Drugs for hypertension, angina and heart failure

12.1 Drugs for hypertension 12.1.1 Epidemiology and pathophysiology 12.1.2 Diuretics for hypertension 12.2.3 Vasodilators for hypertension 12.4.4 β-Adrenoceptor blockers for hypertension 12.2. Drugs for angina 12.2.1 Typical angina 12.2.2 Drugs to treat an attack of typical angina 12,2.3 Drugs to prevent an attack of typical angina 12.2.4 Atypical angina 12.3 Drugs for heart failure 12.3.1 The heart failure epidemic 12.3.2 Compensatory changes in heart failure 12.3.3 Diuretics for heart failure 12.3.4 ACE inhibitors and AT1-receptor antagonists 12.3.5 β-adrenoceptor antagonists 12.3.6 Digoxin

Antihemostatic molecules from saliva of blood-feeding arthropods

The ability to feed on vertebrate blood has evolved many times in various arthropod clades. Consequently, saliva of blood-feeding arthropods has proven to be a rich source of antihemostatic molecules. A variety of platelet aggregation inhibitors antagonize platelet responses to wound-generated signals, including ADP, thrombin, and collagen. Anticoagulants disrupt elements of both the intrinsic and extrinsic pathways. Vasodilators include nitrophorins (nitric oxide storage and transport heme proteins), a variety of peptides that mimic endogenous vasodilatory neuropeptides, and proteins that catabolize or sequester endogenous vasoconstrictors. Multiple salivary proteins may be directed against each component of hemostasis, resulting in both redundancy and in some cases cooperative interactions between antihemostatic proteins. The complexity and redundancy of saliva ensures an efficient blood meal for the arthropod, but it also provides a diverse array of novel antihemostatic molecules for the pharmacologist.

Relation entre CaMKII et les dynamiques calciques endothéliales : impact de l'hypertension arterielle.

L’endothélium vasculaire joue un rôle prépondérant dans la régulation du tonus vasculaire en générant l’oxyde nitrique (NO), la prostacycline (PGI2) et les facteurs hyperpolarisants dérivés de l’endothélium (EDHF) comme puissants vasodilatateurs. Ces mécanismes requièrent le calcium (Ca2+) à divers niveaux, démontrant l’importance des dynamiques calciques endothéliales. Une perturbation de l’homéostasie calcique est observée dans une dysfonction endothéliale liée à l’hypertension artérielle. Il est impératif d’approfondir nos connaissances sur les signalisations calciques endothéliales impliquées dans le contrôle du tonus vasculaire. Des études récentes ont montré qu’une variation locale de la concentration en Ca2+ libre intracellulaire ([Ca2+]i) est suffisante pour générer une réponse physiologique importante. Les pulsars calciques sont caractérisés par une augmentation de [Ca2+]i spontanée et transitoire spécifiquement localisée au niveau des projections myoendothéliales (PMEs). Ces PMEs sont des sites de communication privilégiés entre les cellules endothéliales (CEs) et les cellules musculaires lisses vasculaires (CMLVs). Les pulsars calciques sont impliqués dans le mécanisme de l’EDHF via l’activation des canaux potassiques Ca2+-dépendant de moyenne conductance (KCa3.1 ou IKCa). Les travaux de cette thèse visent à améliorer nos connaissances sur les signalisations calciques locales en caractérisant une nouvelle voie de signalisation pouvant être impliquée dans la régulation du tonus vasculaire en condition physiopathologique. Outre les canaux KCa3.1 peu d’informations sont disponibles sur les cibles sensibles aux pulsars calciques. Une première étude a permis d’identifier la protéine kinase II dépendante du complexe Ca2+/calmoduline (CaMKII) sous ses isoformes α, β et δ dans les CEs d’artères natives de souris comme une cible pouvant être modulée par les pulsars calciques. Des études en immunofluorescence ont permis d’observer la localisation particulière de CaMKII endothéliale dans les PMEs, les sites des pulsars calciques. Une stimulation spécifique des pulsars calciques par la phényléphrine (PE) engendre un recrutement de CaMKII dans les PMEs. Sachant que CaMKII active l’oxyde nitrique synthase endothéliale (NOS3), nous avons évalué l’impact d’une stimulation des pulsars calciques sur la production de NO en présence d’un inhibiteur de CaMKII, le KN-93. Nous avons démontré que la production de NO est en partie dépendante de l’activation de CaMKII par les pulsars calciques. En utilisant un modèle d’hypertension induite par l’infusion chronique de PE, nous avons permis de mettre en évidence une perturbation dans la relation entre les pulsars calciques et CaMKII. Dans une seconde étude nous avons établi deux modèles (normo- et hypertendus) d’infusion chronique à l’angiotensine II (AngII) afin évaluer l’impact des ROS et de l’hypertension sur la voie de signalisation pulsars/CaMKII/NO. Nos résultats ont montré une augmentation des pulsars calciques accompagnée d’un recrutement de CaMKII dans les PMEs. Une stimulation aigue à l’AngII suggère que les ROS modulent les dynamiques calciques et que l’AngII stimule la production de NO. Cette étude propose que ces voies de signalisations impliquent les récepteurs de type 1 et 2 à l’AngII (AT1 et AT2). L’étude des pulsars calciques dépend fortement de la structure native des artères qui permet de conserver la formation des PMEs. La dernière étude présentée dans cette thèse a permis d’établir une relation entre les PMEs et les pulsars calciques dans trois lits vasculaires distincts (artères mésentériques, pulmonaires et coronariennes). Nos résultats ont montré que les paramètres cinétiques des pulsars calciques sont fortement conservés entre les différents lits vasculaires. Toutefois, la fréquence globale ainsi que le nombre de sites actifs des pulsars calciques diffèrent avec une proportion plus élevée dans les artères mésentériques et coronariennes comparativement aux artères pulmonaires. Ces résultats corrèlent avec le nombre plus élevé de PMEs retrouvé dans les artères mésentériques et coronariennes. Ces travaux suggèrent que les pulsars calciques sont fondamentaux pour les artères de résistance. Les études de cette thèse ont mené à l’identification d’une nouvelle voie de signalisation impliquant les pulsars calciques et CaMKII endothéliale dans la stimulation de la production de NO. Cette nouvelle voie de signalisation pourrait être impliquée dans la régulation du tonus vasculaire en condition physiopathologique. Les pulsars calciques semblent être fortement conservés entre les différentes artères de résistances et ce malgré la disparité dans les PMEs, suggérant un rôle prépondérant dans la fonction vasculaire. Ces travaux ouvrent une avenue pour le développement de potentielles cibles thérapeutiques pouvant contrer la dysfonction endothéliale associée à l’hypertension artérielle.

