Method to treat cardiofibrosis with a combination therapy of an angiotensin II antagonist and an epoxy-steroidal aldosterone antagonist

Abstract

A therapeutic method is described for treating cardiofibrosis or cardiac hypertrophy using a combination therapy comprising a therapeutically-effective amount of an epoxy-steroidal aldosterone receptor antagonist and a therapeutically-effective amount of an angiotensin II receptor antagonist. Preferred angiotensin II receptor antagonists are those compounds having high potency and bioavailability and which are characterized in having an imidazole or triazole moiety attached to a biphenylmethyl or pyridinyl/phenylmethyl moiety. Preferred epoxy-steroidal aldosterone receptor antagonists are 20-spiroxane steroidal compounds characterized by the presence of a 9α, 11α-substituted epoxy moiety. A preferred combination therapy includes the angiotensin II receptor antagonist 5-[2-[5-[(3,5-dibutyl-1H-1,2,4-triazol-1-yl)methyl]-2-pyridinyl]phenyl-1H-tetrazole and the aldosterone receptor antagonist epoxymexrenone.

Description

FIELD OF THE INVENTION

[0001] Therapeutic methods are described for treatment of cardiofibrosis and cardiac hypertrophy. Of particular interest are therapies using an epoxy-containing steroidal aldosterone receptor antagonist compound such as epoxymexrenone in combination with an angiotensin II receptor antagonist compound.

BACKGROUND OF THE INVENTION

[0002] Myocardial (or cardiac) failure, whether a consequence of a previous myocardial infarction, heart disease associated with hypertension, or primary cardiomyopathy, is a major health problem of worldwide proportions. The incidence of symptomatic heart failure has risen steadily over the past several decades.

[0003] In clinical terms, decompensated cardiac failure consists of a constellation of signs and symptoms that arises from congested organs and hypoperfused tissues to form the congestive heart failure (CHF) syndrome. Congestion is caused largely by increased venous pressure and by inadequate sodium (Na+) excretion, relative to dietary Na+ intake, and is importantly related to circulating levels of aldosterone (ALDO). An abnormal retention of Na+ occurs via tubular epithelial cells throughout the nephron, including the later portion of the distal tubule and cortical collecting ducts, where ALDO receptor sites are present.

[0004] ALDO is the body's most potent mineralocorticoid hormone. As connoted by the term mineralocorticoid, this steroid hormone has mineral-regulating activity. It promotes Na+ reabsorption not only in the kidney, but also from the lower gastrointestinal tract and salivary and sweat glands, each of which represents classic ALDO-responsive tissues. ALDO regulates Na+ and water resorption at the expense of potassium (K+) and magnesium (Mg2+) excretion.

[0005] ALDO can also provoke responses in nonepithelial cells. Elicited by a chronic elevation in plasma ALDO level that is inappropriate relative to dietary Na− intake, these responses can have adverse consequences on the structure of the cardiovascular system. Hence, ALDO can contribute to the progressive nature of myocardial failure for multiple reasons.

[0006] Multiple factors regulate ALDO synthesis and metabolism, many of which are operative in the patient with myocardial failure. These include renin as well as non-renin-dependent factors (such as K+, ACTH) that promote ALDO synthesis. Hepatic blood flow, by regulating the clearance of circulating ALDO, helps determine its plasma concentration, an important factor in heart failure characterized by reduction in cardiac output and hepatic blood flow.

[0007] The renin-angiotensin-aldosterone system (RAAS) is one of the hormonal mechanisms involved in regulating pressure/volume homeostasis and also in the development of hypertension. Activation of the renin-angiotensin-aldosterone system begins with renin secretion from the juxtaglomerular cells in the kidney and culminates in the formation of angiotensin II, the primary active species of this system. This octapeptide, angiotensin II, is a potent vasoconstrictor and also produces other physiological effects such as stimulating aldosterone secretion, promoting sodium and fluid retention, inhibiting renin secretion, increasing sympathetic nervous system activity, stimulating vasopressin secretion, causing positive cardiac inotropic effect and modulating other hormonal systems.

[0008] Previous studies have shown chat antagonizing angiotensin II binding at its receptors is a viable approach to inhibit the renin-angiotensin system, given the pivotal role of this octapeptide which mediates the actions of the renin-angiotensin system through interaction with various tissue receptors. There are several known angiotensin II antagonists, most of which are peptidic in nature. Such peptidic compounds are of limited use due to their lack of oral bioavailability or their short duration of action. Also, commercially-available peptidic angiotensin II antagonists (e.g., Saralasin) have a significant residual agonist activity which further limit their therapeutic application.

[0009] Non-peptidic compounds with angiotensin II antagonist properties are known. For example, early descriptions of such non-peptidic compounds include the sodium salt of 2-n-butyl-4-chloro-1-(2-chlorobenzyl)imidazole-5-acetic acid which has specific competitive angiotensin II antagonist activity as shown in a series of binding experiments, functional assays and in vivo tests [P. C. Wong et al, J. Pharmacol. Exp. Ther., 247(1), 1-7 (1988)]. Also, the sodium salt of 2-butyl-4-chloro-1-(2-nitrobenzyl)imidazole-5-acetic acid has specific competitive angiotensin II antagonist activity as shown in a series of binding experiments, functional assays and in vivo tests [A. T. Chiu et al, European J. Pharmacol., 157, 31-21 (1988)]. A family of 1-benzylimidazole-5-acetate derivatives has been shown to have competitive angiotensin II antagonist properties [A. T. Chiu et al, J. Pharmacol. Exp. Ther., 250(3), 867-874 (1989)]. U.S. Pat. No. 4,816,463 to Blankey et al describes a family of 4,5,6,7-tetrahydro-1H-imidazo (4,5-c)-tetrahydro-pyridine derivatives useful as antihypertensives, some of which are reported to antagonize the binding of labelled angiotensin II to rat adrenal receptor preparation and thus cause a significant decrease in mean arterial blood pressure in conscious hypertensive rats. Other families or non-peptidic angiotensin II antagonists have been characterized by molecules having a biphenylmethyl moiety attached to a heterocyclic moiety. For example; EP No. 253,310, published Jan. 20, 1988, describes a series of aralkyl imidazole compounds, including in particular a family of biphenylmethyl substituted imidazoles, as antagonists to the angiotensin II receptor. EP No. 323,841 published Jul. 12, 1989 describes four classes of angiotensin II antagonists, namely, biphenylmethylpyrroles, biphenylmethylpyrazoles, biphenylmethyl-1,2,3-triazoles and biphenylmethyl 4-substituted-4H-1,2,4-triazoles, including the compound 3,5-dibutyl-4-[(2′-carboxybiphenyl-4-yl)methyl]-4H-1,2,4-triazole. U.S. Pat No. 4,880,804 to Carini et al describes a family of biphenylmethylbenzimidazole compounds as angiotensin II receptor blockers for use in treatment of hypertension and congestive heart failure.

[0010] Many aldosterone receptor blocking drugs are known. For example, spironolactone is a drug which acts at the mineralocorticoid receptor level by competitively inhibiting aldosterone binding. This steroidal compound has been used for blocking aldosterone-dependent sodium transport in the distal tubule of the kidney in order to reduce edema and to treat essential hypertension and primary hyperaldosteronism [F. Mantero et al, Clin. Sci. Mol. Med., 45 (Suppl 1), 219s-224s (1973)]. Spironolactone is also used commonly in the treatment of other hyperaldosterone-related diseases such as liver cirrhosis and congestive heart failure [F. J. Saunders et al, Aldactone; Spironolactone: A Comprehensive Review, Searle, N.Y. (1978)]. Progressively-increasing doses of spironolactone from 1 mg to 400 mg per day [i.e., 1 mg/day, 5 mg/day, 20 mg/day] were administered to a spironolactone-intolerant patient to treat cirrhosis-related ascites [P. A. Greenberger et al, N. End. Reg. Allergy Proc., 7(4), 343-345 (July-August, 1986)]. It has been recognized that development of myocardial fibrosis is sensitive to circulating levels of both Angiotensin II and aldosterone, and that the aldosterone antagonist spironolactone prevents myocardial fibrosis in animal models, thereby linking aldosterone to excessive collagen deposition [D. Klug et al, Am. J. Cardiol., 71 (3), 46A-54A (1993)]. Spironolactone has been shown to prevent fibrosis in animal models irrespective of the development of left ventricular hypertrophy and the presence of hypertension [C. G. Brilla et al, J. Mol. Cell. Cardiol., 25(5), 563-575 (1993)]. Spironolactone at a dosage ranging from 25 mg to 100 mg daily is used to treat diuretic-induced hypokalemia, when orally-administered potassium supplements or other potassium-sparing regimens are considered inappropriate [Physicians' Desk Reference, 46th Edn., p. 2153, Medical Economics Company Inc., Montvale, N.J. (1992)].

[0011] Previous studies have shown that inhibiting ACE inhibits the renin-angiotensin system by substantially complete blockade of the formation of angiotensin II. Many ACE inhibitors have been used clinically to control hypertension. While ACE inhibitors may effectively control hypertension, side effects are common including chronic cough, skin rash, loss of taste sense, proteinuria and neutropenia.

[0012] Moreover, although ACE inhibitors effectively block the formation of angiotensin II, aldosterone levels are not well controlled in certain patients having cardiovascular diseases. For example, despite continued ACE inhibition in hypertensive patients receiving captopril, there has been observed a gradual return of plasma aldosterone to baseline levels [J. Staessen et al, J. Endocrinol., 91, 457-465 (1981)]. A similar effect has been observed for patients with myocardial infarction receiving zofenopril [C. Borghi et al, J. Clin. Pharmacol., 33, 40-45 (1993)]. This phenomenon has been termed “aldosterone escape”.

[0013] Another series of steroidal-type aldosterone receptor antagonists is exemplified by epoxy-containing spironolactone derivatives. For example, U.S. Pat. No. 4,559,332 issued to Grob et al describes 9α,11α-epoxy-containing spironolactone derivatives as aldosterone antagonists useful as diuretics. These 9α, 11α-epoxy steroids have been evaluated for endocrine effects in comparison to spironolactone [M. de Gasparo et al, J. Pharm, Exp. Ther., 240(2), 650-656 (1987)].

[0014] Combinations of an aldosterone antagonist and an ACE inhibitor have been investigated for treatment of heart failure. It is known that mortality is higher in patients with elevated levels of plasma aldosterone and that aldosterone levels increase as CHF progresses from activation of the Renin-Angiontensin-Aldosterone System (RAAS). Routine use of a diuretic may further elevate aldosterone levels. ACE inhibitors consistently inhibit angiotensin II production but exert only a mild and transient antialdosterone effect.

[0015] Combining an ACE inhibitor and spironolactone has been suggested to provide substantial inhibition of the entire RAGS. For example, a combination of enalapril and spironolactone has been administered to ambulatory patients with monitoring of blood pressure [P. Poncelet et al, Am. J. Cardiol., 65(2), 33K-35K (1990)]. In a 90-patient study, a combination of captopril and spironolactone was administered and found effective to control refractory CHF without serious incidents of hyperkalemia [U. Dahlstrom et al, Am. J. Cardiol., 71, 29A-33A (Jan. 21, 1993)]. Spironolactone coadministered with an ACE inhibitor was reported to be highly effective in 13 of 16 patients afflicted with congestive heart failure [A. A. van Vliet et al, Am. J. Cardiol., 71, 21A-28A (Jan. 21, 1993)]. Clinical improvements have been reported for patients receiving a co-therapy of spironolactone and the ACE inhibitor enalapril, although this report mentions that controlled trials are needed to determine the lowest effective doses and to identify which patients would benefit most from combined therapy [F. Zannad, Am. J. Cardiol. 71(3), 34A-39A (1993)].

