymorphism and and desensitisationdesensitisation

ββ22--AR Polymorphisms Influences the AR Polymorphisms Influences the Response to Response to CarvedilolCarvedilol Therapy in Heart Therapy in Heart

FailureFailure

Glu27Glu = Glu27Glu = ββ22--AR AR downregulationdownregulation::ββ22 sensitivitysensitivity

ββ22--AR Gln27GluAR Gln27Glu

∆∆Ej

ectio

nEj

ectio

nFr

actio

nFr

actio

n(( a

bsol

ute

abso

lute

units

units

))

PolymorphismPolymorphism

MetraMetra M M etet al. HF 2003al. HF 2003

00

55

1010

1515

2020

Gln27GlnGln27Gln

P < 0.01P < 0.01

Gln27GluGln27Glu Glu27GluGlu27Glu

Liggett J.Clin.Invest

wild-type β2

β2allele

ββ--adrenergicadrenergic polymorphismpolymorphism and and survivalsurvival

JCI 1998

ResponseResponse totoBucindolol Bucindolol in in ArgArghomozygoteshomozygotes and and GlyGly--389 389 carrierscarriers

K K MasuoMasuo CirculationCirculation 20082008

TrpTrp 64/64/ArgArg 64 64 polymorphismpolymorphism

EFFECT OF SARCOMERIC EFFECT OF SARCOMERIC PROTEIN OXIDATION PROTEIN OXIDATION

ON EXERCISE CAPACITYON EXERCISE CAPACITY

C C chf nebichf nebi bisobiso

ProteinProtein OxidationOxidation in CHF andin CHF andEffectEffect of of NebivololNebivolol and and BisoprololBisoprolol

BetaBeta--blockersblockers skeletalskeletal musclemuscle oxidationoxidationand in vitro and in vitro contractilitycontractility

CHFCHF

BISOPROLOLBISOPROLOL

NEBIVOLOLNEBIVOLOL

C

EFFECTS OF NEBIVOLOL AND BISOPROLOL EFFECTS OF NEBIVOLOL AND BISOPROLOL ON SKELETAL MUSCLE APOPTOSIS AND ATROPHYON SKELETAL MUSCLE APOPTOSIS AND ATROPHY

CONCLUSIONSCONCLUSIONSββ33ADR ADR stimulationstimulation decreasesdecreases contractilitycontractility and and lusitropismlusitropism in the in the heartheart

•• In CHF In CHF ββ33 overexpressionoverexpression furtherfurther depressesdepressesinotropisminotropismThe The improvementimprovement in in contractioncontraction and and relaxationrelaxationafter after ββ--blockadeblockade isis a a balancebalance betweenbetween ββ11 and and ββ33blockade blockade

•• At At endothelialendothelial levellevel PE and PE and EndoEndo producesproducesvasoconstrictionvasoconstriction..ββ33 agonismagonism ((nebivololnebivolol) ) inducesinduces NO NO dependentdependentvasodilatationvasodilatation

•• ItIt isis possiblepossible thatthat changeschanges occurringoccurring at at musclemusclelevellevel are are partiallypartially mediatedmediated byby ββ11 and and partlypartly bybyββ33 agonismagonism (NO production)(NO production)

NEBIVOLOLONEBIVOLOLO

•• ß1ß1--antagonismo antagonismo altamente selettivoaltamente selettivo

•• Vasodilatazione NOVasodilatazione NO--mediatamediata

NEBIVOLOLONEBIVOLOLONebivololoNebivololo 5 mg è 5 mg è unauna miscelamiscela racemicaracemica costituitacostituita dada ugualiuguali

quantitàquantità didi due due enantiomerienantiomeri: :

L L -- nebivololonebivololo 2,5 mg e D 2,5 mg e D -- nebivololonebivololo 2,5 mg2,5 mg

2,5 mg L 2,5 mg L -- nebivololonebivololo•• ATTIVITA’ VASODILATANTE ATTIVITA’ VASODILATANTE NONO--MEDIATAMEDIATA

2,5 mg D 2,5 mg D -- nebivololonebivololo••ATTIVITA’ ß1ATTIVITA’ ß1--BLOCCANTE BLOCCANTE ALTAMENTE SELETTIVAALTAMENTE SELETTIVA••ATTIVITA’ VASODILATANTE ATTIVITA’ VASODILATANTE NONO--MEDIATAMEDIATA

NEBIVOLOLO: VASODILATAZIONE NO-MEDIATANEBIVOLOLO: VASODILATAZIONE NONEBIVOLOLO: VASODILATAZIONE NO--MEDIATAMEDIATA

RitterRitter. J . J CardiovascCardiovasc PharmacolPharmacol 2001;38(s3):132001;38(s3):13--6.6.*L*L--NMMA (LNMMA (L--N monoN mono--metilmetil--argininaarginina): ): antagonistaantagonista selettivoselettivo dell’edell’e--NOSNOS

0

1

2

3

4

5

6

0 12 24 36 48 60 72

AVAMBRACCIO NON INFUSO AVAMBRACCIO INFUSO CON NEBIVOLOLO

88,5

177

354

88,5

177

354

Soluzione fisiologica L-NMMA (2 mg/min)

Nebivololoµg/min

EffettoEffetto sulsul flussoflusso ematicoematico dell’avambracciodell’avambraccio dell’infusionedell’infusioneintraintra--arteriosaarteriosa didi nebivololonebivololo e e nebivololonebivololo+L+L--NMMA*NMMA*