Suplementación de hormona tiroidea en pacientes pediátricos críticos con síndrome eutiroideo enfermo

Introducción : el síndrome del eutiriodeo enfermo en enfermedades graves es factor de pobre pronóstico. La suplementación con hormona tiroidea mejora la contractibilidad miocardica y estimula la producción de surfactante pulmonar; sin embargo existe controversia debido a las complicaciones secundarias, ausencia de efectos a nivel hemodinámico y de estancia hospitalaria. Objetivo : determinar el efecto de la suplementación oral de hormonas tiroideas en pacientes con choque refractario y necesidad de más de dos inotrópicos con respecto a estabilidad hemodinámica, arritmias, requerimientos de inotrópicos y mortalidad asociada al tratamiento. Metodología : estudio longitudinal observacional de variables repetidas con análisis previo y posterior a la intervención. Realizado en pacientes con choque refractario de la unidad de cuidado intensivo pediátrico del Hospital Simón Bolívar, desde el 1 de enero del 2007 hasta 1 enero del 2009. Resultados: la suplementación tiroidea mostró una disminución significativa en el requerimiento de los inotrópicos adrenérgicos: dopamina, adrenalina y noradrenalina con rangos de [4,78-2.4], [3.92 - 2.98] y [3.58- 2.24] (p <0.001) respectivamente, sin haber diferencia en los vasodilatadores, inodilatadores y diuréticos. No se encontró asociación entre su uso y la presencia de arritmias. Discusión y conclusiones: La hormona tiroidea mostró efecto benéfico en términos de disminución de soporte inotrópico. resultado en concordancia con la literatura y relacionado con la función moduladora de la hormona tiroidea favoreciendo la inotropía miocardica y los índices de contractilidad ventricular izquierda.