[0016] Combinations of an angiotensin II receptor antagonist and aldosterone receptor antagonist, are known, For example, PCT Application No. US91/09362 published Jun. 25, 1992 describes treatment of hypertension using a combination of an imidazole-containing angiotensin II antagonist compound and a diuretic such as spironolactone.

SUMMARY OF THE INVENTION

[0017] A therapeutic method for treating or preventing the progression of cardiofibrosis or cardiac hypertrophy is provided by a combination therapy comprising a therapeutically-effective amount of an epoxy-steroidal aldosterone receptor antagonist and a therapeutically-effective amount of an angiotensin II receptor antagonist.

[0018] The phrase “angiotensin II receptor antagonist”, is intended to embrace one or more compounds or agents having the ability to interact with a receptor site located on various human body tissues, which site is a receptor having a relatively high affinity for angiotensin II and which receptor site is associated with mediating one or more biological functions or events such as vasoconstriction or vasorelaxation, kidney-mediated sodium and fluid retention, sympathetic nervous system activity, and in modulating secretion of various substances such as aldosterone, vasopressin and renin, to lower blood pressure in a subject susceptible to or afflicted with elevated blood pressure. Interactions of such angiotensin II receptor antagonist with this receptor site may be characterized as being either “competitive” (i.e., “surmountable”) or as being “insurmountable”. These terms, “competitive” and “insurmountable”, characterize the relative rates, faster for the former term and slower for the latter term, at which the antagonist compound dissociates from binding with the receptor site.

[0019] The phrase “epoxy-steroidal aldosterone receptor antagonist” is intended to embrace one or more agents or compounds characterized by a steroid-type nucleus and having an epoxy moiety attached to the nucleus and which agent or compound binds to the aldosterone receptor, as a competitive inhibitor of the action of aldosterone itself at the receptor site, so as to modulate the receptor-mediated activity of aldosterone.

[0020] The phrase “combination therapy”, in defining use of an angiotensin II antagonist and an epoxy-steroidal aldosterone receptor antagonist, is intended to embrace administration of each antagonist in a sequential manner in a regimen that will provide beneficial effects of the drug combination, and is intended to embrace co-administration of the antagonist agents in a substantially simultaneous manner, such as in a single capsule having a fixed ratio of active ingredients or in multiple, separate capsules for each antagonist agent.

[0021] The phrase “therapeutically-effective” is intended to qualify the amount of each antagonist agent for use in the combination therapy which will improve cardiac sufficiency by reducing or preventing the progression of myocardial fibrosis or cardiac hypertrophy.

[0022] Another combination therapy of interest would consist essentially of three active agents, namely, an AII antagonist, an aldosterone receptor antagonist agent and a diuretic.

[0023] For a combination of AII antagonist agent and an ALDO antagonist agent, the agents would be used in combination in a weight ratio range from about 0.5-to-one to about twenty-to-one of the AII antagonist agent to the aldosterone receptor antagonist agent. A preferred range of these two agents (AII antagonist-to-ALDO antagonist) would be from about one-to-one to about fifteen-to-one, while a more preferred range would be from about one-to-one to about five-to-one, depending ultimately on the selection of the AII antagonist and ALDO antagonist. The diuretic agent may be present in a ratio range of 0.1-to-one to about ten to one (AII antagonist to diuretic).

DETAILED DESCRIPTION OF THE INVENTION

[0024] Epoxy-steroidal aldosterone receptor antagonist compounds suitable for use in the combination therapy consist of these compounds having a steroidal nucleus substituted with an epoxy-type moiety. The term “epoxy-type” moiety is intended to embrace any moiety characterized in having an oxygen atom as a bridge between two carbon atoms, examples of which include the following moieties: 1

[0025] The term “steroidal”, as used in the phrase “epoxy-steroidal”, denotes a nucleus provided by a cyclopentenophenanthrene moiety, having the conventional “A”, “B”, “C” and “D” rings. The epoxy-type moiety may be attached to the cyclopentenophenanthrene nucleus at any attachable or substitutable positions, that is, fused to one of the rings of the steroidal nucleus or the moiety may be substituted on a ring member of the ring system. The phrase “epoxy-steroidal” is intended to embrace a steroidal nucleus having one or a plurality of epoxy-type moieties attached thereto.

[0026] Epoxy-steroidal aldosterone receptor antagonists suitable for use in combination therapy include a family of compounds having an epoxy moiety fused to the “C” ring of the steroidal nucleus. Especially preferred are 20-spiroxane compounds characterized by the presence of a 9α,11α-substituted epoxy moiety. Table I, below, describes a series of 9α,11α-epoxy-steroidal compounds which may be used in the combination therapy. These epoxy steroids may be prepared by procedures described in U.S. Pat. No. 4,559,332 to Grob et al issued Dec. 17, 1985.

TABLE I
Aldosterone Receptor Antagonists
Compound #	Structure	Name
1	2	Pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy- 17-hydroxy-3-oxo-,γ-lactone, methyl ester, (7α,11.α.,17α)-
2	3	Pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy- 17-hydroxy-3-oxo-dimethyl ester, (7α,11α,17α)
3	4	3′H-cyclopropa[6,7] pregna-4,6-diene-21- carboxylic acid, 9,11-epoxy-6,7-dihydro-17- hydroxy-3-oxo-,γ-lactone, (6β,7β,11β,17β)-
4	5	Pregn-4-ene-7,21-dicarboxylic acid, 9,11- epoxy-17-hydroxy-3-oxo-, 7-(1-methylethyl) ester, monopotassium salt, (7α,11α,17α)-
5	6	Pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy- 17-hydroxy-3-oxo-,7-methyl ester, monopotassium salt, (7α,11α,17α)-
6	7	3′H-cyclopropa[6,7]pregna-1,4,6-triene-21- carboxylic acid, 9,11-epoxy-6,7-dihydro-17- hydroxy-3-oxo-,γ-lactone(6α,7α,11.α)-
7	8	3′H-cyclopropa[6,7]pregna-4,6-diene-21-carboxylic acid, 9,11-epoxy-6,7-dihydro-17-hydroxy-3-oxo-, methyl ester, (6α,7α,11α,17α)-
8	9	3′H-cyclopropa[6,7]pregna-4,6-diene-21-carboxylic acid, 9,11-epoxy-6,7-dihydro-17-hydroxy-3-oxo-, monopotassium salt, (6α,7α,11α,17α)
9	10	3′H-cyclopropa[6,7]pregna-4,6-diene-21-carboxylic acid, 9,11-epoxy-6,7-dihydro-17-hydroxy-3-oxo-,γlactone, (6α,7α,11α.,17α)-
10	11	Pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy- 17-hydroxy-3-oxo-,γ-lactone, ethyl ester, (7α,11α,17α)-
11	12	Pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy- 17-hydroxy-3-oxo-,γ-lactone, 1-methylethyl ester, (7α,11α,17α)-

[0027] Angiotensin II receptor antagonist compounds suitable for use in the combination therapy are described in Table II, below. Preferred compounds for use in the combination therapy may be generally characterized structurally as having two portions. A first portion constitutes a mono-aryl-alkyl moiety, or a bi-aryl-alkyl moiety, or a mono-heteroaryl-alkyl moiety, or a bi-heteroaryl-alkyl moiety. A second-portion constitutes a heterocyclic moiety or an open chain hetero-atom-containing moiety.

[0028] Typically, the first-portion mono/bi-aryl/heteroaryl-alkyl moiety is attached to the second portion heterocyclic/open-chain moiety through the alkyl group of the mono/bi-aryl/heteroaryl-alkyl moiety to any substitutable position on the heterocyclic/open-chain moiety second portion. Suitable first-portion mono/bi-aryl/heteroaryl-alkyl moieties are defined by any of the various moieties listed under Formula I:

Ar-Alk-L Ar-L-Ar-Alk-L Het-L-Ar-Alk-L Het-L-Het-Alk-L Ar-L-Het-Alk-L Het-L-Alk-L  (I)

[0029] wherein the abbreviated notation used in the moieties of Formula I is defined as follows:

[0030] “Ar” means a five or six-membered carbocyclic ring system consisting of one ring or two fused rings, with such ring or rings being typically fully unsaturated but which also may be partially or fully saturated. “Phenyl” radical most typically exemplifies “Ar”.

[0031] “Het” means a monocyclic or bicyclic fused ring system having from five to eleven ring members, and having at least one of such ring members being a hetero atom selected from oxygen, nitrogen and sulfur, and with such ring system containing up to six of such hetero atoms as ring members.

[0032] “Alk” means an alkyl radical or alkylene chain, linear or branched, containing from one to about five carbon atoms. Typically, “Alk” means “methylene”, i.e., —CH2—.

[0033] “L” designates a single bond or a bivalent linker moiety selected from carbon, oxygen and sulfur. When “L” is carbon, such carbon has two hydrido atoms attached thereto.

[0034] Suitable second-portion heterocyclic moieties of the angiotensin II antagonist compounds, for use in the combination therapy, are defined by any of the various moieties listed under Formula IIa or IIb: 13

[0035] wherein each of X1 through X6 is selected from —CH═, —CH2—, —N═, —NH—, O, and S, with the proviso that at least one of X1 through X6 in each of Formula IIa and Formula IIb must be a hetero atom. The heterocyclic moiety of Formula IIa or IIb may be attached through a bond from any ring member of the Formula IIa or IIb heterocyclic moiety having a substitutable or a bond-forming position.

[0036] Examples of monocyclic heterocyclic moieties of Formula IIa include thienyl, furyl, pyranyl, pyrrolyl, imidazolyl, triazolyl, pyrazolyl, pyridyl, pyrazinyl, pyrimidinyl, pyridazinyl, isothiazolyl, isoxazolyl, furazanyl, pyrrolidinyl, pyrrolinyl, furanyl, thiophenyl, isopyrrolyl, 3-isopyrrolyl, 2-isoimidazolyl, 1,2,3-triazolyl, 1,2,4-triazolyl, 1,2-dithiolyl, 1,3-dithiolyl, 1,2,3-oxathiolyl, oxazolyl, thiazolyl, 1,2,3-oxadiazolyl, 1,2,4-oxadiazolyl, 1,2,5-oxadiazolyl, 1,3,4-oxadiazolyl, 1,2,3,4-oxatriazolyl, 1,2,3,5-oxatriazolyl, 1,2,3-dioxazolyl, 1,2,4-dioxazolyl, 1,3,2-dioxazolyl, 1,3,4-dioxazolyl, 1,2,5-oxathiazolyl, 1,3-oxathiolyl, 1,2-pyranyl, 1,4-pyranyl, 1,2-pyronyl, 1,4-pyronyl, pyridinyl, piperazinyl, s-triazinyl, as-triazinyl, v-triazinyl, 1,2,4-oxazinyl, 1,3,2-oxazinyl, 1,3,6-oxazinyl, 1,2,6-oxazinyl, 1,4-oxazinyl, o-isoxazinyl, p-isoxazinyl, 1,2,5-oxathiazinyl, 1,2,6-oxathiazinyl, 1,4,2-oxadiazinyl, 1,3,5,2-oxadiazinyl, morpholinyl, azepinyl, oxepinyl, thiepinyl and 1,2,4-diazepinyl.

