New perspectives in cardiopulmonary therapeutics: receptor-selective adrenergic drugs

Recent advances in basic biomedical research have led to the development of clinically useful drugs known as "second generation" adrenergic receptor stimulants (agonists) and blockers (antagonists). Adrenergic receptors are now differentiated into 4 distinct subtypes: alpha 1, alpha 2, beta 1, and beta 2. The new drugs are more receptor-selective and tissue-specific than older ones and, hence, have increased potential for directed therapeutic action, with relatively less side effects on nontargeted organs. The beta 2-selective agonist terbutaline, eg, causes bronchodilation with less beta 1-cardiac excitation than does the beta 1-beta 2 nonselective agonist isoproterenol. Compared with the latter, the beta 1-selective agonist dobutamine increases myocardial contractile force and cardiac output with less beta 2-mediated vasodilation and hypotension. The beta 1-selective antagonist metoprolol has advantage over the beta 1-beta 2 nonselective blocker propranolol for controlling beta 1-cardiac excitation in patients with compromised pulmonary function. Prazosin, an alpha 1-selective blocking agent, evokes peripheral vasodilation with less reflex tachycardia than does the nonselective alpha 1-alpha 2 blocker phentolamine, probably because the former spares the prejunctional alpha 2-receptors that subserve autoinhibition of norepinephrine release from the sympathetic neuron. The contemporary practice of internal medicine will no doubt include an understanding of the pharmacologic properties associated with the various adrenergic receptor subtypes.