Angiotensin-converting Inhibitors Research Articles

Captopril Pretreatment Produces an Additive Cardioprotection to Isoflurane Preconditioning in Attenuating Myocardial Ischemia Reperfusion Injury in Rabbits and in Humans.

Background. Pretreatment with the angiotensin-converting inhibitor captopril or volatile anesthetic isoflurane has, respectively, been shown to attenuate myocardial ischemia reperfusion (MI/R) injury in rodents and in patients. It is unknown whether or not captopril pretreatment and isoflurane preconditioning (Iso) may additively or synergistically attenuate MI/R injury. Methods and Results. Patients selected for heart valve replacement surgery were randomly assigned to five groups: untreated control (Control), captopril pretreatment for 3 days (Cap3d), or single dose captopril (Cap1hr, 1 hour) before surgery with or without Iso (Cap3d+Iso and Cap1hr+Iso). Rabbit MI/R model was induced by occluding coronary artery for 30 min followed by 2-hour reperfusion. Rabbits were randomized to receive sham operation (Sham), MI/R (I/R), captopril (Cap, 24 hours before MI/R), Iso, or the combination of captopril and Iso (Iso+Cap). In patients, Cap3d+Iso but not Cap1hr+Iso additively reduced postischemic myocardial injury and attenuated postischemic myocardial inflammation. In rabbits, Cap or Iso significantly reduced postischemic myocardial infarction. Iso+Cap additively reduced cellular injury that was associated with improved postischemic myocardial functional recovery and reduced myocardial apoptosis and attenuated oxidative stress. Conclusion. A joint use of 3-day captopril treatment and isoflurane preconditioning additively attenuated MI/R by reducing oxidative stress and inflammation.

Should I have this on my bookshelf? A review of Cardiac Drugs in Pregnancy

“Cardiac drugs in pregnancy” is a pocket-sized book published by Springer as part of their “Current Cardiovascular Therapy” series. The book is a 130 page synopsis of cardiovascular therapy in the setting of pregnancy, edited by two South African cardiologists, Drs. Karen Sliwa and John Anthony. There are six chapters in the book, beginning with General Principles and then proceeding through a series of common cardiovascular problems such as hypertension, heart failure, and arrhythmias written by a series of experienced South African and European cardiologists. The title and topic seem unusual at first glance—after all, how common is cardiovascular therapy in pregnancy? The editors make the case—and this reviewer agrees with them—that cardiovascular disease is pregnancy is in fact relatively common, notably in the era of older and older women having children, and that cardiologists need an approach to these problems. As well, some of the few well-described human teratogens include drugs commonly used by cardiologists, notably the angiotensin-converting inhibitors and warfarin. The book is an easy and enjoyable read, clearly written, and intended for practicing clinicians. The editors and chapter authors have focused on the common and important rather than the esoteric and arcane, which this reviewer thoroughly agrees with. As an example, fetal therapy is not discussed, being beyond the scope of this book. The first chapter deals with how the cardiovascular system adapts during pregnancy and how this may impact on therapy. Succeeding chapters are disorder-specific. The authors take care to ensure that their chapters provide not only a conceptual overview but also recommendations to guide therapy. The authors address what is confirmed by the literature and, of equal importance, areas where there is paucity of evidence based medicine (or data) to guide therapy decisions of cardiovascular disease in pregnancy. That being said, the book is not perfect and one wonders if perhaps the inclusion of one of small but active community of human teratogen investigators or a consulting obstetrician as a chapter author might have been useful. As an example, the concept of baseline risk and the importance of a fulsome discussion on baseline risk as part of the evaluation and therapeutic planning for pregnancy is understated, which is regrettable given the clear and compelling evidence as to the importance of this—and the consequences of misinformation—in the setting of pregnancy and drug therapy. There is also a somewhat uncritical view of some important issues in the care of the pregnant woman. As an example, more than one chapter cites the US Food and Drug Administration classification of drug teratogenicity in terms of assessment of pregnancy risk without a deeper discussion as to the very real limitations—acknowledged by the FDA - of this classification system in terms of real world evidence. The chapter on cardiovascular adjustments during pregnancy is there but is somewhat light on some issues such as drug transfer across the placenta, which is an increasingly interesting and complex area of study. An increasing population of cardiac patients—adult survivors of congenital cardiac disease—is not covered in a separate chapter but is dealt with piece-meal. It seems to this reviewer that this is not the best way to address the complex problems of a new and growing population of cardiac patients, and the addition of a chapter on pregnancy in adult survivors of congenital cardiac disease would be a useful addition to the next edition of this book. These reservations aside, the book does bring together in a single small volume a large amount of highly relevant and practical material covering those conditions and problems most likely to be encountered by cardiologists and consulting internists. The advantages and limitations of current therapy are concisely outlined and the recommendations provided will be very useful in guiding therapy. The inclusion of a final chapter on the use of obstetrical drugs in the management of cardiovascular disease is both novel and very interesting. In summary, this small volume is a useful and practical book that would be a very useful part of the library of cardiologists as well as internists whose consulting practices include the care of pregnant women.