[0037] Examples of bicyclic heterocyclic moieties of Formula IIb include benzo[b]thienyl, isobenzofuranyl, chromenyl, indolizinyl, isoindolyl, indolyl, indazolyl, purinyl, quinolizinyl, isoquinolyl, quinolyl, phthalazinyl, naphthyridinyl, quinoxalinyl, quinazolinyl, cinnolinyl, pteridinyl, isochromanyl, chromanyl, thieno[2,3-b]furanyl, 2H-furo[3,2-b]pyranyl, 5H-pyrido[2,3-d][1,2]oxazinyl, 1H-pyrazolo[4,3-d]oxazolyl, 4H-imidazo[4,5-d]thiazolyl, pyrazino[2,3-d]pyridazinyl, imidazo[2,1-b]thiazolyl, cyclopenta[b]pyranyl, 4H-[1,3]oxathiolo-[5,4-b]pyrrolyl, thieno[2,3-b]furanyl, imidazo[1,2-b][1,2,4]triazinyl and 4H-1,3-dioxolo[4,5-d]imidazolyl.

[0038] The angiotensin II receptor antagonist compounds, as provided by the first-and-second-portion moieties of Formula I and II, are further characterized by an acidic moiety attached to either of said first-and-second-portion moieties. Preferably this acidic moiety is attached to the first-portion moiety of Formula I and is defined by Formula III:

—UnA  (III)

[0039] wherein n is a number selected from zero through three, inclusive, and wherein A is an acidic group selected to contain at least one acidic hydrogen atom, and the amide, ester and salt derivatives of said acidic moieties; wherein U is a spacer group independently selected from one or more of alkyl, cycloalkyl, cycloalkylalkyl, alkenyl, alkynyl, aryl, aralkyl and heteroaryl having one or more ring atoms selected from oxygen, sulfur and nitrogen atoms.

[0040] The phrase “acidic group selected to contain at least one acidic hydrogen atom”, as used to define the —UnA moiety, is intended to embrace chemical groups which, when attached to any substitutable position of the Formula I-IIa/b moiety, confers acidic character to the compound of Formula I-IIa/b. “Acidic character” means proton-donor capability, that is, the capacity of the compound of Formula I-IIa/b to be a proton donor in the presence of a proton-receiving substance such as water. Typically, the acidic group should be selected to have proton-donor capability such that the product compound of Formula I-IIa/b has a pKa in a range from about one to about twelve. More typically, the Formula I-IIa/b compound would have a pKa in a range from about two to about seven. An example of an acidic group containing at least one acidic hydrogen atom is carboxyl group (—COOH). Where n is zero and A is —COOH, in the —UnA moiety, such carboxyl group would be attached directly to one of the Formula I-IIa/b positions. The Formula I-IIa/b compound may have one —UnA moiety attached at one of the Formula I-IIa/b positions, or may have a plurality of such —UnA moieties attached at more than one of the Formula I-IIa/b positions. There are many examples of acidic groups other than carboxyl group, selectable to contain at least one acidic hydrogen atom. Such other acidic groups may be collectively referred to as “bioisosteres of carboxylic acid”, or referred to as “acidic bioisosteres”. Specific examples of such acidic bioisosteres are described hereinafter. Compounds of Formula I-IIa/b may have one or more acidic protons and, therefore, may have one or more pKa values. It is preferred, however, that at least one of these pKa values of the Formula I-IIa/b compound as conferred by the —UnA moiety be in a range from about two to about seven. The —UnA moiety may be attached to one of the Formula I-IIa/b positions through any portion of the —UnA moiety which results in a Formula I-IIa/b compound being relatively stable and also having a labile or acidic proton to meet the foregoing pKa criteria. For example, where the —UnA acid moiety is tetrazole, the tetrazole is typically attached at the tetrazole ring carbon atom.

[0041] For any of he moieties embraced by Formula I and Formula II, such moieties may be substituted at any substitutable posit on by one or more radicals selected from hydrido, hydroxy, alkyl, alkenyl, alkynyl, aralkyl, hydroxyalkyl, haloalkyl, halo, oxo, alkoxy, aryloxy, aralkoxy, aralkylthio, alkoxyalkyl, cycloalkyl, cycloalkylalkyl, aryl, aroyl, cycloalkenyl, cyano, cyanoamino, nitro, alkylcarbonyloxy, alkoxycarbonyloxy, alkylcarbonyl, alkoxycarbonyl, aralkoxycarbonyl, carboxyl, mercapto, mercaptocarbonyl, alkylthio, arylthio, alkylthiocarbonyl, alkylsulfinyl, alkylsulfonyl, haloalkylsulfonyl, aralkylsulfinyl, aralkylsulfonyl, arylsulfinyl, arylsulfonyl, heteroaryl having one or more ring atoms selected from oxygen, sulfur and nitrogen atoms, and amino and amido radicals of the formula 14

[0042] wherein W is oxygen atom or sulfur atom; wherein each of R1 through R5 is independently selected from hydrido, alkyl, cycloalkyl, cycloalkylalkyl, aralkyl, aryl, YR6 and 15

[0043] wherein Y is selected from oxygen atom and sulfur atom and R6 is selected from hydrido, alkyl, cycloalkyl, cycloalkylalkyl, aralkyl and aryl; wherein each of R1, R2, R3, R4, R5, R7 and R8 is independently selected from hydrido, alkyl, cycloalkyl, cyano, hydroxyalkyl, haloalkyl, cycloalkylalkyl, alkoxyalkyl, alkylcarbonyl, alkoxycarbonyl, carboxyl, alkylsulfinyl, alkylsulfonyl, arylsulfinyl, arylsulfonyl, haloalkylsulfinyl, haloalkylsulfonyl, aralkyl and aryl, and wherein each of R1, R2, R3, R4, R5, R7 and R8 is further independently selected from amino and amido radicals of the formula 16

[0044] wherein W is oxygen atom or sulfur atom; wherein each of R9, R10, R11, R12, R13 and R14 is independently selected from hydrido, alkyl, cycloalkyl, cyano, hydroxyalkyl, cycloalkylalkyl, alkoxyalkyl, haloalkylsulfinyl, haloalkylsulfonyl, aralkyl and aryl, and wherein each of R2 and R3 taken together and each of R4 and R5 taken together may form a heterocyclic group having five to seven ring members including the nitrogen atom of said amino or amido radical, which heterocyclic group may further contain one or more hetero atoms as ring members selected from oxygen, nitrogen and sulfur atoms and which heterocyclic group may be saturated or partially unsaturated; wherein each of R2 and R3 taken together and each of R7 and R8 taken together may form an aromatic heterocyclic group having five ring members including the nitrogen atom of said amino or amido radical and which aromatic heterocyclic group may further contain one or more hetero atoms as ring atoms selected from oxygen, nitrogen and sulfur atoms; or a tautomer thereof or a pharmaceutically-acceptable salt thereof.

[0045] The combination therapy of the invention would be useful in treating myocardial fibrosis or cardiac hypertrophy, particularly left ventricular hypertrophy. The combination therapy would also be useful with adjunctive therapies. For example, the combination therapy may be used in combination with other drugs, such as a diuretic, to aid in treatment of hypertension.

[0046] Table II, below, contains description of angiotensin II antagonist compounds which may be used in the combination therapy. Associated with each compound listed in Table II is a published patent document describing the chemical preparation of the angiotensin II antagonist compound as well as the biological properties of such compound. The content of each of these patent documents is incorporated herein by reference.