Possible role for K+ in endothelium-derived hyperpolarizing factor–linked dilatation in rat middle cerebral artery

Background and Purpose— Endothelium-derived hyperpolarizing factor (EDHF) and K+ are vasodilators in the cerebral circulation. Recently, K+ has been suggested to contribute to EDHF-mediated responses in peripheral vessels. The EDHF response to the protease-activated receptor 2 ligand SLIGRL was characterized in cerebral arteries and used to assess whether K+ contributes as an EDHF. Methods— Rat middle cerebral arteries were mounted in either a wire or pressure myograph. Concentration-response curves to SLIGRL and K+ were constructed in the presence and absence of a variety of blocking agents. In some experiments, changes in tension and smooth muscle cell membrane potential were recorded simultaneously. Results— SLIGRL (0.02 to 20 μmol/L) stimulated concentration and endothelium-dependent relaxation. In the presence of NG-nitro-L-arginine methyl ester, relaxation to SLIGRL was associated with hyperpolarization and sensitivity to a specific inhibitor of IKCa, 1-[(2-chlorophenyl)diphenylmethyl]-1H-pyrazole (1μmol/L), reflecting activation of EDHF. Combined inhibition of KIR with Ba2+ (30μmol/L) and Na+/K+-ATPase with ouabain (1 μmol/L) markedly attenuated the relaxation to EDHF. Raising extracellular [K+] to 15 mmol/L also stimulated smooth muscle relaxation and hyperpolarization, which was also attenuated by combined application of Ba2+ and ouabain. Conclusions— SLIGRL evokes EDHF-mediated relaxation in the rat middle cerebral artery, underpinned by hyperpolarization of the smooth muscle. The profile of blockade of EDHF-mediated hyperpolarization and relaxation supports a pivotal role for IKCa channels. Furthermore, similar inhibition of responses to EDHF and exogenous K+ with Ba2+ and ouabain suggests that K+ may contribute as an EDHF in the middle cerebral artery.

Targeting myocardial remodelling to develop novel therapies for heart failure: a position paper from the Working Group on Myocardial Function of the European Society of Cardiology

The failing heart is characterized by complex tissue remodelling involving increased cardiomyocyte death, and impairment of sarcomere function, metabolic activity, endothelial and vascular function, together with increased inflammation and interstitial fibrosis. For years, therapeutic approaches for heart failure (HF) relied on vasodilators and diuretics which relieve cardiac workload and HF symptoms. The introduction in the clinic of drugs interfering with beta-adrenergic and angiotensin signalling have ameliorated survival by interfering with the intimate mechanism of cardiac compensation. Current therapy, though, still has a limited capacity to restore muscle function fully, and the development of novel therapeutic targets is still an important medical need. Recent progress in understanding the molecular basis of myocardial dysfunction in HF is paving the way for development of new treatments capable of restoring muscle function and targeting specific pathological subsets of LV dysfunction. These include potentiating cardiomyocyte contractility, increasing cardiomyocyte survival and adaptive hypertrophy, increasing oxygen and nutrition supply by sustaining vessel formation, and reducing ventricular stiffness by favourable extracellular matrix remodelling. Here, we consider drugs such as omecamtiv mecarbil, nitroxyl donors, cyclosporin A, SERCA2a (sarcoplasmic/endoplasmic Ca(2 +) ATPase 2a), neuregulin, and bromocriptine, all of which are currently in clinical trials as potential HF therapies, and discuss novel molecular targets with potential therapeutic impact that are in the pre-clinical phases of investigation. Finally, we consider conceptual changes in basic science approaches to improve their translation into successful clinical applications.

A perspective on the role of natriuretic peptides in amphibian osmoregulation

The natriuretic peptide (NP) system is a complex family of peptides and receptors that is primarily linked to the maintenance of osmotic and cardiovascular homeostasis. In amphibians, the potential role(s) of NPs is complicated by the range of osmoregulatory strategies found in amphibians, and the different tissues that participate in osmoregulation. Atrial NP, brain NP, and C-type NP have been isolated or cloned from a number of species, which has enabled physiological studies to be performed with homologous peptides. In addition, three types of NP receptors have been cloned and partially characterised. Natriuretic peptides are always potent vasodilators in amphibian blood vessels, and ANP has been shown to increase the permeability of the microcirculation. In the perfused kidney, ANP causes vasodilation, diuresis and natriuresis that are caused by an increased GFR rather than effects in the renal tubules. These data are supported by the presence of ANP receptors only on the glomeruli and renal blood vessels. In the bladder and skin, the function of NPs is enigmatic because physiological analysis of the effects of ANP on bladder and skin function has yielded conflicting data with no clear role for NPs being revealed. Overall, NPs often have no direct effect, but in some studies they have been shown to inhibit the function of AVT. In addition, there is evidence that ANP can inhibit salt retention in amphibians since it can inhibit the ability of adrenocorticotrophic hormone or angiotensin II to stimulate corticosteroid secretion. It is proposed that an important role for cardiac NPs could be in the control of hypervolaemia during periods of rapid rehydration, which occurs in terrestrial amphibians.