ACE-I/ARB Therapy prior to Contrast Exposure: What Should the Clinician Do?

Contrast-induced nephropathy (CIN) is now one of the three leading causes of acute kidney injury in the world. A lot is known about the risk factors of CIN, yet it remains a major cause of morbidity, end stage renal disease, prolonged hospital stay, and increased costs as well as a high mortality. Many patients undergoing contrast-based radiological investigations are treated with angiotensin converting inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) for their cardiac and renal benefits and their known mortality benefits. However, controversy exists among clinicians as to whether ACE-Is and ARBs should be continued or discontinued prior to contrast media exposure. In this paper we review the current evidence on ACE-I/ARB therapy for patients undergoing procedures involving use of contrast media and provide recommendations as to whether these drugs should be continued or held prior to contrast exposure.

Letter to the Editor Hypercalcemia and acute renal failure associated with calcium carbonate consumption in a patient with hypoparathyroidism

Letter to the Editor Hypercalcemia and acute renal failure associated with calcium carbonate consumption in a patient with hypoparathyroidism

Association between angiotensin-converting enzyme inhibitors and troponin in acute coronary syndrome.

BackgroundCardiovascular disease is the leading cause of mortality in the western world and its treatment should be optimized to decrease severe adverse events.ObjectiveTo determine the effect of previous use of angiotensin-converting enzyme inhibitors on cardiac troponin I measurement in patients with acute coronary syndrome without ST-segment elevation and evaluate clinical outcomes at 180 days.MethodsProspective, observational study, carried out in a tertiary center, in patients with acute coronary syndrome without ST-segment elevation. Clinical, electrocardiographic and laboratory variables were analyzed, with emphasis on previous use of angiotensin-converting enzyme inhibitors and cardiac troponin I. The Pearson chi-square tests (Pereira) or Fisher's exact test (Armitage) were used, as well as the non-parametric Mann-Whitney's test. Variables with significance levels of <10% were submitted to multiple logistic regression model.ResultsA total of 457 patients with a mean age of 62.1 years, of whom 63.7% were males, were included. Risk factors such as hypertension (85.3%) and dyslipidemia (75.9%) were the most prevalent, with 35% of diabetics. In the evaluation of events at 180 days, there were 28 deaths (6.2%). The statistical analysis showed that the variables that interfered with troponin elevation (> 0.5 ng / mL) were high blood glucose at admission (p = 0.0034) and ST-segment depression ≥ 0.5 mm in one or more leads (p = 0.0016). The use of angiotensin-converting inhibitors prior to hospitalization was associated with troponin ≤ 0.5 ng / mL (p = 0.0482). The C-statistics for this model was 0.77.ConclusionThis study showed a correlation between prior use of angiotensin-converting enzyme inhibitors and reduction in the myocardial necrosis marker troponin I in patients admitted for acute coronary syndrome without ST-segment elevation. However, there are no data available yet to state that this reduction could lead to fewer severe clinical events such as death and re-infarction at 180 days.