TABLE II
Angiotensin II Antagonists
Compound #	Structure	Source
1	17	WO #91/17148 pub. 14 Nov 91
2	18	WO #91/17148 pub. 14 Nov 91
3	19	WO #91/17148 pub. 14 Nov 91
4	20	WO #91/17148 pub. 14 Nov 91
5	21	WO #91/17148 pub. 14 Nov 91
6	22	WO #91/17148 pub. 14 Nov 91
7	23	WO #91/17148 pub. 14 Nov 91
8	24	WO #91/17148 pub. 14 Nov 91
9	25	WO #91/17148 pub. 14 Nov 91
10	26	WO #91/17148 pub. 14 Nov 91
11	27	WO #91/17148 pub. 14 Nov 91
12	28	WO #91/17148 pub. 14 Nov 91
13	29	WO #91/17148 pub. 14 Nov 91
14	30	WO #91/17148 pub. 14 Nov 91
15	31	WO #91/17148 pub. 14 Nov 91
16	32	WO #91/17148 pub. 14 Nov 91
17	33	WO #91/17148 pub. 14 Nov 91
18	34	WO #91/17148 pub. 14 Nov 91
19	35	WO #91/17148 pub. 14 Nov 91
20	36	WO #91/17148 pub. 14 Nov 91
21	37	WO #91/17148 pub. 14 Nov 91
22	38	WO #91/17148 pub. 14 Nov 91
23	39	WO #91/17148 pub. 14 Nov 91
24	40	WO #91/17148 pub. 14 Nov 91
25	41	WO #91/17148 pub. 14 Nov 91
26	42	WO #91/17148 pub. 14 Nov 91
27	43	WO #91/17148 pub. 14 Nov 91
28	44	WO #91/17148 pub. 14 Nov 91
29	45	WO #91/17148 pub. 14 Nov 91
30	46	WO #91/17148 pub. 14 Nov 91
31	47	WO #91/17148 pub. 14 Nov 91
32	48	WO #91/17148 pub. 14 Nov 91
33	49	WO #91/17148 pub. 14 Nov 91
34	50	WO #91/17148 pub. 14 Nov 91
35	51	WO #91/17148 pub. 14 Nov 91
36	52	WO #91/17148 pub. 14 Nov 91
37	53	WO #91/17148 pub. 14 Nov 91
38	54	WO #91/17148 pub. 14 Nov 91
39	55	WO #91/17148 pub. 14 Nov 91
40	56	WO #91/17148 pub. 14 Nov 91
41	57	WO #91/17148 pub. 14 Nov 91
42	58	WO #91/17148 pub. 14 Nov 91
43	59	WO #91/17148 pub. 14 Nov 91
44	60	WO #91/17148 pub. 14 Nov 91
45	61	WO #91/17148 pub. 14 Nov 91
46	62	WO #91/17148 pub. 14 Nov 91
47	63	WO #91/17148 pub. 14 Nov 91
48	64	WO #91/17148 pub. 14 Nov 91
49	65	WO #91/17148 pub. 14 Nov 91
50	66	WO #91/17148 pub. 14 Nov 91
51	67	WO #91/17148 pub. 14 Nov 91
52	68	WO #91/17148 pub. 14 Nov 91
53	69	WO #91/17148 pub. 14 Nov 91
54	70	WO #91/17148 pub. 14 Nov 91
55	71	WO #91/17148 pub. 14 Nov 91
56	72	WO #91/17148 pub. 14 Nov 91
57	73	WO #91/17148 pub. 14 Nov 91
58	74	WO #91/17148 pub. 14 Nov 91
59	75	WO #91/17148 pub. 14 Nov 91
60	76	WO #91/17148 pub. 14 Nov 91
61	77	WO #91/17148 pub. 14 Nov 91
62	78	WO #91/17148 pub. 14 Nov 91
63	79	WO #91/17148 pub. 14 Nov 91
64	80	WO #91/17148 pub. 14 Nov 91
65	81	WO #91/17148 pub. 14 Nov 91
66	82	WO #91/17148 pub. 14 Nov 91
67	83	WO #91/17148 pub. 14 Nov 91
68	84	WO #91/17148 pub. 14 Nov 91
69	85	WO #91/17148 pub. 14 Nov 91
70	86	WO #91/17148 pub. 14 Nov 91
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72	88	WO #91/17148 pub. 14 Nov 91
73	89	WO #91/17148 pub. 14 Nov 91
74	90	WO #91/17148 pub. 14 Nov 91
75	91	WO #91/17148 pub. 14 Nov 91
76	92	WO #91/17148 pub. 14 Nov 91
77	93	WO #91/17148 pub. 14 Nov 91
78	94	WO #91/18888 pub.
79	95	WO #91/18888 pub.
80	96	WO #91/18888 pub.
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107	123	WO #91/18888 pub.
108	124	WO #91/19715 pub. 26 Dec 91
109	125	WO #91/19715 pub. 26 Dec 91
110	126	WO #91/19715 pub. 26 Dec 91
111	127	WO #91/19715 pub. 26 Dec 91
112	128	WO #91/19715 pub. 26 Dec 91
113	129	WO #91/19715 pub. 26 Dec 91
114	130	WO #91/19715 pub. 26 Dec 91
115	131	WO #91/19715 pub. 26 Dec 91
116	132	WO #91/19715 pub. 26 Dec 91
117	133	WO #91/19715 pub. 26 Dec 91
118	134	WO #91/19715 pub. 26 Dec 91
119	135	WO #91/19715 pub. 26 Dec 91
120	136	WO #91/19715 pub. 26 Dec 91
121	137	WO #91/19715 pub. 26 Dec 91
122	138	WO #91/19715 pub. 26 Dec 91
123	139	WO #91/19715 pub. 26 Dec 91
124	140	WO #91/19715 pub. 26 Dec 91
125	141	WO #91/19715 pub. 26 Dec 91
126	142	WO #92/05161 pub. 2 Apr 92
127	143	WO #92/05161 pub. 2 Apr 92
128	144	WO #92/05161 pub. 2 Apr 92
129	145	WO #92/05161 pub. 2 Apr 92
130	146	WO #92/05161 pub. 2 Apr 92
131	147	WO #92/05161 pub. 2 Apr 92
132	148	WO #92/07834 pub. 14 May 92
133	149	WO #92/07834 pub. 14 May 92
134	150	WO #92/07834 pub. 14 May 92
135	151	WO #92/07834 pub. 14 May 92
136	152	WO #92/07834 pub. 14 May 92
137	153	WO #92/07834 pub. 14 May 92
138	154	WO #92/07834 pub. 14 May 92
139	155	WO #92/11255 pub. 9 Jul 92
140	156	WO #92/11255 pub. 9 Jul 92
141	157	WO #92/11255 pub. 9 Jul 921
142	158	WO #92/11255 pub. 9 Jul 92
143	159	WO #92/11255 pub. 9 Jul 92
144	160	WO #92/11255 pub. 9 Jul 92
145	161	WO #92/11255 pub. 9 Jul 92
146	162	WO #92/11255 pub. 9 Jul 92
147	163	WO #92/15577 pub. 17 Sep 92
148	164	WO #92/15577 pub. 17 Sep 92
149	165	WO #92/15577 pub. 17 Sep 92
150	166	WO #92/16523 pub. 1 Oct 92
151	167	WO #92/16523 pub. 1 Oct 92
152	168	WO #92/16523 pub. 1 Oct 92
153	169	WO #92/16523 pub. 1 Oct 92
154	170	WO #92/16523 pub. 1 Oct 92
155	171	WO #92/16523 pub. 1 Oct 92
156	172	WO #92/16523 pub. 1 Oct 92
157	173	WO #92/16523 pub. 1 Oct 92
158	174	WO #92/16523 pub. 1 Oct 92
159	175	WO #92/16523 pub. 1 Oct 92
160	176	WO #92/16523 pub. 1 Oct 92
161	177	WO #92/16523 pub. 1 Oct 92
162	178	WO #92/16523 pub. 1 Oct 92
163	179	WO #92/16523 pub. 1 Oct 92
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166	182	WO #92/16523 pub. 1 Oct 92
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182	198	WO #92/16523 pub. 1 Oct 92
183	199	WO #92/16523 pub. 1 Oct 92
184	200	WO #92/16523 pub. 1 Oct 92
185	201	WO #92/17469 pub. 15 Oct 92
186	202	WO #92/17469 pub. 15 Oct 92
187	203	WO #92/17469 pub. 15 Oct 92
188	204	WO #92/17469 pub. 15 Oct 92
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239	255	WO #92/18092 pub. 29 Oct 92
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271	287	PCT/US95/02156 filed 8 Mar 94
272	288	PCT/US94/02156 filed 8 Mar 94
273	289	PCT/US94/02156 filed 8 Mar 94
274	290	PCT/US94/02156 filed 8 Mar 94
275	291	PCT/US94/02156 filed 8 Mar 94
276	292	PCT/US94/02156 filed 8 Mar 94
277	293	PCT/US94/02156 filed 8 Mar 94
278	294	PCT/US94/02156 filed 8 Mar 94
279	295	PCT/US94/02156 filed 8 Mar 94
280	296	WO #91/17148 pub. 14 Nov 91
281	297	EP #475,206 pub. 18 Mar 92
282	298	WO #93/18035 pub. 16 Sep 93
283	299	WO #93/17628 pub. 16 Sep 93
284	300	WO #93/17628 pub. 16 Sep 93
285	301	EP #513,533 pub. 19 Nov 92
286	302	EP #535,463 pub. 07 Apr 93
287	303	EP #535,465 pub. 07 Apr 93
288	304	EP #539,713 pub. 05 May 93
289	305	EP #542,059 pub. 19 May 93
290	306	EP #05 557,843 pub. 01 Sep 93
291	307	EP #563,705 pub. 06 Oct 93
292	308	EP #562,261 pub. 29 Sep 93
293	309	EP #05 557,843 pub. 15 Sep 93
294	310	EP #560,163 pub. 15 Sep 93
295	311	EP #564,788 pub. 13 Oct 93
296	312	EP #565,986 pub. 20 Oct 93
297	313	EP #0,569,795 pub. 18 Nov 93
298	314	EP #0,569,794 pub. 18 Nov 93
299	315	EP #0,578,002 pub. 12 Jan 94
300	316	EP #581,003 pub. 02 Feb 94
301	317	EP #392,317 pub. 17 Oct 90
302	318	EP #392,317 pub. 17 Oct 90
303	319	EP #502,314 pub. 09 Sep 92
304	320	EP #468,740 pub. 29 Jan 92
305	321	EP #470,543 pub. 12 Feb 92
306	322	EP #502,314 pub. 09 Sep 92
307	323	EP #529,253 pub. 03 Mar 93
308	324	EP #543,263 pub. 26 May 93
309	325	EP #552,765 pub. 28 Jul 93
310	326	EP #555,825 pub. 18 Aug 93
311	327	EP #556,789 pub. 25 Aug 93
312	328	EP #560,330 pub. 15 Sep 93
313	329	EP #566,020 pub. 20 Oct 93
314	330	EP #581,166 pub. 02 Feb 94
315	331	EP #94/01436 pub. 20 Jan 94
316	332	EP #253,310 pub. 20 Jan 88
317	333	EP #324,377 pub. 19 Jul 89
318	334	US #5,043,349 issued 27 Aug 91
319	335	WO #91/00281 pub. 10 Jan 91
320	336	US #5,015,651 pub. 14 May 91
321	337
322	338	WO #92/00977 pub. 23 Jan 92
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324	340	WO #93/04046 pub. 04 Mar 93
325	341	WO #93/10106 pub. 27 May 93
326	342	US #5,219,856 pub. 15 Jun 93
327	343	US #5,260,325 pub. 09 Nov 93
328	344	US #5,264,581 pub. 23 Nov 93
329	345	EP #400,974 pub. 05 Dec 90
330	346	EP #411,766 pub. 06 Feb 91
331	347	EP #412,594 pub. 13 Feb 91
332	348	EP #419,048 pub. 27 Mar 91
333	349	WO #91/12,001 pub. 22 Aug 91
334	350	WO #91/11,999 pub. 22 Aug 91
335	351	WO #91/11,909 pub. 22 Aug 91
336	352	WO #91/12,002 pub. 22 Aug 91
337	353	US #5,053,329 pub. 01 Oct 91
338	354	US #5,057,522 pub 15 Oct 91
339	355	WO #91/15,479 pub. 17 Oct 91
340	356	EP #456,510 pub. 13 Nov 91
341	357	EP #467,715 pub. 22 Jan 92
342	358	US #5,087,702 pub. 11 Feb 92
343	359	EP #479,479 pub. 08 Apr 92
344	360
345	361	EP #481,614 pub. 22 Apr 92
346	362	EP #490,587 pub. 17 Jun 92
347	363	US #5,128,327 pub. 07 Jul 92
348	364	US #5,132,216 pub. 21 Jul 92
349	365	EP #497,516 pub. 05 Aug 92
350	366	EP #502,725 pub. 09 Sep 92
351	367	EP #502,575 pub. 09 Sep 92
352	368	EP #503,838 pub. 16 Sep 92
353	369	EP #505,111 pub. 23 Sep 92
354	370	EP #505,098 pub. 23 Sep 92
355	371	EP #507,594 pub. 07 Oct 92
356	372	EP #508,723 pub. 14 Oct 92
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358	374	EP #512,675 pub. 11 Nov 92
359	375	EP #512,676 pub. 11 Nov 92
360	376	EP #512,870 pub. 11 Nov 92
361	377	EP #513,979 pub. 19 Nov 92
362	378	WO #92/20,660 pub. 26 Nov 92
363	379	WO #92,20,661 pub. 26 Nov 92
364	380	WO #92/20,662 pub. 26 Nov 92
365	381	WO #92/20,687 pub. 26 Nov 92
366	382	EP #517,357 pub. 09 Dec 92
367	383	WO #93/01177 pub. 21 Jan 93
368	384	US #5,187,159 pub. 16 Feb 93
369	385	US #5,198,438 pub. 30 Mar 93
370	386	US #5,202,322 pub. 13 Apr 93
371	387	EP #537,937 pub. 21 Apr 93
372	388	US #5,217,882 pub. 08 Jun 93
373	389	US #5,214,153 pub. 25 May 93
374	390	US #5,218,125 pub. 08 Jun 93
375	391	US #5,236,928 pub. 17 Aug 93
376	392	US #5,240,938 pub. 31 Aug 93
377	393	GB #2,264,709 pub. 08 Sep 93
378	394	GB #2,264,710 pub. 08 Sep 93
379	395	US #5,356,667 pub. 26 Oct 93
380	396	US #5,525,574 pub. 12 Oct 93
381	397	WO #93/23,399 pub. 25 Nov 93
382	398	US #5,262,412 pub. 16 Nov 93
383	399	US #5,264,447 pub. 23 Nov 93
384	400	US #5,266,583 pub. 01 Sep 92
385	401	US #5,276,054 pub. 04 Jan 94
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386	403	US #5,278,068 pub. 11 Jan 94
387	404	WO #94/02142 pub. 03 Feb 94
388	405	WO #94/02467 pub. 03 Feb 94
389	406	EP #403,159 pub. 19 Dec 90
390	407	EP #425,211 pub. 02 May 91
391	408	EP #427,463 pub 15 May 91
392	409	WO #92/00068 pub. 09 Jan 92
393	410	WO #92/02,510 pub. 20 Feb 92
394	411	WO #92/09278 pub. 11 Jun 92
395	412	WO #92/10181 pub. 25 Jun 92
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403	420	WO #92/10097 pub. 25 Jun 92
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407	424	WO #92/20651 pub. 26 Nov 92
408	425	WO #93/03018 pub. 18 Feb 93
409	426	WO #94/00120 pub. 06 Jan 94
410	427	EP #459,136 pub. 04 Dec 91
411	428	EP #411,507 pub. 05 Feb 91
412	429	EP #425,921 pub. 08 May 91
413	430	EP #430,300 pub. 05 Jun 91
414	431	EP #434,038 pub. 26 Jun 91
415	432	EP #442,473 pub. 21 Aug 91
416	433	EP #443,568 pub. 28 Aug 91
417	434	EP #459,136 pub. 04 Dec 91
418	435	EP #483,683 pub. 05 May 92
419	436	EP #518,033 pub. 16 Dec 92
420	437	EP #520,423 pub. 30 Dec 92
421	438	EP #546,358 pub. 16 Jun 93
422	439	WO #93/00341 pub. 07 Jan 93
423	440	WO #92/06081 pub. 16 Apr 92
424	441	WO #93/00341 pub. 07 Jan 93
425	442	US #5,210,204 pub. 11 May 93
426	443	EP #343,654 pub. 29 Nov 89
427	444	WO #93/13077 pub. 08 Jul 93
428	445	WO #93/15734 pub. 19 Aug 93
429	446	US #5,246,943 pub. 21 Sep 93

