Carvedilol

Our inclusion criteria were male sex and treatment with the β-adrenoceptor blocker metoprolol, bisoprolol, or carvedilol. Exclusion criteria were treatment of any thyroid disorder, NYHA class higher than 3, ejection fraction under 35%, and treatment with more than 12 different drugs (one patient). The mean NYHA class was 2.02 ± 0.2, the mean left ventricular ejection fraction was 63.65 ± 8.25%, and the mean CCS was 2.25 ± 0.4. All patients were between 48 and 84 years of age. All patients gave their written informed consent. Patients underwent open heart surgery because of bypass coronary grafting, and small cardiac tissue samples from the right atrial appendage were collected. The study was approved by the ethical committee of the University Hospital in Halle, Germany (hm-bü 04.08.2005), and the study was conducted according to the principles expressed in the Declaration of Helsinki.

For both complexes, diffraction data were collected from a single cryocooled crystal (100 K) at the European Synchrotron Radiation Facility, Grenoble, France, with a Mar 225 CCD detector on beamline ID23-2 (wavelength, 0.8726 Å) using a 10 μm focused beam. The microfocus beam was required for the location of the best diffracting parts of crystals, as well as allowing wedges of data (20–80°) to be collected from different positions on the crystal. For the β₁AR crystals grown in the presence of bucindolol or carvedilol, 9 or 16 wedges of data from single crystals were merged, respectively. Images were processed with MOSFLM (Leslie, 2006 (link)) and SCALA (Evans, 2006 (link)). Both structures were solved by molecular replacement with PHASER using the β₁AR44-m23 structure with the agonist carmoterol bound (PDB code 2Y02) as a starting model (McCoy et al., 2007 (link)). Refinement, rebuilding and validation were carried out with REFMAC5 (Murshudov et al., 1997 (link)), COOT (Emsley and Cowtan, 2004 (link)) and MOLPROBITY (Davis et al., 2007 (link)). Noncrystallographic symmetry restraints were applied as appropriate between the two monomers in the asymmetric unit for both structures, using the electron density maps and R_free values to judge which residues should be excluded. The two independent copies of the receptor in the asymmetric unit are very similar for the bucindolol complex, although the ligand density was better defined for monomer A. In the carvedilol complex, there is a distortion of the ligand binding pocket in monomer A due to lattice contacts and monomer B represents the more physiologically relevant conformation.

Vascular smooth muscle cell line (A7r5) was obtained from American Type Culture Collection (ATCC) and cultured in Dulbecco's Modified Eagle's Medium (DMEM) supplemented with 10% fetal bovine serum (FBS), 100 U/mL penicillin and 100 U/mL streptomycin (Life Technologies). Cells were maintained at 37°C in an atmosphere of 5% CO₂ with the medium replaced every 24 hours.
1.5×10⁷ cells were treated with either S- or R-Carvedilol at a concentration of 5 µM due to MTT reduction analysis [10] (link). Cells treated in parallel with equal amounts of dimethyl sulfoxide (DMSO) were used as control. After 48 hours, culture medium was collected, filtered through a 0.2 µm filter (WHATMAN), and immediately frozen in liquid nitrogen. Cells were washed with cold PBS twice, harvested and snapped frozen in liquid nitrogen. Carvedilol enantiomers were previously separated from their racemic form using High Performance Liquid Chromatography (HPLC) in our lab [10] (link). Four independent experiments were conducted.
The extraction of intracellular metabolites from A7r5 cells was performed using a modified Mainak Mal [41] (link) and Hindrik Mulder [11] (link) procedure. Cell pellets were dissolved in a mixture of chloroform/methanol/water in ratio of 2∶5∶2 (v/v/v). Ribitol (2 mg/mL dissolved in water, 10 µL) was added into the extraction solvent as internal standard to correct for metabolites losses during sample preparation. The samples were ultra-sonicated in an ice bath ultra-sonicator for 30 min and subsequently centrifuged at 18000 g for 10 mins at 4°C. 0.8 mL supernatant was collected and evaporated to complete dryness overnight using a TurboVap® LV Concentration Workstation. The culture medium samples were prepared by spiking 500 µL of each culture medium with 10 µL internal standard solution (ribitol, 2 mg/mL dissolved in water) and lyophilised. Immediately prior to GC-MS analysis, derivatization was performed in two steps: Firstly, methoximation was carried out by dissolving the sample in 50 µL of 20 mg/mL solution of methoxyamine hydrochloride in pyridine to protect the carbonyls. The incubation was kept at 37°C for 60 min. Silylation was then carried out by adding 100 µL of N-methyl-N-(trimethylsilyl)-trifluoroacetamide (MSTFA) with 1% trimethylchlorosilane (TMCS) to each sample for 30 min at 70°C. After incubation, samples were shaken for 2 hours at room temperature and then transferred to vials for GC-MS analysis.