ABFM'S HEART FAILURE SELF-ASSESSMENT MODULE SIMULATION ACTIONS VIS-A-VIS GUIDELINE RECOMMENDATIONS

The American Board of Family Medicine (ABFM) introduced Maintenance of Certification for Family Physicians (MC-FP) in 2004 in response to policy adopted by the American Board of Medical Specialties (ABMS.)1 ABFM reported in 2006 the initial Diplomate experiences with MC-FP.2 At that time, ABFM had Self-Assessment Modules (SAMs), consisting of a 60-item knowledge assessment followed by a virtual patient clinical simulation available only for hypertension, type 2 diabetes mellitus, asthma, and depression. Since that time, ABFM has deployed modules for coronary artery disease, chronic heart failure, well child care, maternity care, preventive care, care of the vulnerable elderly, pain management, early childhood illness, cerebrovascular disease, and health behavior. Each of the SAMs includes a Diplomate assessment of both the knowledge assessment and the simulation components. In addition to the Diplomates’ subjective assessments of the SAMs, ABFM captures the actions taken during each simulation, including the action itself, the simulated date and time of the action, and the simulated patient’s current health state. This information is captured in an action log, which serves as a persistent record of the Diplomate’s traversal through the simulation scenario. ABFM introduced the chronic heart failure (CHF) SAM and associated simulation in 2006. We present in Figure 1 a graphical summary of simulation actions taken in the CHF SAM, as extracted from the simulation action logs from 2006 to 2011. We present the results as percentage of simulations in which given actions occurred. Figure 1 Chronic heart failure Self-Assessment Module simulations including indicated actions. The results indicate overall high use of angiotensin converting inhibitors (ACEInhibitors), ACE inhibitors and/or angiotensin receptor blockers (ACEInhibitor-sARBS), but surprisingly low use of beta-adrenergic blocking agents (BetaBlockers.) Digitalis preparations (DigitalisPrep) demonstrated very low use. The majority of Diplomates also did a formal assessment of left ventricular function (Echocardiogram.) The CHF simulations generally present scenarios representing patients with stage C heart failure, as defined in the 2009 ACCF/AHA heart failure guideline.3 According to that guideline, ACE inhibitors and beta-adrenergic blockers should routinely be used in these patients.3 This discrepancy between recommended therapy and the low percentage of beta-adrenergic blocker prescriptions in the simulations suggests that the knowledge assessments should perhaps place greater emphasis on the use of these agents in class C .heart failure. The current CHF knowledge assessment contains only 7 items that reference beta-blockers, and nearly all of these present a beta-adrenergic agent only as historical information in the clinical stem of the item, rather than as a focus of decision-making in the item. These results suggest that the simulations, although clearly presenting a virtual patient environment, can serve as a useful probe for identifying possible management gaps that should be emphasized in the SAM knowledge assessments.

Analysis of baseline parameters in the HALT polycystic kidney disease trials

HALT PKD consists of two ongoing randomized trials with the largest cohort of systematically studied patients with autosomal dominant polycystic kidney disease to date. Study A will compare combined treatment with an angiotensin-converting inhibitor and receptor blocker to inhibitor alone and standard compared with low blood pressure targets in 558 early-stage disease patients with an eGFR over 60 ml/min per 1.73 m(2). Study B will compare inhibitor-blocker treatment to the inhibitor alone in 486 late-stage patients with eGFR 25-60 ml/min per 1.73 m(2). We used correlation and multiple regression cross-sectional analyses to determine associations of baseline parameters with total kidney, liver, or liver cyst volumes measured by MRI in Study A and eGFR in both studies. Lower eGFR and higher natural log-transformed urine albumin excretion were independently associated with a larger natural log-transformed total kidney volume adjusted for height (ln(HtTKV)). Higher body surface area was independently associated with a higher ln(HtTKV) and lower eGFR. Men had larger height-adjusted total kidney volume and smaller liver cyst volumes than women. A weak correlation was found between the ln(HtTKV) and natural log-transformed total liver volume adjusted for height or natural log liver cyst volume in women only. Women had higher urine aldosterone excretion and lower plasma potassium. Thus, our analysis (1) confirms a strong association between renal volume and functional parameters, (2) shows that gender and other factors differentially affect the development of polycystic disease in the kidney and liver, and (3) suggests an association between anthropomorphic measures reflecting prenatal and/or postnatal growth and disease severity.