Natriuretic peptides and their receptors in the brain of the amphibian, Bufo marinus

The natriuretic peptides, atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP) and C-type natriuretic peptide (CNP) are members of a family of hormones that play an important role in mammalian fluid and electrolyte balance. In the periphery, natriuretic peptides reduce blood volume and subsequently blood pressure by increasing renal natriuresis and diuresis and relaxation of vascular smooth muscle. The actions of natriuretic peptides are mediated via two membrane-linked guanylate cyclase receptors (NPR-GC); natriuretic peptide receptor-A (NPR-A) which has a high affinity for ANP and BNP; and natriuretic peptide receptor-B (NPR-B)which has the greatest affinity for CNP. A third receptor not linked to guanylate cyclase, natriuretic peptide receptor-C (NPR-C) also exists, which binds to ANP, BNP and CNP with a relatively equal affinity, and is involved with clearance of the peptides from the circulation and tissues. The natriuretic peptides are present in the brain and are particularly predominant in cardiovascular and fluid and electrolyte regulating areas such as the anteroventral third ventricle (AV3V) region. This distribution has led to the suggestion natriuretic peptides play a neuromodulatory role in the central control of fluid homeostasis. Natriuretic peptides in the brain have been observed to inhibit the release of other fluid and electrolyte regulating hormones such as arginine vasopressin (AVP) and angiotensin II (AII). Natriuretic peptides have also been identified in the non-mammalian vertebrates although information regarding the distribution of the peptides and their receptors in the non-mammalian brain is limited. In amphibians, immunohistochemical studies have shown that natriuretic peptides are highly concentrated in the preoptic region of the brain, an area believed to be analogous to the A\T3\ region in mammals, which suggests that natriuretic peptides may also be involved in central fluid and electrolyte regulation in amphibians. To date, CNP is the only natriuretic peptide that has been isolated and cloned from the lower vertebrate brain, although studies on the distribution of CNP binding sites in the brain have only been performed in one fish species. Studies on the distribution of ANP binding sites in the lower vertebrate brain are similarly limited and have only been performed in one fish and two amphibian species. Moreover, the nature and distribution of the natriuretic peptide receptors has not been characterised. The current study therefore, used several approaches to investigate the distribution of natriuretic peptides and their receptors in the brain of the amphibian Bufo marinus. The topographical relationship of natriuretic peptides and the fluid and electrolyte regulating hormone arginine vasotocin was also investigated, in order to gain a greater understanding of the role of the natriuretic peptide system in the lower vertebrate brain. Immunohistochemical studies showed natriuretic peptides were distributed throughout the brain and were highly concentrated in the preoptic region and interpeduncular nucleus. No natriuretic peptide-like immunoreactivity (NP-IR) was observed in the pituitary gland. Arginine vasotocin-like immunoreactivity (AvT-IR) was confined to distinct regions, particularly in the preoptic/hypothalamic region and pituitary gland. Double labelling studies of NP-JR and AvT-IR showed the peptides are not colocalised in the same neural pathways. The distribution of natriuretic peptide binding sites using the ligands 125I-rat ANP (125I-rANP) and 125I-porcine CNP (125I-pCNP) showed different distributions in the brain of B. marinus. The specificity of binding was determined by displacement with unlabelled rat ANP, porcine CNP and C-ANF, an NPR-C specific ligand. 125I-rANP binding sites were broadly distributed throughout the brain with the highest concentration in pituitary gland, habenular, medial pallium and olfactory region. Minimal 125I-rANP binding was observed in the preoptic region. Residual 125I-rANP binding in the presence of C-ANF was observed in the olfactory region, habenular and pituitary gland indicating the presence of both NPR-GC and NPR-C in these regions. 125I-pCNP binding was limited to the olfactory region, pallium and posterior pituitary gland. All 125I-pCNP binding was displaced by C-ANF which suggests that CNP in the brain of B. marinus binds only to NPR-C. Affinity cross-linking and SDS-PAGB demonstrated two binding sites at 136 kDa and 65 kDa under reducing conditions. Guanylate cyclase assays showed 0.1 µM ANP increased cGMP levels 50% above basal whilst a 10-fold higher concentration of CNP was required to produce the same result. Molecular cloning studies revealed a 669 base pair fragment showing 91% homology with human and rat NPR-A and 89% homology with human, rat and eel NPR-B. A 432 base pair fragment showing 67% homology to the mammalian NPR-C and 58% homology with eel NPR-D was also obtained. The results show natriuretic peptides and their receptors are distributed throughout the brain of B. marinus which indicates that natriuretic peptides may participate in a range of regulatory functions throughout the brain. The potential for natriuretic peptides to regulate the release of the fluid and electrolyte regulating hormone AVT also exists due to the high number of natriuretic peptide binding sites in the posterior pituitary gland. At least two populations of natriuretic peptide receptors are present in the brain of B. marinus, one linked to guanylate cyclase and one resembling the mammalian clearance receptor. Furthermore, autoradiography and guanylate cyclase studies suggest ANP may be the major ligand in the brain of B. marinus, even though CNP is the only natriuretic peptide that has been isolated from the lower vertebrate brain to date.