[0047] The term “hydrido” denotes a single hydrogen atom (H). This hydrido group may be attached, for example, to an oxygen atom to form a hydroxyl group; or, as another example, one hydrido group may be attached to a carbon atom to form a 447

[0048] group, or, as another example, two hydrido atoms may be attached to a carbon atom to form a —CH2— group. Where the term “alkyl” is used, either alone or within other terms such as “haloalkyl” and “hydroxyalkyl”, the term “alkyl” embraces linear or branched radicals having one to about twenty carbon atoms or, preferably, one to about twelve carbon atoms. More preferred alkyl radicals are “lower alkyl” radicals having one to about ten carbon atoms. Most preferred are lower alkyl radicals having one to about five carbon atoms. The term “cycloalkyl” embraces cyclic radicals having three to about ten ring carbon atoms, preferably three to about six carbon atoms, such as cyclopropyl, cyclobutyl, cyclopentyl and cyclohexyl. The term “haloalkyl” embraces radicals wherein any one or more of the alkyl carbon atoms is substituted with one or more halo groups, preferably selected from bromo, chloro and fluoro. Specifically embraced by the term “haloalkyl” are monohaloalkyl, dihaloalkyl and polyhaloalkyl groups. A monohaloalkyl group, for example, may have either a bromo, a chloro, or a fluoro atom within the group. Dihaloalkyl and polyhaloalkyl groups may be substituted with two or more of the same halo groups, or may have a combination of different halo groups. A dihaloalkyl group, for example, may have two fluoro atoms, such as difluoromethyl and difluorobutyl groups, or two chloro atoms, such as a dichloromethyl group, or one fluoro atom and one chloro atom, such as a fluoro-chloromethyl group. Examples of a polyhaloalkyl are trifluoromethyl, 1,1-difluoroethyl, 2,2,2-trifluoroethyl, perfluoroethyl and 2,2,3,3-tetrafluoropropyl groups. The term “difluoroalkyl” embraces alkyl groups having two fluoro atoms substituted on any one or two of the alkyl group carbon atoms. The terms “alkylol” and “hydroxyalkyl” embrace linear or branched alkyl groups having one to about ten carbon atoms any one of which may be substituted with one or more hydroxyl groups. The term “alkenyl” embraces linear or branched radicals having two to about twenty carbon atoms, preferably three to about ten carbon atoms, and containing at least one carbon-carbon double bond, which carbon-carbon double bind may have either cis or trans geometry within the alkenyl moiety. The term “alkynyl” embraces linear or branched radicals having two to about twenty-carbon atoms, preferably two to about ten carbon atoms, and containing at least one carbon-carbon triple bond. The term “cycloalkenyl” embraces cyclic radicals having three to about ten ring carbon atoms including one or more double bonds involving adjacent ring carbons. The terms “alkoxy” and “alkoxyalkyl” embrace linear or branched oxy-containing radicals each having alkyl portions of one to about ten carbon atoms, such as methoxy group. The term “alkoxyalkyl” also embraces alkyl radicals having two or more alkoxy groups attached to the alkyl radical, that is, to form monoalkoxyalkyl and dialkoxyalkyl groups. The “alkoxy” or “alkoxyalkyl” radicals may be further substituted with one or more halo atoms, such as fluoro, chloro or bromo, to provide haloalkoxy or haloalkoxyalkyl groups. The term “alkylthio” embraces radicals containing a linear or branched alkyl group, of one to about ten carbon atoms attached to a divalent sulfur atom, such as a methythio group. Preferred aryl groups are those consisting of one, two, or three benzene rings. The term “aryl” embraces aromatic radicals such as phenyl, naphthyl and biphenyl. The term “aralkyl” embraces aryl-substituted alkyl radicals such as benzyl, diphenylmethyl, triphenylmethyl, phenyl-ethyl, phenylbutyl and diphenylethyl. The terms “benzyl” and “phenylmethyl” are interchangeable. The terms “phenalkyl” and “phenylalkyl” are interchangeable. An example of “phenalkyl” is “phenethyl” which is interchangeable with “phenylethyl”. The terms “alkylaryl”, “alkoxyaryl” and “haloaryl” denote, respectively, the substitution of one or more “alkyl”, “alkoxy” and “halo” groups, respectively, substituted on an “aryl” nucleus, such as a phenyl moiety. The terms “aryloxy” and “arylthio” denote radicals respectively, provided by aryl groups having an oxygen or sulfur atom through which the radical is attached to a nucleus, examples of which are phenoxy and phenylthio. The terms “sulfinyl” and “sulfonyl”, whether used alone or linked to ocher terms, denotes, respectively, divalent radicals SO and SO2. The term “aralkoxy”, alone or within another term, embraces an aryl group attached to an alkoxy group to form, for example, benzyloxy. The term “acyl” whether used alone, or within a term such as acyloxy, denotes a radical provided by the residue after removal of hydroxyl from an organic acid, examples of such radical being acetyl and benzoyl. “Lower alkanoyl” is an example of a more prefered sub-class of acyl. The term “amido” denotes a radical consisting of nitrogen atom attached to a carbonyl group, which radical may be further substituted in the manner described herein. The term “monoalkylaminocarbonyl” is interchangeable with “N-alkylamido”. The term “dialkylaminocarbonyl” is interchangeable with “N,N-dialkylamido”. The term “alkenylalkyl” denotes a radical having a double-bond unsaturation site between two carbons, and which radical may consist of only two carbons or may be further substituted with alkyl groups which may optionally contain additional double-bond unsaturation. The term “heteroaryl”, where not otherwised defined before, embraces aromatic ring systems containing one or two hetero atoms selected from oxygen, nitrogen and sulfur in a ring system having five or six ring members, examples of which are thienyl, furanyl, pyridinyl, thiazolyl, pyrimidyl and isoxazolyl. Such heteroaryl may be attached as a substituent through a carbon atom of the heteroaryl ring system, or may be attached through a carbon atom of a moiety substituted on a heteroaryl ring-member carbon atom, for example, through the methylene substituent of imidazolemethyl moiety. Also, such heteroaryl may be attached through a ring nitrogen atom as long as aromaticity of the heteroaryl moiety is preserved after attachment. For any of the foregoing defined radicals, preferred radicals are those containing from one to about ten carbon atoms.

[0049] Specific examples of alkyl groups are methyl, ethyl, n propyl, isopropyl, n-butyl, sec-butyl, isobutyl, tert-butyl, n-pentyl, isopentyl, methylbutyl, dimethylbutyl and neopentyl. Typical alkenyl and alkynyl groups may have one unsaturated bond, such as an allyl group, or may have a plurality of unsaturated bonds, with such plurality of bonds either adjacent, such as allene-type structures, or in conjugation, or separated by several saturated carbons.

[0050] Also included in the combination of the invention are the isomeric forms of the above-described angiotensin II receptor compounds and the epoxy-steroidal aldosterone receptor compounds, including diastereoisomers, regioisomers and the pharmaceutically-acceptable salts thereof. The term “pharmaceutically-acceptable salts” embraces salts commonly used to form alkali metal salts and to form addition salts of free acids or free bases. The nature of the salt is not critical, provided that it is pharmaceutically-acceptable. Suitable pharmaceutically-acceptable acid addition salts may be prepared from an inorganic acid or from an organic acid. Examples of such inorganic acids are hydrochloric, hydrobromic, hydroiodic, nitric, carbonic, sulfuric and phosphoric acid. Appropriate organic acids may be selected from aliphatic, cycloaliphatic, aromatic, araliphatic, heterocyclic, carboxylic and sulfonic classes of organic acids, example of which are formic, acetic, propionic, succinic, glycolic, gluconic, lactic, malic, tartaric, citric, ascorbic, glucuronic, maleic, fumaric, pyruvic, aspartic, glutamic, benzoic, anthranilic, p-hydroxybenzoic, salicyclic, phenylacetic, mandelic, embonic (pamoic), methansulfonic, ethanesulfonic, 2-hydroxyethanesulfonic, pantothenic, benzenesulfonic, toluenesulfonic, sulfanilic, mesylic, cyclohexylaminosulfonic, stearic, algenic, β-hydroxybutyric, malonic, galactaric and galacturonic acid. Suitable pharmaceutically-acceptable base addition salts include metallic salts made from aluminium, calcium, lithium, magnesium, potassium, sodium and zinc or organic salts made from N,N′-dibenzylethylenediamine, chloroprocaine, choline, diethanolamine, ethylenediamine, meglumine (N-methylglucamine) and procaine. All of these salts may be prepared by conventional means from the corresponding compound by reacting, for example, the appropriate acid or base with such compound.

BIOLOGICAL EVALUATION

[0051] In order to determine the Probable effectiveness of a combination therapy for treating or preventing the progression of cardiofibrosis or cardiac hypertrophy, it is important to determine the potency of individual components of the combination therapy. Accordingly, in Assays “A” through “C”, the angiotensin II receptor antagonist profiles were determined for many of the compounds described in Table II, herein. In Assay “D”, there is described a method for evaluating a combination therapy of the invention, namely, an angiotensin II receptor antagonist of Table II and an epoxy-steroidal aldosterone receptor antagonist of Table I. The efficacy of each of the individual drugs, epoxymexrenone and the angiotensin II receptor blocker, and of these drugs given together at various doses, is evaluated in a rodent model. The methods and results of such assays are described below.

[0052] Assay A: Antiotensin II Binding Activity

[0053] Compounds of the invention were tested for ability to bind to the smooth muscle angiotensin II receptor using a rat uterine membrane preparation. Angiotensin II (AII) was purchased from Peninsula Labs. 125I-angiotensin II (specific activity of 2200 Ci/mmol) was purchased from Du Pont-New England Nuclear. Other chemicals were obtained from Sigma Chemical Co. This assay was carried out according to the method of Douglas et al [Endocrinology, 106, 120-124 (1980)]. Rat uterine membranes were prepared from fresh tissue. All procedures were carried out at 4° C. Uteri were stripped of fat and homogenized in phosphate-buffered saline at pH 7.4 containing 5 mM EDTA. The homogenate was centrifuged at 1500×g for 20 min., and the supernatant was recentrifuged at 100,000×g for 60 min. The pellet was resuspended in buffer consisting of 2 mM EDTA and 50 mM Tris-HCl (pH 7.5) to a final protein concentration of 4 mg/ml. Assay tubes were charged with 0.25 ml of a solution containing 5 mM MgCl2, 2 mM EDTA, 0.5% bovine serum albumin, 50 mM Tris-HCl, pH 7.5 and 125I-AII (approximately 105 cpm) in the absence or in the presence of unlabelled ligand. The reaction was initialed by the addition of membrane protein and the mixture was incubated at 25° C. for 60 min. The incubation was terminated with ice-cold 50 mM Tris-HCl (pH 7.5) and the mixture was filtered to separate membrane-bound labelled peptide from the free ligand. The incubation tube and filter were washed with ice-cold buffer. Filters were assayed for radioactivity in a Micromedic gamma counter. Nonspecific binding was defined as binding in the presence of 10 μM of unlabelled AII. Specific binding was calculated as total binding minus nonspecific binding. The receptor binding affinity of an AII antagonist compound was indicated by the concentration (IC50) of the tested AII antagonist which gives 50% displacement of the total specifically bound 125I-AII from the angiotensin II AT1 receptor. Binding data were analyzed by a nonlinear least-squares curve fitting program. Results are reported in Table III.

