Early treatment with low-dose enalapril after acute myocardial infarction: an equilibrium radionuclide angiographic study. Enalapril despues del Infarto (EDI) Trial Investigators.

BACKGROUND: To further elucidate the mechanisms involved in the treatment of acute myocardial infarction (AMI) with angiotensin-converting enzyme inhibitors, we compared the effects on left ventricular volumes of early (< 48 hours) versus late (45 days) administration of a fixed low dose of enalapril (10 mg) in patients with AMI. We also analyzed the changes of left ventricular volumes after withdrawal of the study drug. Reduced dilation of the left ventricle is one of the beneficial effects of angiotensin-converting enzyme inhibition after AMI. However, the nature of this effect is not completely understood. METHODS AND RESULTS: We included 89 patients within 48 hours after onset of a first AMI and radionuclide left ventricular ejection fraction less than 45%. The study was double-blind and compared enalapril and placebo with a crossover design. All patients were randomly assigned to a sequence A (enalapril, 45 days; placebo, 45 days) or B (placebo, 45 days; enalapril, 45 days). The end point was the change of left ventricular volume at 45 and 90 days. Thrombolysis was administered to 26 patients (70%) in group A and 25 (75%) in group B. All pretreatment clinical variables were similar in both groups. Median and 95% confidence intervals (CIs) of left ventricular diastolic volumes were 46.8 ml/m2 (39 to 61 ml/m2) and 46.6 ml/m2 (39 to 60 ml/m2) for groups A and B, respectively. Baseline end systolic volumes were 28.5 ml/m2 (20 to 36 ml/m2) and 28.9 ml/m2 (23 to 28 ml/m2) in the same groups. Placebo treatment during the initial 45 days was associated with an increase of left ventricular diastolic volume of 8.75 ml/m2 (95% CI, 3.25 to 17.1 ml/m2; p < 0.01) and end-systolic volume of 4.20 ml/m2 (95% CI, 0.00 to 10.1 ml/m2; p < 0.05). No significant changes during other phases of the study were observed. At 45 days left ventricular diastolic volume was 11.1 ml/m2 (95% CI, 0.5 to 2.2 ml/m2), greater in placebo-treated patients compared with patients receiving enalapril. CONCLUSIONS: In patients with a first Q wave AMI and left ventricular ejection fraction less than 45%, treatment with enalapril can prevent left ventricular dilation. This protective effect involves at least partially a structural modification of the left ventricle. Hence, maximal benefit can be obtained only with early initiation of treatment.

Long-term efficacy of amlodipine in patients with severe coronary artery disease.

The long-term efficacy of amlodipine was assessed in 21 patients with chronic stable angina. After a 2-week run-in period, patients received 5 mg amlodipine once daily for 2 weeks. This was increased to 10 mg daily during the following 10-week dose-adjustment/maintenance phase, if angina attacks were not abolished. Patients were then followed up for an additional 21 months (total 24 months). During follow-up, patients were evaluated at least once a month, and sitting blood pressure and heart rate were monitored. Angina attack rate and nitroglycerin consumption were recorded in angina diaries throughout the study. Patients underwent a treadmill exercise test at baseline, at the end of the dose-adjustment phase and again during long-term follow-up at 20 months. Amlodipine (mean final daily dose, 8.2 mg) resulted in a significant reduction in angina attack rate and nitroglycerin consumption (both p < 0.001), which was maintained during follow-up. Systolic blood pressure was also reduced (p < 0.01) by amlodipine. Diastolic blood pressure and heart rate were not significantly affected. Amlodipine significantly increased mean exercise time (p < 0.001). ST-segment depression at maximum common load was reduced when compared with baseline values (p < 0.001), and the metabolic equivalent (MET) score at peak exercise was significantly improved by amlodipine (p < 0.001). All of these effects on exercise performance were sustained during follow-up. These data indicate that long-term treatment with amlodipine, in patients with severe coronary artery disease, reduced the number of angina attacks and nitroglycerin consumption and produced a sustained improvement in exercise performance.

Pseudomonas mendocina, an environmental bacterium isolated from a patient with human infective endocarditis.

Pseudomonas mendocina has been isolated from soil and water samples. Although it has been recovered from some human clinical samples, its pathogenic role has not yet been documented. We report the first known case of endocarditis in humans due to P. mendocina.

Acción del propranolol sobre la función ventricular izquierda en el hipertiroidismo / Effect of propranolol on the left ventricular function in hyperthyroidism

Para valorar la función cardíaca en hipertiroidismo y su modificación con betabloqueadores estudianos 9 pacientes hipertiroideos con ventriculograma radioisotópico, midiendo fracción de eyección de reposo (FER) y esfuerzo (FEE) antes y después de la administración de propranolol. La FER fue significativamente mayor que en controles normales. La FEE aumentó normalmente en 4 pacients (Grupo A) y no se elevó en 5 (Grupo B). No hubo diferencia significativa de FER pre y post propranolol, si bien 5/9 pacientes mostraron descenso de la misma después de dicha medicación. La FEE tampoco mostró diferencia significativa pre post batabloqueo. Si bien señalamos que la diferencia entre los grupos A y B no se mantuvo post propranolol ya que 4/5 pacientes del grupo B aumentaron la FEE después del mismo, destacamos que los que presentaron FEE anormal antes y después del betabloqueo partían de valores de FER elevados. Estos hallazgos pueden interpretarse como superponibles a los que de una población normal , ya que la falta de crecimiento de FEE post propranolol en 4/5 pacientes del grupo B podría se mediado por dicha droga, que modificaría la respuesta hemodinámica. Nuestros hallazgos cuestionan la hipótesis de la existencia de daño miocárdico en el hipertiroidismo

Acción del propranolol sobre la función ventricular izquierda en el hipertiroidismo / Effect of propranolol on the left ventricular function in hyperthyroidism

Para valorar la función cardíaca en hipertiroidismo y su modificación con betabloqueadores estudianos 9 pacientes hipertiroideos con ventriculograma radioisotópico, midiendo fracción de eyección de reposo (FER) y esfuerzo (FEE) antes y después de la administración de propranolol. La FER fue significativamente mayor que en controles normales. La FEE aumentó normalmente en 4 pacients (Grupo A) y no se elevó en 5 (Grupo B). No hubo diferencia significativa de FER pre y post propranolol, si bien 5/9 pacientes mostraron descenso de la misma después de dicha medicación. La FEE tampoco mostró diferencia significativa pre post batabloqueo. Si bien señalamos que la diferencia entre los grupos A y B no se mantuvo post propranolol ya que 4/5 pacientes del grupo B aumentaron la FEE después del mismo, destacamos que los que presentaron FEE anormal antes y después del betabloqueo partían de valores de FER elevados. Estos hallazgos pueden interpretarse como superponibles a los que de una población normal , ya que la falta de crecimiento de FEE post propranolol en 4/5 pacientes del grupo B podría se mediado por dicha droga, que modificaría la respuesta hemodinámica. Nuestros hallazgos cuestionan la hipótesis de la existencia de daño miocárdico en el hipertiroidismo (AU)