Management of hypertension in adults in primary care: NICE guideline

Hypertension is common and is one of the leading causes of cardiovascular events such as stroke and ischaemic heart disease. It is responsible for approximately 12% of consultations in primary care. This is a summary of the key points in the 2011 National Institute for Health and Clinical Excellence (NICE) hypertension guideline.1 This is an update of NICE clinical guideline 18, which was first published in 2004 and was partially updated in 2006 (clinical guideline 34). The 2006 and 2011 updates were developed in collaboration with the British Hypertension Society (BHS). The areas included for updating were selected because of new evidence that might change existing recommendations. These included the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) in diagnosis; the place of new thresholds and targets for treatment; and a re-examination of the position of angiotensin-converting inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium-channel blockers (CCBs), and diuretics in the treatment algorithm. Consideration of differences in management for people of various ages and ethnicity, as well as how to treat resistant hypertension, were also included. The management of blood pressure in people with diabetes was not included in this guideline. ### Diagnosis The diagnosis of hypertension uses both clinic blood pressure monitoring (CBPM) and ABPM readings (Box 1). If blood pressure measured in the clinic is 140/90 mmHg or higher, a second measurement should be taken during the consultation. If the second measurement is substantially different from the first, take a third measurement. The lower of the last two measurements should be recorded as …

Common and less common adverse effects of antihypertensives: a general practitioner's perspective

About 35% of hypertensive patients will discontinue their medication within six months, 1 and in at least 50% of cases, the reason for discontinuation relates to adverse effects and patient dissatisfaction. 2 Therefore, it is imperative that hypertension practitioners are fully cognisant of the adverse effects of antihypertensive drugs. The focus in this article will be on the six major classes of drugs, namely diuretics, angiotensin-converting (ACE) inhibitors, angiotensinreceptor blockers (ARBs), calcium-channel blockers, beta blockers and alpha blockers. 3 The most universal adverse effect of antihypertensive therapy is hypotension, due to overtreatment. This can be subtle, and includes vague symptoms of dizziness, fatigue, tiredness, and anxiety. This is often not detected in the consulting room because of counter-regulatory measures to restore the blood pressure (BP), white-coating (especially in the elderly), and failure to perform a standing BP. Another clue to overtreatment is an unexplained increase in creatinine. Home and 24-hour ambulatory BP monitoring are useful in detecting this.

Lessons From the KK-Ay Mouse, a Spontaneous Animal Model for the Treatment of human Type 2 Diabetic Nephropathy

Diabetic nephropathy is a major cause of end-stage kidney disease (ESKD) in patients with type 1 and type 2 diabetes throughout the world. In human glomeruli, expansion of diffuse mesangial matrices, exudative lesions and/or segmental nodular sclerosis are pathological features of diabetic nephropathy. There have been many reports on the pathogenesis and treatment of type 2 diabetes using various animal models.It appears that KK-Ay mice, especially in terms of their immunohistological findings, are a suitable animal model for human type 2 diabetic nephropathy. Many compounds have been reported to be advanced glycation end product (AGE) inhibitors such as aminoguanidine, angiotensin II receptor inhibitors and pyridoxamine, and these are useful in therapeutic interventions for reducing AGEs. Pyridoxamine ameliorates lipid peroxidation and insulin resistance in KK-Ay mice. Combination therapy with angiotensin converting inhibitors (ACE-I) and angiotensin II type 1 receptor blockers (ARB), including an ARB and 1,25-dihydroxyvitamin D3, i.e. anti-hypertensive and anti-reactive oxygen species effects, or with eicosapentaenoic acid (EPA), i.e. anti-microinflammation effect, have shown efficacy in the treatment of diabetic nephropathy in KK-Ay mice. It appears that KK-Ay mice are a useful spontaneous animal model for the evaluation of pathogenesis and treatment in patients with type 2 diabetic nephropathy.

A comparative study of adverse drug reactions during two heat waves that occurred in France in 2003 and 2006

