Muscarinic control of cardiovascular function in humans: a review of current clinical evidence

• Published in: Clinical autonomic research Vol. 34; no. 1; pp. 31 - 44
• Main Author: Palma, Jose-Alberto
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-02-2024; Springer Nature B.V
• Subjects: Acetylcholine receptors (muscarinic); Allosteric properties; Alzheimer Disease - drug therapy; Alzheimer's disease; Autoimmune diseases; Autonomic nervous system; Blood Pressure; Cardiology; Cardiovascular diseases; Cardiovascular system; Cholinergic Agents - therapeutic use; Clinical trials; Cognitive ability; Diabetes; Endocrinology; Gastroenterology; Heart rate; Humans; Medicine; Medicine & Public Health; Mental disorders; Neurodegenerative diseases; Neurology; Ophthalmology; Phenotypes; Receptor mechanisms; Receptors, Muscarinic - therapeutic use; Regulatory approval; Review Article; Schizophrenia; Schizophrenia - drug therapy; Hypertension; Tilt-table; Tachycardia; Syncope; Hypotension
• ISSN: 0959-9851; 1619-1560; 1619-1560
• DOI: 10.1007/s10286-024-01016-5

Purpose
To review the available evidence on the impact of muscarinic receptor modulation on cardiovascular control in humans.
Methods
In this narrative Review we summarize data on cardiovascular endpoints from clinical trials of novel subtype-selective or quasi-selective muscarinic modulators, mostly PAMs, performed in the last decade. We also review the cardiovascular phenotype in recently described human genetic and autoimmune disorders affecting muscarinic receptors.
Results
Recent advancements in the development of compounds that selectively target muscarinic acetylcholine receptors are expanding our knowledge about the physiological function of each muscarinic receptor subtype (M1, M2, M3, M4, M5). Among these novel compounds, positive allosteric modulators (PAMs) have emerged as the preferred therapeutic to regulate muscarinic receptor subtype function. Many muscarinic allosteric and orthosteric modulators (including but not limited to xanomeline-trospium and emraclidine) are now in clinical development and approaching regulatory approval for multiple indications, including the treatment of cognitive and psychiatric symptoms in patients with schizophrenia as well as Alzheimer’s disease and other dementias. The results of these clinical trials provide an opportunity to understand the influence of muscarinic modulation on cardiovascular autonomic control in humans. While the results and the impact of each of these therapies on heart rate and blood pressure control have been variable, in part because the clinical trials were not specifically designed to measure cardiovascular endpoints, the emerging data is valuable to elucidate the relative cardiovascular contributions of each muscarinic receptor subtype.
Conclusion
Understanding the muscarinic control of cardiovascular function is of paramount importance and may contribute to the development of novel therapeutic strategies for treating cardiovascular disease.