[0054] Assay B. In Vitro Vascular Smooth Muscle-Response for AII

[0055] The compounds of the invention were tested for antagonist activity in rabbit aortic rings. Male New Zealand white rabbits (2-2.5 kg) were sacrificed using an overdose of pentobarbital and exsanguinated via the carotid arteries. The thoracic aorta was removed, cleaned of adherent fat and connective tissue and then cut into 3-mm ring segments. The endothelium was removed from the rings by gently sliding a rolled-up piece of filter paper into the vessel lumen. The rings were then mounted in a water-jacketed tissue bath, maintained at 37° C., between moveable and fixed ends of a stainless steel wire with the moveable end attached to an FT03 Grass transducer coupled to a Model 7D Grass Polygraph for recording isometric force responses. The bath was filled with 20 ml of oxygenated (95% oxygen/5% carbon dioxide) Krebs solution of the following composition (mM): 130 NaCl, 15 NaHCO3, 15 KCl, 1.2 NaH2PO4, 1.2 MgSO4, 2.5 CaCl2, and 11.4 glucose. The preparations were equilibrated for one hour before approximately one gram of passive tension was placed on the rings. Angiotensin II concentration-response curves were then recorded (3×10−10 to 1×10−5 M). Each concentration of AII was allowed to elicit its maximal contraction, and then AII was washed out repeatedly for 30 minutes before rechallenging with a higher concentration of AII. Aorta rings were exposed to the test antagonist at 10−5 M for 5 minutes before challenging with AII. Adjacent segments of the same aorta ring were used for all concentration-response curves in the presence or absence of the test antagonist. The effectiveness of the test compound was expressed in terms of pA2 values and were calculated according to H. O. Schild [Br. J. Pharmacol. Chemother., 2, 189-206 (1947)]. The pA2 value is the concentration of the antagonist which increases the EC50 value for AII by a factor of two. Each test antagonist was evaluated in aorta rings from two rabbits. Results are reported in Table III.

[0056] Assay C: In Vivo Intragastric Pressor Assay Response for All Antagonists

[0057] Male Sprague-Dawley rats weighing 225-300 grams were anesthetized with methohexital (30 mg/kg, i.p.) and catheters were implanted into the femoral artery and vein. The catheters were tunneled subcutaneously to exit dorsally, posterior to the head and between the scapulae. The catheters were filled with heparin (1000 units/ml of saline). The rats were returned to their cage and allowed regular rat chow and water ad libitum. After full recovery from surgery (3-4 days), rats were placed in Lucite holders and the arterial line was connected to a pressure transducer. Arterial pressure was recorded on a Gould polygraph (mmHg). Angiotensin II was administered as a 30 ng/kg bolus via the venous catheter delivered in a 50 μl volume with a 0.2 ml saline flush. The pressor response in mm Hg was measured by the difference from pre-injection arterial pressure to the maximum pressure achieved. The AII injection was repeated every 10 minutes until three consecutive injections yielded responses within 4 mmHg of each other. These three responses were then averaged and represented the control response to AII. The test compound was suspended in 0.5% methylcellulose in water and was administered by gavage. The volume administered was 2 ml/kg body weight. The standard dose was 3 mg/kg. Angiotensin II bolus injections were given at 30, 45, 60, 75, 120, 150, and 180 minutes after gavage. The pressor response to AII was measured at each time point. The rats were then returned to their cage for future testing. A minimum of 3 days was allowed between tests. Percent inhibition was calculated for each time point following gavage by the following formula: [(Control Response−Response at time point)/Control Response]×100. Results are shown in Table III.

[0058] Assay “D”: Renal Hypertensive Rat Model

[0059] A combination therapy of an angiotensin II receptor antagonist and an epoxy-steroidal aldosterone receptor antagonist may be evaluated for blood pressure lowering activity in the renal-artery ligated hypertensive rat, a model of high renin hypertension. In this model, six days after ligation of the left renal artery, both plasma renin activity and blood pressure are elevated significantly [J. L. Cangiano et al, J. Pharmacol. Exp. Ther., 206, 310-313 (1979)]. Male Sprague-Dawley rats are instrumented with a radiotelemetry blood pressure transmitter for continuous monitoring of blood pressure. The rats are anesthetized with a mixture of ketamine-HCl (100 mg/kg) and acepromazine maleate (2.2 mg/ka). The abdominal aorta is exposed via a midline incision. Microvascular clamps are placed on the aorta distal to the renal arteries and at the iliac bifurcation. The aorta is punctured with a 22-gauge needle and the tip of a catheter is introduced. The catheter, which is held in place by a ligature in the psoas muscle, is connected to a radiotelemetry blood pressure transmitter (Mini-Mitter Co. Inc., Sunriver, Oreg.). The transmitter is placed in the peritoneal cavity and sutured to abdominal muscle upon closing of the incision. Rats are housed singly above a radiotelemetry receiver and are allowed standard rat chow and water ad libitum. At least 5 days are allowed for recovery from surgery. Mean arterial Pressure and heart rate are measured on a Compaq DeskPro 286 AT computer. Data are sampled for 10 seconds at 200-500 hz at 2.5 to 10 min intervals 24 hours per say. After collecting control data for 24 hours, the rats are anesthetized with methohexital (30 mg/kg, i.p.) and supplemented as needed. A midline abdominal incision is made, approximately 2 cm in length to expose the left kidney. The renal artery is separated from the vein near the aorta, with care taken not to traumatize the vein. The artery is completely ligated with sterile 4-O silk. The incision is closed by careful suturing of the muscle layer and skin. Six days later, when MAP is typically elevated by 50-70 mmHg, an AII receptor antagonist, or an aldosterone receptor antagonist, or a combination of the two compounds are administered by gavage each day for about 8 weeks. Single drug dosing is carried out using 20 and 200 mg/kg/day of epoxymexrenone and 1, 3, 10, 30 and 100 mg/kg/day of an AII receptor antagonist. Drug mixtures are obtained by administering a combination of a dose of 1, 3, 10, 30 or 100 mg/kg/day of the AII receptor antagonist with a dose of either 20 or 200 mg/kg/day of the aldosterone antagonist. Blood pressure lowering is monitored by the radiotelemetry system and responses with the compounds are compared to responses obtained in vehicle-treated animals. Plasma and urinary sodium and potassium levels are monitored as a measure of the effectiveness of the aldosterone blockade. Urine samples are collected overnight using metabolic cages to isolate the samples. Plasma samples are obtained by venous catheterization. Sodium and potassium are measured by flame photometry. Cardiac fibrosis is determined by histological and chemical measurements of the excised hearts following perfusion fixation. Left and right ventricles are weighed, embedded and sectioned. Subsequently, sections are stained with picrosirius red and the red staining collagen areas are quantitated by computerized image analysis. The apex of the heart is acid digested and the free hydroxyproline measured colorimetrically. It is expected that MAP will be significantly lowered toward normal pressures in the test animals, treated with the combination therapy and that the condition of myocardial fibrosis will be arrested or avoided.