Heat waves could reveal or aggravate several 'serious' adverse drug reactions (ADRs) in elderly. Thus, we wanted to describe the main characteristics of heat-related 'serious' ADRs occurred in patients older than 70 years during these two events in France (2003 and 2006). We analysed 'serious' ADRs reported to the network of French pharmacovigilance centres in summer 2003 and 2006 and suspected to be heat related. 'Serious' ADRs occurred during summers with heat waves (2003 and 2006) were compared with ADRs occurred during the same months in the summers of 2004 and 2005 (reference period). Patients' characteristics and number of 'serious' ADRs were similar whatever the year of the study. Number of drug-related deaths seemed higher in 2003 than in 2004-2005. More 'serious' heat-related ADRs were reported in the summers of 2003 and 2006 (68 in 2003 and 72 in 2006). Comparing with the reference period, metabolic ADRs were less frequent during the summers of 2003 (29%, p = 0.0001) and 2006 (39%, p = 0.003). Occurrence of other ADRs was similar whatever the period. Drugs more frequently involved during heat waves were diuretics, serotonic antidepressants, angiotensin converting inhibitors and proton pump inhibitors. Differences between 2003 and 2006 were found for non-dopaminergic (atropinic) antiparkinsonians or antiepileptics (most frequently involved in 2006) and beta-blockers or proton pump inhibitors (less frequently involved in 2006). The present study underlines the interest of a National Pharmacovigilance Database to follow each year the role of drugs in heat-related ADRs. This survey should be associated with other pharmacoepidemiological methods, such as case-control or population-based studies.

Abstract P366: Apical Ballooning Syndrome in Women and Outcome

Background: Apical ballooning syndrome (ABS) management has not been extensively studied. These patients are often managed as those with acute coronary syndrome. The objective of our study is to examine the role of medications like selective beta-blockers, statins, clopidogrel, and angiotensin converting (ACE) inhibitors post-discharge. Methods: From January, 2002 to December, 2007 18 consecutive patients were treated for ABS. Each patient was assessed by history, physical exam, electrocardiogram, laboratory investigations, telemetry, echocardiogram, coronary angiogram and later, by a follow up echo in 4-8 weeks. Results: All patients were female, the majority were caucasian and postmenopausal. The most common presentation was angina. Common EKG findings were T wave inversions, and prolonged QTc. Echocardiogram images demonstrated mid-ventricular and apical wall motion abnormalities and reduced ejection fraction, this was later confirmed by angiogram. All patients were alive at the time of discharge. Medications these patients received post discharge were selective beta-blockers 87.5 % (14/16), aspirin 100% (16/16), statins 62.5% (10/16), ACE inhibitors 81.2% ( 13/16), and clopidogrel 12.5% (2/16). After discharge from the hospital 31.2% (5/16) had recurrent chest pain on the above medical management. Recurrent chest pain developed in three out of five patients discharged on selective beta-blockers (p &lt; 0.08, Fisher exact) and in three out of five patients who were discharged on statins (p &lt; 0.65, Fisher exact). Patients who developed recurrent chest pain discharged on ACE inhibitors were four out of five (p&lt;0.70, fisher exact test), and on clopidogrel were 0 out of five (p &lt;0.45, fisher exact). Conclusion: Patients from our study have a higher rate of recurrent chest pain than previously reported. Chronic treatment with selective beta-blockers, ACE inhibitors, clopidogrel, and statins did not reduce the frequency of recurrent chest pain post-discharge. Although there is no evidence demonstrating a benefit, these patients are often treated as per guidelines for acute coronary syndrome. Our study demonstrates that ABS patients are subjected to ineffective treatment and there is an emergent need for management guidelines

Angioedema due to the renin inhibitor aliskiren (May 2011)

Readers comment on the management of atrial fibrillation (April 2011) and on angioedema due to angiotensin-converting inhibitors and related drugs (May 2011).

Atrial fibrillation management: Issues of concern (April 2011)

Readers comment on the management of atrial fibrillation (April 2011) and on angioedema due to angiotensin-converting inhibitors and related drugs (May 2011).

Managing Chronic Kidney Disease in Type 2 Diabetes in Family Practice

Diabetic nephropathy is the leading cause of stage 5 chronic kidney disease (CKD) and occurs in 1 in 9 persons with newly diagnosed type 2 diabetes. Screening should begin at the time of type 2 diabetes diagnosis to detect the presence of a decreased estimated glomerular filtration rate (GFR) and/or an elevated albumin excretion rate. The estimated GFR can be used to stage CKD, assess cardiovascular risk, and develop treatment strategies. A multifaceted treatment plan delivered using a collaborative care approach that fosters person self-management is important. Glucose-lowering agents should be selected based on renal function and titrated to achieve an A1c less than 7.0%. Lipid-lowering therapy with a statin should be utilized to achieve a low-density lipoprotein cholesterol less than 100 mg/dL, possibly less than 70 mg/dL. An angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or direct renin inhibitor, typically in combination with other antihypertensive therapies, is recommended for persons with hypertension, microalbuminuria/macroalbuminuria, and type 2 diabetes, as this approach has been shown to be renoprotective. Angiotensin-converting inhibitors have an additional benefit of improving cardiovascular outcomes in CKD.