Nitric oxide and vascular regulation in fishes and amphibians

Nitric oxide is an important molecule in the regulation of the cardiovascular system and blood pressure. This research provided new insights into the evolution of nitric oxide control of blood vessels by showing how nitric oxide signalling causes vasodilation in the circulation of amphibians and fishes.

The natriuretic peptide system of the heart and central blood vessels of the toad, Bufo marinus

This research has established the presence of a natriuretic peptide system in the cardiovascular system of the toad, Bufo marinus. The presence of atrial natriuretic peptide mRNA and the peptide itself were shown in the heart which does not contain natriuretic peptide receptors in contrast to the large arteries and veins. In arteries these receptors mediated vasodilation. Atrial natriuretic peptide released from the heart may act on large arteries to regulate blood flow, but the action does not target the heart.

Chemical coding of vascular nitrergic nerves in lower vertebrates

Nitric oxide is an important regulator of blood pressure in mammals. This study provided new information on the role of nitric-oxide releasing sympathetic nerves in vascular regulation of lower vertebrates. The research outcomes advance knowledge on the potential role of these unique nerves in the control of the lower vertebrate cardiovascular system.

Nervous control of circulation--the role of gasotransmitters, NO, CO, and H2S.

The origins and actions of gaseous signaling molecules, nitric oxide (NO), carbon monoxide (CO) and hydrogen sulfide (H(2)S) in the mammalian cardiovascular system have received considerable attention and it is evident that these three "gasotransmitters" perform a variety of homeostatic functions. The origins, actions and disposition of these gasotransmitters in the piscine vasculature are far from resolved. In most fish examined to date, NO or NO donors are generally in vitro and in vivo vasodilators acting via soluble guanylyl cyclase, although there is evidence for NO-mediated vasoconstriction. Injection of sodium nitroprusside into trout causes hypotension that is attributed to a reduction in systemic resistance. Unlike mammals, NO does not appear to have an endothelial origin in fish blood vessels as an endothelial NO synthase has not identified. However, neural NO synthase is prevalent in perivascular nerves and is the most likely source of NO for cardiovascular control in fish. CO is a vasodilator in lamprey and trout vessels, and it, like NO, appears to exert its action, at least in part, via guanylyl cyclase and potassium channel activation. Inhibition of CO production increases resting tone in trout vessels suggestive of tonic CO activity, but little else is known about the origin or control of CO in the fish vasculature. H(2)S is synthesized by fish vessels and its constrictory, dilatory, or even multi-phasic actions, are both species- and vessel-specific. A small component of H(2)S-mediated basal activity may be endothelial in origin, but to a large extent H(2)S affects vascular smooth muscle directly and the mechanisms are unclear. H(2)S injected into the dorsal aorta of unanesthetized trout often produces oscillations in arterial blood pressure suggestive of H(2)S activity in the central nervous system as well as peripheral vasculature. Collectively, these studies hint at significant involvement of the gasotransmitters in piscine cardiovascular function and hopefully provide a variety of avenues for future research.

Implementação de um sistema embarcado aplicado ao controle de pressão arterial

Hypertension is a dangerous disease that can cause serious harm to a patient health. In some situations the necessity to control this pressure is even greater, as in surgical procedures and post-surgical patients. To decrease the chances of a complication, it is necessary to reduce blood pressure as soon as possible. Continuous infusion of vasodilators drugs, such as sodium nitroprusside (SNP), rapidly decreased blood pressure in most patients, avoiding major problems. Maintaining the desired blood pressure requires constant monitoring of arterial blood pressure and frequently adjusting the drug infusion rate. Manual control of arterial blood pressure by clinical personnel is very demanding, time consuming and, as a result, sometimes of poor quality. Thus, the aim of this work is the design and implementation of a database of tuned controllers based on patients models, in order to find a suitable PID to be embedded in a Programmable Integrated Circuit (PIC), which has a smaller cost, smaller size and lower power consumption. For best results in controlling the blood pressure and choosing the adequate controller, tuning algorithms, system identification techniques and Smith predictor are used. This work also introduces a monitoring system to assist in detecting anomalies and optimize the process of patient care.