TABLE III
In Vivo and In Vitro Angiotensin II
Activity of Compounds of the Invention
Test	1Assay A			3Assay C
Compound	IC50	2Assay B	Dose	Inhibition	Duration
Example #	(nM)	pA2	(mg/kg)	(%)	(min.)
1	NT	NT	NT	NT	NT
2	95	7.37/7.59	10	95	60
			30	98	90-120
3	5.4	8.70 ± 0.2	10	50	>180
			30	100	200+
4	NT	NT	NT	NT	NT
5	200	7.48/6.91	30	38	20-30
6	1300	6.55/6.82	100	90	120
7	84	8.01/8.05	30	90	130
8	17,000	NT	NT	NT	NT
9	700	6.67/6.12	30	80	75
			100	100	130
10	4.9	8.19/7.59	3	86	100
			30	100	240
11	160	6.45/6.77	NT	NT	NT
12	6.0	8.66/8.59	NT	NT	NT
13	17	8.70/8.85	NT	NT	NT
14	7.2	8.84/8.71	NT	NT	NT
15	16	8.31/8.30	NT	NT	NT
16	6.4	8.95/9.24	NT	NT	NT
17	4.0	8.64/8.40	NT	NT	NT
18	970	6.14/6.09	NT	NT	NT
19	12,000	5.18/5.35	NT	NT	NT
20	78,000	5.89/5.99	100	10	45
21	87	7.71.7.21	NT	NT	NT
22	460	6.60/6.46	NT	NT	NT
23	430	6.48/7.15	NT	NT	NT
24	10	7.56/7.73	NT	NT	NT
25	480	6.80/6.73	NT	NT	NT
26	3.2	9.83/9.66	10	50	>180
27	180	NT	NT	NT	NT
28	570	5.57/6.00	NT	NT	NT
29	160	NT	NT	NT	NT
30	22	7.73/7.88	30	50	>180
31	14	NT	NT	NT	NT
32	16	7.68/7.29	NT	NT	NT
33	630	6.73/6.36	NT	NT	NT
34	640	5.34/5.69	NT	NT	NT
35	41	7.25/7.47	NT	NT	NT
36	1400	5.92/5.68	NT	NT	NT
37	340	6.90/6.85	NT	NT	NT
38	10	7.82/8.36	NT	NT	NT
39	10	7.88/7.84	NT	NT	NT
40	83	7.94/7.61	NT	NT	NT
41	3700	5.68/5.96	NT	NT	NT
42	370	6.56/6.26	NT	NT	NT
43	19	8.97/8.61	NT	NT	NT
44	16	8.23/7.70	NT	NT	NT
45	4.4	8.41/8.24	NT	NT	NT
46	110	6.80/6.64	NT	NT	NT
47	21	7.85/7.58	NT	NT	NT
48	680	6.27/6.75	NT	NT	NT
49	120	7.06/7.67	NT	NT	NT
50	54	7.71/7.89	NT	NT	NT
51	8.7	8.39/8.51	NT	NT	NT
52	100	8.14/8.12	NT	NT	NT
53	65	7.56/7.83	NT	NT	NT
54	3100	6.02	NT	NT	NT
55	80	6.56/7.13	NT	NT	NT
56	5.0	9.04/8.35	NT	NT	NT
57	2300	6.00	NT	NT	NT
58	140	6.45/6.57	NT	NT	NT
59	120	7.23/7.59	NT	NT	NT
60	2200	6.40/6.03	NT	NT	NT
61	110	7.29/7.70	NT	NT	NT
62	26	8.69/8.61	NT	NT	NT
63	61	7.77/7.67	NT	NT	NT
64	54	7.00/6.77	NT	NT	NT
65	23	7.85/7.75	NT	NT	NT
66	12	9.34/8.58	NT	NT	NT
67	3100	5.88/5.78	NT	NT	NT
68	8.6	8.19/8.65	NT	NT	NT
69	15	7.80/8.28	NT	NT	NT
70	44	7.71/8.05	NT	NT	NT
71	12,000	*	NT	NT	NT
72	83	6.11/6.10	NT	NT	NT
73	790	7.65/7.46	NT	NT	NT
74	6.5	8.56/8.39	NT	NT	NT
75	570	6.00/5.45	NT	NT	NT
76	5400	5.52/5.78	NT	NT	NT
77	15,000	5.77	NT	NT	NT
78	101	7.0		93	60-100
79	4.9	9.2		100	>200
				50	>180
80	25	8.1		NT	NT
81	18	8.0		40	180
82	7.9	8.5		20	180
83	3.6	8.3		15	>180
84	16	7.1		20	30
85	8.7	8.9		NT	NT
86	9	7.8		NT	NT
87	91	7.8		NT	NT
88	50	7.7		NT	NT
89	18	7.9		NT	NT
90	5.6	9.0		NT	NT
91	30	8.6		40	>180
92	35	7.9		NT	NT
93	480	NT		NT	NT
94	5,800	NT		NT	NT
95	66	8.2		NT	NT
96	21	8.0		NT	NT
97	280	7.7		NT	NT
98	22	8.1		NT	NT
99	280	6.5		NT	NT
100	4.4	9.4		NT	NT
101	36	7.8		NT	NT
102	43	7.7		NT	NT
103	12	8.0		NT	NT
104	15	8.0		NT	NT
105	290	6.6		NT	NT
106	48	7.7		NT	NT
107	180	8.3		NT	NT
108	720	5.3	100	45	90
109	250	7.3	30	50	30
110	590	6.4		NT	NT
111	45	9.0	30	87	160
112	2000	5.2		NT	NT
113	12	8.4	10	60	180
114	400	6.4		NT
115	11	8.2	3	40	>240
116	230	6.5		NT
117	170	6.5		NT
118	37	9.21/9.17	10	70	120
119	16	9.21/9.00	3	20	60
120	25	9.05/8.77	10	80	240
121	46	NT		NT
122	46	NT		NT
123	50	NT		NT
124	40	9.42/9.12	3	45	>180
125	40	9.25/8.80	3	35	>240
126	240	7.20/7.05		NT
127	12,000	4.96		NT
128	16	8.63/8.40		NT
129	6,700	5.30		NT
130	40	8.10/7.94		NT
131	9.5	7.53/8.25
132	12	8.6		NT
133	10	8.7	3	20	180
					90-120
134	22	9.3	3	35	180
135	16	8.5	3	35	>180
136	NT	NT		NT
137	220	8.3		NT
138	130	8.2		NT
139	0.270	6.3		NT
140	0.031	8.1		100	160
141	0.110	8.02		NT	NT
142	2.000	NA		NT	NT
143	0.052	7.7		85	75
144	0.088	7.7		50	125
145	0.480	6.7		NT	NT
146	0.072	6.4		NT	NT
147	5.8	5.6	3	74	5-10
148	0.87	5.8	3	92	20-30
149	1.1	6.1	3	NT	NT
150	14	8.03/7.80	3	25	>180
151	17	7.76/7.97	3	15	180
152	150	7.46/7.23	3	10	140
153	13	8.30/7.69	3	25	>180
154	97	8.19/8.38		NA
155	86	7.60/7.14		NA
156	78	8.03/7.66		NA
157	530	—/6.22		NA
158	54	8.23/8.14	3	30	>180
159	21	7.92/7.56	3	10	150
160	64	7.87/7.71
161	28			NA
162	380	6.21/6.55		NA
163	420	7.42/6.75		NA
164	1700			NA
165	410	6.90/7.18		NA
166	160	7.57/7.74		NA
167	370	7.08/7.11		NA
168	420	7.69/7.58		NA
169	150	7.78/7.58	3	15	180
170	26	7.08/7.77	3	40	>180
171	28	7.52/7.11	3	0	0
172	70	7.15/7.04		NA
173	90	7.49/6.92		NA
174	180	7.29/7.02		NA
175	27	NA	3	0	0
176	9.8	7.69/7.55	3	10	150
177	26	7.41/7.85	3	15	180
178	88	7.54/7.47		NA
179	310	6.67/—		NA
180	20	7.56/7.15	3	25	180
181	21	7.70/7.12	3	20	180
182	59	NA		NA
183	390	NA		NA
184	1100	6.78/—		NA
185	6.5	8.82/8.53	3	50	>180
186	38	8.33/7.40	3	25	180
187	770	7.46/6.95		NA
188	140	7.72/7.09		NA
189	29	8.64/8.23		NA
190	10	27.87/7.89	3	10	180
191	81	7.75/7.76	3	10	180
192	140			NA
193	11	9.27/8.87	3	10	180
194	47	7.64/7.35		NA
195	34	8.44/8.03		NA
196	31	7.68/8.26		NA
197	14	8.03/8.60		NA
198	7.6	8.76/8.64	3	35	>180
199	10	8.79/8.85	3	60	>180
200	20	8.42/8.77	3	45	>180
201	17	8.78/8.63	3	10	180
202	12	8.79/8.64	3	65	>180
203	9.2	8.43/8.36	3	50	>180
204	16	9.17/8.86	3	75	>180
205	20	9.14/9.15	3	40	>180
206	5.4	8.75/8.89	3	30	>180
207	99	9.04/8.60		NA
208	22	9.19/8.69	3	50	>180
209	5.0	9.41/9.16	3	25	>180
210	3.6	8.36/8.44	3	15	180
211	18	8.74/8.67	3	35	>180
212	23	8.85/8.25	3	15	180
213	51	NA		NA
214	65	NA		NA
215	45	NA		NA
216	5.4	8.80/9.04	3	50	>180
217	9.4	NA	3	65	>180
218	9.0	NA		NA
219	14	NA		NA
220	7.0	NA	3	75	120
221	4.8	NA	3	25	>180
222	5.0	NA		NA
223	14	7.45/7.87	3	20	>180
224	91	NA		NA
225	160	NA		NA
226	93	NA		NA
227	89	7.55/7.67		NA
228	4.5	9.17/8.25	3	80	>180
229	19	NT	3	40	>180
230	2.6	8.23/8.69	3	25	>180
231	3.6	NT	3	75	>180
232	4.4	8.59/8.89	3	70	>180
233	84	8.51/8.78		NT
234	5.0	8.49/9.00	3	20	—
235	34	7.14/7.07		NT
236	4.9	NC	3	70	>180
237	3.6	NT		NT
238	1.7	NT	3	15	>180
239	6.8	7.88/8.01	3	20	>180
240	120	NA		NA
241	6.9	8.57/8.24	3	40	>180
242	110	7.11/6.60		NA
243	250	NA		NA
244	150	7.17/7.17		NA
245	98	6.64/7.04		NA
246	72	7.46/7.59		NA
247	9.4	8.26/8.41	3	20	180
248	20	7.68/7.50	3	10	—
249	4.4	NA	3	20	>180
250	43	NA	3	0	—
251	25	NA		NA
252	13	NA		NA
253	2.6	NA		NA
254	72	NA		NA
255	12	7.61/7.46	3	20	>180
256	4.1	8.43/7.78	3	30	>180
257	160	6.63/6.68		NA
258	350	6.84/6.84		NA
259	54	NA		NA
260	220	NA		NA
261	18	NA		NA
262	530	—/6.22		NA
263	57	NA		NA
264	11	NA		NA
265	110	NA		NA
266	290	NA		NA
267	25	NA	3	25	>180
268	520	NA	3	0	—
269	9.7	NA		NA
270	21	NA		NA
271	14	NC	3	20%	—
272	97	NC	3	70%	>180 min.
273	9.8	8.53/8.61	3	25%	>180 min.
274	13	9.06/8.85	3	35%	>180 min.
275	6.3	9.07/—	3	40%	>180 min.
276	33	8.71/8.64	3	<20%
277	190	—/6.54		NT
278	30	8.49/8.51	3	50%	>180 min.
279	270	8.06/8.25		NT
280	480	6.41/6.35	NT	NT	NT
NT = NOT TESTED
NC = Non-Competitive antagonist
* Antagonist Activity not observed up to 10 μM of test compound.
1Assay A: Angiotensin II Binding Activity
2Assay B: In Vitro Vascular Smooth Muscle Response
3Assay C: In Vivo Pressor Response
Test Compounds administered intragastrically, except for compounds of examples #1-#2, #4-#25, #27-#29, #30-#79, #108-#109, #111, #118 and #139-#149 which were given intraduodenally.

[0060] Administration of the angiotensin II receptor antagonist and the aldosterone receptor antagonist may take place sequentially in separate formulations, or may be accomplished by simultaneous administration in a single formulation or separate formulations. Administration may be accomplished by oral route, or by intravenous, intramuscular or subcutaneous injections. The formulation may be in the form of a bolus, or in the form of aqueous or non-aqueous isotonic sterile injection solutions or suspensions. These solutions and suspensions may be prepared from sterile powders or granules having one or more pharmaceutically-acceptable carriers or diluents, or a binder such as gelatin or hydroxypropyl-methyl cellulose, together with one or more of a lubricant, preservative, surface-active or dispersing agent.

[0061] For oral administration, the pharmaceutical composition may be in the form of, for example, a tablet, capsule, suspension or liquid. The pharmaceutical composition is preferably made in the form of a dosage unit containing a particular amount of the active ingredient. Examples of such dosage units are tablets or capsules. These may with advantage contain an amount of each active ingredient from about 1 to 250 mg, preferably from about 25 to 150 mg. A suitable daily dose for a mammal may vary widely depending on the condition of the patient and other factors. However, a dose of from about 0.01 to 30 mg/kg body weight, particularly from about 1 to 15 mg/kg body weight, may be appropriate.

[0062] The active ingredients may also be administered by injection as a composition wherein, for example, saline, dextrose or water may be used as a suitable carrier. A suitable daily dose of each active component is from about 0.01 to 15 mg/kg body weight injected per day in multiple doses depending on the disease being treated. A preferred daily dose would be from about 1 to 10 mg/kg body weight. Compounds indicated for prophylactic therapy will preferably be administered in a daily dose generally in a range from about 0.1 mg to about 15 mg per kilogram of body weight per day. A more preferred dosage will be a range from about 1 mg to about 15 mg per kilogram of body weight. Most preferred is a dosage in a range from about 1 to about 10 mg per kilogram of body weight per day. A suitable dose can be administered, in multiple sub-doses per day. These sub-doses may be administered in unit dosage forms. Typically, a dose or sub-dose may contain from about 1 mg to about 100 mg of active compound per unit dosage form. A more preferred dosage will contain from about 2 mg to about 50 mg of active compound per unit dosage form. Most preferred is a dosage form containing from about 3 mg to about 25 mg of active compound per unit dose.

[0063] In combination therapy, the aldosterone receptor antagonist may be present in an amount in a range from about 5 mg to about 400 mg, and the AII antagonist may be present in an amount in a range from about 1 mg to about 800 mg, which represents aldosterone antagonist-to-AII antagonist ratios ranging from about 400:1 to about 1:160.

[0064] In a preferred combination therapy, the aldosterone receptor antagonist may be present in an amount in a range from about 10 mg to about 200 mg, and the AII antagonist may be present in an amount in a range from about 5 mg to about 600 mg, which represents aldosterone antagonist-to-AII antagonist ratios ranging from about 40:1 to about 1:60.

[0065] In a more preferred combination therapy, the aldosterone receptor antagonist may be present in an amount in a range from about 20 mg to about 100 mg, and the AII antagonist may be present in an amount in a range from about 10 mg to about 400 mg, which represents aldosterone antagonist-to-AII antagonist ratios ranging from about 10:1 to about 1:20.

[0066] The dosage regimen for treating a disease condition with the combination therapy of this invention is selected in accordance with a variety of factors, including the type, age, weight, sex and medical condition of the patient, the severity of the disease, the route of administration, and the particular compound employed, and thus may vary widely.