We performed systematic review of randomized controlled trials with a parallel‐group design that compared blood pressure lowering effects of non‐atenolol β‐blockers as add‐on to monotherapy or as a component of combination antihypertensive therapy in patients with hypertension. We searched MEDLINE (PubMed) databases from inception to 28 November 2021. The complete search strategy is provided in Supplementary Appendix A.
Other components of combination therapy included diuretics, CCBs, angiotensin‐converting enzyme inhibitors (ACEIs), and ARBs. Among β‐blockers, atenolol was excluded, and metoprolol, bisoprolol, acebutolol, esmolol, carvedilol, labetalol, arotinolol, bevantolol, celiprolol, nebivolol, and bucindolol were included in the search. There was no restriction in terms of study duration or type of blood pressure measurement device; however, studies with a sample size smaller than 50 participants were excluded.

This cross-sectional study was performed in 2021 at Khorshid Hospital, affiliated with Isfahan University of Medical Sciences. The records of all patients who were referred to our center in 2018 because of beta-blocker poisoning were reviewed. The study protocol was approved by the Research Committee of Isfahan University of Medical Sciences, and the Ethics Committee confirmed it (IR.MUI.MED.REC.1399.040).
The inclusion criteria were the age of more than 8 years, poisoning by beta-blockers, availability of medical records, and complete medical documents. Among 259 patients who were suspected of beta-blocker intoxication, 255 were included in the study. In multiple drug intakes, patients who had taken cardiovascular drugs (antihypertensive andantiarrhythmic) with beta-blockers were excluded from the study. Patients with a history of severe cardiac arrhythmia, renal and hepatic dysfunction, and those who left the hospital voluntarily or without permission while their follow-up was continuing were excluded. Patients were categorized into three groups according to the type of drug poisoning as propranolol, other beta-blockers (including metoprolol, bisoprolol, atenolol, and carvedilol), and the combination of beta-blockers, respectively (Figure 1).
The following information about poisoning was collected from the documents: personal characteristics (such as age, sex, marital status, level of education, and occupation), characteristics related to poisoning (type of drug, number of drug taken, and location of drug use), and mode of poisoning (intentional, accidental, and overdose), history of addiction and type of addiction (alcohol, cigarettes, opiates, or others), length of hospitalization, medical history related to psychiatric illness, and suicide history, as well as clinical findings in main organs including the central nervous system (CNS), heart, skin, eye (miosis or mydriasis), deep tendon reflex, palmar reflex, and vital signs (blood pressure, respiration rate, pulse rate, and body temperature) at baseline, laboratory data, treatments performed (receiving charcoal, atropine, glucose, calcium glucagon, dialysis) and other treatments, and treatment outcome (complete recovery or death). All poisonings registered in our medical center were collected after extracting the desired data and entering them into a computer file with a special format.
The obtained data were entered into the Statistical Package for Social Sciences (SPSS) version 24. Statistical analyzes were performed in two parts: descriptive and analytical. In the descriptive part, the reports were presented in the form of a percentage (number) for qualitative variables and an average (variance) for quantitative variables. In the analytical section, the relationship between age, sex, frequency of predictive factors, and outcome therapy was examined based on different outcomes by eliminating possible confounders using logistic regression. We used independent t-tests and repeated measure tests to compare data between different timelines and different groups. P < 0.05 was considered statistically significant.

Patient demographics and clinical data, including Barcelona Clinic Liver Cancer (BCLC) stage, Child-Pugh (CP) class, Eastern Cooperative Oncology Group (ECOG) performance status, alpha fetoprotein (AFP) level, presence of cirrhosis (clinically or radiologically diagnosed), etiology of liver disease, type and duration of ICI therapy, type and indication of BB use, duration of BB use, follow-up and vital status, were collected retrospectively. Baseline data were defined at the time of ICI initiation, and treatment response was evaluated through radiologic staging of the disease using computerized tomography and/or magnetic resonance imaging approximately every 9 weeks during treatment. BB use was defined as exposure at any time during ICI therapy. BBs were classified as nonselective (propranolol, nadolol, carvedilol, labetalol) and cardio-selective (metoprolol, atenolol, bisoprolol, nebivolol), and standard doses were used. Indications for BB use were evaluated and included variceal prophylaxis, cardiovascular disease, and other indications.
The primary outcome was to evaluate the association between BB use and OS, measured from the time of ICI initiation until date of death from any cause or date of last follow-up. Secondary outcomes included assessing the effect of BB use on objective response rate (ORR), defined as the proportion of patients with either radiographic complete response (CR) or partial response (PR), duration of response (DOR), defined as best response of CR, PR, or stable disease (SD), progression-free survival (PFS), measured from the time of ICI initiation until radiographic progression, and development of treatment-related adverse events (AEs) of any grade. All responses were evaluated according to RECIST 1.1 criteria. AEs were defined based on the Common Terminology Criteria for Adverse Events (CTCAE) classification, version 5.0, and identified based on investigator review of clinical notes, radiographic, and laboratory data. Evaluation of BB exposure was based on the presence of an active prescription in the medical record per clinical notes or medication records. Baseline BB use was defined as exposure within 30 days prior to ICI initiation, and concurrent BB use was defined as exposure between the dates of ICI initiation and cessation.