Rat model of depending prostaglandin renal state: Effect of ketoprofen

Introduction .The renal prostaglandins (PGs), vasodilators, preserve kidney function during increased activity of the renin-angiotensin system or renal sympathetic nerves (renal PG-dependent state [RPGD]). Ketoprofen (Ket) inhibits cyclooxygenase and, therefore, the synthesis of PGs. The aim of this study was to determine, in the rat, the action of Ket in the renal histology and function in a RPGD state (stress of anesthesia and hemorrhage). Material and Methods . Twenty male Wistar rats, anesthetized with sodium pentobarbital, were randomly divided into two groups: G1-control ( n = 10) and G2-Ket ( n = 10) submitted to arterial hemorrhage of 30% of volemia (estimated as 6% of body weight) three times (10% each 10 min), 65 min after anesthesia. G2 animals received Ket, 1.5 mg. kg -1 , venously, 5 min after anesthesia and 60 min before the first hemorrhage moment (first moment of the study [M1]). Medium arterial pressure (MAP), rectal temperature (T), and heart rate were monitored. G1 and G2 received para-aminohippurate sodium (PAH) and iothalamate sodium (IOT) solutions during the entire experimental time in order to determine clearance of PAH (effective renal plasma flow [ERPF]) and clearance of IOT (glomerular filtration rate [GFR]) without urine collection (determination of blood concentrations of PAH and IOT through the high-performance liquid chromatography), filtration fraction (FF), and renal vascular resistance (RVR). The animals were sacrificed in M3, 30 min after the third hemorrhage (M2) moment, and the kidneys and blood collected during the hemorrhage periods were utilized for histological study and determinations of hematocrit (Ht), serum creatinine (S Cr ), ERPF, GFR, FF, and RVR, respectively. Results . There were significant reductions of MAP, T, and Ht and a significant increase of S Cr . During the experiment, ERPF and GFR did not change, but ERPF was always higher in G1 than in G2. Ket did not alter FF, which increased in G1 over the duration of experiment. The Ket group had significantly higher RVR than the control group. The histology verified that both G1 and G2 were similar for tubular dilation and necrosis, but they were significantly different for tubular degeneration: G1 > G2. Conclusion . The changes observed in kidney histology probably were determined by hemorrhage and hypotension. Ket inhibited the synthesis of PGs and diminished tubular degeneration.

Beta-bloqueadores em anestesiologia: aspectos farmacológicos e clínicos

JUSTIFICATIVA E OBJETIVOS: Informações experimentais e clínicas têm sugerido que os b-bloqueadores apresentam efeitos hemodinâmicos importantes e protetores durante o ato anestésico-cirúrgico. O objetivo deste trabalho é revisar as informações farmacológicas e clínicas dos b-bloqueadores para sua utilização adequada na medicina per-operatória. CONTEÚDO: Os b-bloqueadores seletivos inibem preferencialmente os b1-receptores reduzindo a freqüência e inotropismo cardíacos e determinando redução no consumo de oxigênio do miocárdio. Os b-bloqueadores não seletivos inibem também os b2-receptores, aumentando a resistência bronquiolar e vascular periférica. Alguns b-bloqueadores são, também, vasodilatadores. O tratamento prolongado com os b-bloqueadores aumenta a densidade dos b-receptores na membrana celular, o que pode explicar a hiperatividade simpática que pode ocorrer durante a parada do tratamento desses medicamentos. em cirurgia não cardíaca, os efeitos benéficos do b-bloqueadores em pacientes hipertensos ou nos que apresentam doença coronariana têm sido demonstrados, com redução da incidência de isquemia miocárdica no pós-operatório e da mortalidade durante o período de dois anos que se segue à operação. CONCLUSÕES: O tratamento com b-bloqueadores deve ser mantido até o período da manhã da operação, exceto nos pacientes com sinais de intolerância à droga, como hipotensão ou bradicardia importante. Os b-bloqueadores exercem efeito benéfico na recuperação pós-operatória de pacientes com doenças cardiovasculares ou nos que apresentam fatores de risco. Por isso, o emprego desses medicamentos é importante na medicina per-operatória e deve ser ampliado.