A double blind comparative study of lisinopril and enalapril in patients with essential hypertension.

The efficacy and safety profiles of lisinopril (10-40 mg) and enalapril (5-20 mg) were compared in 169 hypertensive patients during 12 weeks' treatment in a randomised double-blind parallel group study. BP was measured hourly for the first 8 hours following the first dose of lisinopril 10 mg and enalapril 5 mg. The peak reduction in sitting systolic and diastolic BP occurred approximately 6 hours post dose in both groups. At 8 hours post dose lisinopril had reduced sitting systolic and diastolic BP by 2.9 mmHg and 3.5 mmHg (P = 0.02) respectively, more than enalapril with similar results for standing BP. One patient on enalapril developed first dose postural hypotension. After 12 weeks' therapy lisinopril produced a greater decrease (P less than 0.05) in BP than enalapril. Sitting BP decreased by 25/15 mmHg on lisinopril and 17/12 mmHg with enalapril. Standing BP decreased by 24/14 mmHg compared with 16/10 mmHg on enalapril. Eighteen patients did not complete the study, 8 on lisinopril (6 adverse events, 1 uncontrolled BP, 1 protocol violator) and 10 on enalapril (8 adverse events, 1 uncontrolled BP, 1 protocol violator). Overall, the results indicated that while both drugs are well tolerated, the dose range of lisinopril 10-40 mg may produce a greater antihypertensive effect than enalapril 5-20 mg.

Use of amiodarone during pregnancy.

Two cases are reported in which amiodarone was administered during pregnancy for longer periods than has been reported previously. Limited placental transfer of amiodarone and its desethyl metabolite was observed in both cases. A normal child resulted from each pregnancy despite, in one case, amiodarone therapy throughout the entire pregnancy. However, caution is urged in the use of amiodarone during pregnancy in view of the limited data available.

Coexistence of asymmetric septal hypertrophy and aortic valve disease in adults.

Echocardiography detected asymmetric septal hypertrophy (ASH) in five of 200 adults being assessed for aortic valve surgery. Four of these were among 119 patients with dominant aortic stenosis, which was severe in three. ASH was confirmed at the time of aortic valve replacement in two of these patients; the third declined operation. The finding of ASH in only one of 81 patients with free aortic reflux is consistent with chance association. While the same explanation could apply to the higher prevalence in those with aortic stenosis, it may be that a long-standing pressure overload can trigger inappropriate septal hypertrophy in predisposed individuals.

Valvar aortic stenosis with unusual features.

This case report documents the co-existence of valvar aortic stenosis and hypertrophic obstructive cardiomyopathy with systemic hypertension and calcific mitral annulus, a combination which has not hitherto been reported. It is the purpose of this paper to help assess the true incidence of the co-existence of aortic stenosis and hypertrophic cardiomyopathy.

Echocardiographic assessment of mitral valve calcification.

The mitral valve was assessed by echocardiography in 20 patients, aged 27 to 67 years, who subsequently underwent mitral valve replacement. After removal, the mitral valve cusps were examined by direct measurement, radiography, and quantitative calcium extraction. Increased thickness of the E-F echo was found where calcification or fibrosis was present, differentiation by echocardiography alone being unreliable. However, multiple dense parallel E-F echoes were found in all 10 patients with more than 80 milligrammes of calcium in the valve, while a single thin E-F echo indicated the absence of significant calcification or fibrosis.

Echocardiographic left ventricular dimensions in pressure and volume overload. Their use in assessing aortic stenosis.

Left ventricular 'relative wall thickness', determined from the ratio between echocardiographic measurements of end-systolic wall thickness and cavity transverse dimension, was related to peak systolic intraventricular pressure in 15 normal subjects, in 15 patients with left ventricular volume or pressure overload without aortic stenosis, and in 23 patients with aortic stenosis. All these patients had a mean rate of circumferential fibre shortening greater than 1.0 circumference per second and were regarded as having good ventricular function. Relative wall thickness was found to be normal in cases of volume overload and to be increased in pressure overload, being proportional to the systolic intraventricular pressure. Values for the ratio of systolic intraventricular pressure to relative wall thickness in the normal subjects and patients without aortic stenosis were similar (mean 30 +/- 2.5). Based on this relation, estimates of peak systolic intraventricular pressure were made in the cases of aortic stenosis using the formula: systolic intraventricular pressure (kPa) equals 30 x wall thicknes divided by transverse dimension. Peak systolic aortic value gradients derived by subtracting brachial artery systolic pressure, measured by sphygmomanometer, from the echocardiographic estimates of intraventricular pressure compared favourably with the gradients measured at left heart catheterization (r equals 0.87, P less than 0.001). Aortic value orifice areas, derived from echocardiographic estimates of stroke volume, ejection time, and value gradient, ranged from 0.21 to 3.16 cm2 and appeared to correlate with the severity of aortic stenosis. All patients with aortic stenosis, with or without coexistent mild aortic regurgitation, who were recommended for aortic valve surgery, had estimated valve orifice areas of less than 0.8 cm2. A further 10 patients with pressure or volume overload had mean rates of circumferential fibre shortening of less than 1.0 circumference per second and were regarded as having poor ventricular function. In these cases values for relative wall thickness were lower than in those with good ventricular function and were not proportional to systolic intraventricular pressure. In patients with good left ventricular function systolic intraventricular pressure is proportional to, and can be estimated from, echocardiographic measurement of relative wall thickness.