[0067] For therapeutic purposes, the active components of this combination therapy invention are ordinarily combined with one or more adjuvants appropriate to the indicated route of administration. If administered per os, the components may be admixed with lactose, sucrose, starch powder, cellulose esters of alkanoic acids, cellulose alkyl esters, talc, stearic acid, magnesium stearate, magnesium oxide, sodium and calcium salts of phosphoric and sulfuric acids, gelatin, acacia gum, sodium alginate, polyvinylpyrrolidone, and/or polyvinyl alcohol, and then tableted or encapsulated for convenient administration. Such capsules or tablets may contain a controlled-release formulation as may be provided in a dispersion of active compound in hydroxypropylmethyl cellulose. Formulations for parenteral administration may be in the form of aqueous or non-aqueous isotonic sterile injection solutions or suspensions. These solutions and suspensions may be prepared from sterile powders or granules having one or more of the carriers or diluents mentioned for use in the formulations for oral administration. The components may be dissolved in water, polyethylene glycol, propylene glycol, ethanol, corn oil, cottonseed oil, peanut oil, sesame oil, benzyl alcohol, sodium chloride, and/or various buffers. Other adjuvants and modes of administration are well and widely known in the pharmaceutical art.

[0068] Although this invention has been described with respect to specific embodiments, the details of these embodiments are not to be construed as limitations.

Claims

1. A method to treat a subject susceptible to or afflicted with cardiofibrosis or cardiac hypertrophy, which method comprises administering a combination of drug agents comprising a therapeutically-effective amount of an angiotensin II receptor antagonist and a therapeutically-effective amount of an epoxy-steroidal aldosterone receptor antagonist.

2. The method of claim 1 wherein said epoxy-steroidal aldosterone receptor antagonist is selected from epoxy-containing compounds.

3. The method of claim 2 wherein said epoxy-containing compound has an epoxy moiety fused to the “C” ring of the steroidal nucleus of a 20-spiroxane compound.

4. The method of claim 3 wherein said 20-spiroxane compound is characterized by the presence of a 9α,11α-substituted epoxy moiety.

5. The method of claim 2 wherein said epoxy-containing compound is selected from the group consisting of pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy-17-hydroxy-3-oxo, γ-lactone, methyl ester, (7α,11α,17α)-; pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy-17-hydroxy-3-oxo-dimethyl ester, (7α,11α,17α)-; 3′H-cyclopropa[6,7] pregna-4,6-diene-21-carboxylic acid, 9,11-epoxy-6,7-dihydro-17-hydroxy-3-oxo-, γ-lactone, (6β,7β,11β,17β)-; pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy-17-hydroxy-3-oxo-, 7-(1-methylethyl) ester, monopotassium salt, (7α,11α,17α)-; pregn-4-ene-7,21-dicarboxylic acid, 9,11,-epoxy-17-hydroxy-3-oxo-, 7-methyl ester, monopotassium salt, (7α,11α,17α)-; 3′H-cyclopropa [6,7] pregna-1,4,6-triene-21-carboxylic acid, 9,11-epoxy-6,7-dihydro-17-hydroxy-3-oxo-, γ-lactone (6α,7α,11.α)-; 3′H-cyclopropa[6,7]pregna-4,6-diene-21-carboxylic acid, 9,11-epoxy-6,7-dihydro-17-hydroxy-3-oxo-, methyl ester, (6α,7α,11α,17α)-; 3′H-cyclopropa[6,7]pregna-4,6-diene-21-carboxylic acid, 9,11-epoxy-6,7-dihydro-17-hydroxy-3-oxo-, monopotassium salt, (6α,7α,11α,17α)-; 3′H-cyclopropa[6,7]pregna-4,6-diene-21-carboxylic acid, 9,11-epoxy-6,7-dihydro-17-hydroxy-3-oxo-, γ-lactone, (6α,7α,11α.,17α)-; pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy-17-hydroxy-3-oxo-, γ-lactone, ethyl ester, (7α,11α,17α)-; and pregn-4-ene-7,21-dicarboxylic acid, 9,11-epoxy-17-hydroxy-3-oxo-, γ-lactone, 1-methylethyl ester, (7α,11α,17α)-.

6. The method of claim 1 wherein said angiotensin II receptor antagonist is selected from compounds consisting of a first portion and a second portion, wherein said first portion is selected from a fragment of Formula I:

7. The method of claim 6 wherein said monocyclic heterocyclic moiety of Formula IIa is selected from thienyl, furyl, pyranyl, pyrrolyl, imidazolyl, triazolyl, pyrazolyl, pyridyl, pyrazinyl, pyrimidinyl, pyridazinyl, isothiazolyl, isoxazolyl, furazanyl, pyrrolidinyl, pyrrolinyl, furanyl, thiophenyl, isopyrrolyl, 3-isopyrrolyl, 2-isoimidazolyl, 1,2,3-triazolyl, 1,2,4-triazolyl, 1,2-dithiolyl, 1,3-dithiolyl, 1,2,3-oxathiolyl, oxazolyl, thiazolyl, 1,2,3-oxadiazolyl, 1,2,4-oxadiazolyl, 1,2,5-oxadiazolyl, 1,3,4-oxadiazolyl, 1,2,3,4-oxatriazolyl, 1,2,3,5-oxatriazolyl, 1,2,3-dioxazolyl, 1,2,4-dioxazolyl, 1,3,2-dioxazolyl, 1,3,4-dioxazolyl, 1,2,5-oxathiazolyl, 1,3-oxathiolyl, 1,2-pyranyl, 1,4-pyranyl, 1,2-pyronyl, 1,4-pyronyl, pyridinyl, piperazinyl, s-triazinyl, as-triazinyl, v-triazinyl, 1,2,4-oxazinyl, 1,3,2-oxazinyl, 1,3,6-oxazinyl, 1,2,6-oxazinyl, 1,4-oxazinyl, o-isoxazinyl, p-isoxazinyl, 1,2,5-oxathiazinyl, 1,4-oxazinyl, o-isoxazinyl, p-isoxazinyl, 1,2,5-oxathiazinyl, 1,2,6-oxathiazinyl, 1,4,2-oxadiazinyl, 1,3,5,2-oxadiazinyl, morpholinyl, azepinyl, oxepinyl, thiepinyl and 1,2,4-diazepinyl.

8. The method of claim 7 wherein said bicyclic heterocyclic moiety of Formula IIb is selected from benzo[b]thienyl, isobenzofuranyl, chromenyl, indolizinyl, isoindolyl, indolyl, indazolyl, purinyl, quinolizinyl, isoquinolyl, quinolyl, phthalazinyl, naphthyridinyl, quinoxalinyl, quinazolinyl, cinnolinyl, pteridinyl, isochromanyl, chromanyl, thieno[2,3-b]furanyl, 2H-furo[3,2-b]pyranyl, 5H-pyrido[2,3-d][1,2]oxazinyl, 1H-pyrazolo[4,3-d]oxazolyl, 4H-imidazo[4,5-d]thiazolyl, pyrazino[2,3-d]pyridazinyl, imidazo[2,1-b]thiazolyl, cyclopenta[b]pyranyl, 4H-[1,3]oxathiolo-[5,4-b]pyrrolyl, thieno[2,3-b]furanyl, imidazo[1,2-b][1,2,4]triazinyl and 4H-1,3-dioxolo[4,5-d]imidazolyl.

9. The method of claim 8 wherein said angiotensin II receptor antagonist compound having said first-and-second-portion moieties of Formula I and II is further characterized by having an acidic moiety attached to either of said first-and-second-portion moieties.

10. The method of claim 9 wherein said acidic moiety is attached to the first-portion moiety of Formula I and is defined by Formula III:

11. The method of claim 10 wherein said acidic moiety is selected from carboxyl moiety and tetrazolyl moiety.

12. The method of claim 10 wherein any of the moieties of Formula I and Formula II may be substituted at any substitutable position by one or more radicals selected from hydrido, hydroxy, alkyl, alkenyl, alkynyl, aralkyl, hydroxyalkyl, haloalkyl, halo, oxo, alkoxy, aryloxy, aralkoxy, aralkylthio, alkoxyalkyl, cycloalkyl, cycloalkylalkyl, aryl, aroyl, cycloalkenyl, cyano, cyanoamino, nitro, alkylcarbonyloxy, alkoxycarbonyloxy, alkylcarbonyl, alkoxycarbonyl, aralkoxycarbonyl, carboxyl, mercapto, mercaptocarbonyl, alkylthio, arylthio, alkylthiocarbonyl, alkylsulfinyl, alkylsulfonyl, haloalkylsulfonyl, aralkylsulfinyl, aralkylsulfonyl, arylsulfinyl, arylsulfonyl, heteroaryl having one or more ring atoms selected from oxygen, sulfur and nitrogen atoms, and amino and amido radicals of the formula

13. The method of claim 12 wherein said angiotensin II receptor antagonist is 5-[2-[5-[(3,5-dibutyl-1H-1,2,4-triazol-1-yl)methyl]-2-pyridinyl]phenyl-1H-tetrazole or a pharmaceutically-acceptable salt thereof and said epoxy-steroidal aldosterone receptor antagonist is 9α-,11α-epoxy-7α-methoxycarbonyl-20-spirox-4-ene-3,21-dione or a pharmaceutically-acceptable salt thereof.

14. The method of claim 13 further characterized by said angiotensin II receptor antagonist and said epoxy-steroidal aldosterone receptor antagonist being present in said combination in a weight ratio range from about one-to-one to about twenty-to-one of said angiotensin II receptor antagonist to said aldosterone receptor antagonist.

15. The method of claim 14 wherein said weight ratio range is from about five-to-one to about fifteen-to-one.

16. The method of claim 15 wherein said weight ratio range is about ten-to-one.

17. The method of claim 1 wherein said angiotensin II receptor antagonist is selected from the group consisting of: saralasin acetate, candesartan cilexetil, CGP-63170, EMD-66397, KT3-671, LR-B/081, valsartan, A-81282, BIBR-363, BIBS-222, BMS-184698, candesartan, CV-11194, EXP-3174, KW-3433, L-161177, L-162154, LR-B/057, LY-235656, PD-150304, U-96849, U-97018, UP-275-22, WAY-126227, WK-1492.2K, YM-31472, losartan potassium, E-4177, EMD-73495, eprosartan, HN-65021, irbesartan, L-159282, ME-3221, SL-91.0102, Tasosartan, Telmisartan, UP-269-6, YM-358, CGP-49870, GA-0056, L-159689, L-162234, L-162441, L-163007, PD-123177, A-81988, BMS-180560, CGP 38560A, CGP-48369, DA-2079, DE-3489, DuP-167, EXP-063, EXP-6155, EXP-6803, EXP-7711, EXP-9270, FK-739, HR-720, ICI-D6888, ICI-D7155, ICI-D8731, isoteoline, KRI-1177, L-158809, L-158978, L-159874, LR B087, LY-285434, LY-302289, LY-315995, RG-13647, RWJ-38970, RWJ-46458, S-8307, S-8308, saprisartan, saralasin, Sarmesin, WK-1360, X-6803, ZD-6888, ZD-7155, ZD-8731, BIBS39, CI-996, DMP-811, DuP-532, EXP-929, L-163017, LY-301875, XH-148, XR-510, zolasartan and PD-123319.

18. The method of claim 17 wherein said angiotensin II receptor antagonist is selected from the group consisting of: saralasin acetate, candesartan cilexetil, CGP-63170, EMD-66397, KT3-671, LR-B/081, valsartan, A-81282, BIBR-363, BIBS-222, BMS-184698, candesartan, CV-11194, EXP-3174, KW-3433, L-161177, L-162154, LR-B/057, LY-235656, PD-150304, U-96849, U-97018, UP-275-22, WAY-126227, WK-1492.2K, YM-31472, losartan potassium, E-4177, EMD-73495, eprosartan, HN-65021, irbesartan, L-159282, ME-3221, SL-91.0102, Tasosartan, Telmisartan, UP-269-6, YM-358, CGP-49870, GA-0056, L-159689, L-162234, L-162441, L-163007 and PD-123177.

19. The method of claim 1 comprising administering said combination to treat or prevent the progression of cardiofibrosis.

20. The method of claim 1 comprising administering said combination to treat or prevent the progression of cardiac hypertrophy.