Eplerenone, an aldosterone antagonist, reduces hospitalization and death in heart failure patients with nyha class II and an ejection fraction of less than 30%

BackgroundThe renin-angiotensin-aldosterone system (RAAS) playsan important role in pathophysiology of heart failure (HF).RAAS blockade with angiotensin converting (ACE)inhibitor slows the progression of HF and improves thesurvival [1]. However, ACE inhibitors do not block themineralocorticoid receptors, which are usually overexpressed in patients with heart failure, and promote car-diac fibrosis in experimental models [2]. The latter hasbeen confirmed by clinical trials that show a reduction inmortality and hospitalization of patients with severe heartfailure in New York Heart Association class III–IV(NYHA III–IV) treated with spironolactone [3], or inpatients after a myocardial infarction complicated by areduced systolic function treated with eplerenone [4].Thus, it is reasonable to suppose that the use of aldoste-rone antagonists might also delay the progression of heartfailure in patients with mild failure symptoms (NYHA II).SummaryThe Eplerenone in Mild Patients Hospitalization and Sur-vival Study in Heart Failure (EMPHASIS-HF) trial [5]randomized 2,737 patients aged more than 55 years withNYHA II heart failure and an ejection fraction of not morethan 35%, to receive either eplerenone (up to 50 mg daily)or placebo, in addition to recommended therapy. The pri-mary outcome was a composite of death from cardiovas-cular causes or a first hospitalization for heart failure. Deathand hospitalization for any cause were secondary outcomes.The trial was planned to last 48 months, but it wasstopped prematurely, after a median follow-up period of21 months, because of an overwhelming benefit in theeplerenone group. The primary outcome occurred in 18.3%of patients in the eplerenone group as compared with25.9% in the placebo group (hazard ratio, 0.63, 95% con-fidence interval (CI), 0.54–0.74, P\0.001). A total of12.5% of patients receiving eplerenone and 15.5% of thosereceiving placebo died (hazard ratio, 0.76, 95% CI,0.62–0.93, P = 0.008); hospitalizations for heart failureand any other cause were also reduced with eplerenone.Among adverse events, only hyperkalemia showed a sig-nificant difference between the two groups: serum potas-sium level exceeding 5.5 mmol per litre occurred in 11.8%of patients in the eplerenone group and in 7.2% of those inthe placebo group (P\0.001). The estimated number ofpatients who would need to be treated to prevent one pri-mary outcome per year was 19 (95% CI 15–27), and theestimated number needed to treat to postpone one death peryear, was 51 (95% CI 32–180).Strength of the study– It addresses a relevant clinical issue (it’s the first trialconducted among the patients in class NYHA II).– Rationale of the study: there is a strong pathophysio-logic background for the utility of aldosterone antag-onists in heart failure patients, and the previous studyalready confirms this observation [3, 4];

Hypertension as a Risk Factor: Is It Different in Ischemic Stroke and Acute Myocardial Infarction Comparative Cross-Sectional Study?

Objective. To assess differences in age of onset, hypertension duration, type of drug, treatment compliance, and salt-free diet compliance between patients with stroke and myocardial infarction. Patients and Methods. The study was conducted in 3 hospitals in Baghdad between June 2010 and June 2011. First group includes 81 stroke patients (36 females and 45 males), age ranges between (33–82 years). Second group includes 110 myocardial infarction patients (46 females and 64 males), ages ranges from (23–76 years). Results. Salt-free diet noncompliance was seen in 69% and 62% of Myocardial infarction and stroke groups, respectively. Silent hypertension was seen in 6.3% and 19.7% of myocardial infarction and stroke groups, respectively. Noncompliant on antihypertensive therapy was seen in 61%, 71%, and 48% of the total, myocardial infarction, and stroke groups, respectively. The drug type was 24% angiotensin converting enzyme inhibitor, 18.8% combined drugs, 16.2% Beta Blocker, 11% angiotensin 11 receptor blocker, 10.4% calcium channel blocker and 7.3% diuretic. In stroke group, the commonest drug was 23% angiotensin converting inhibitor and the least (5%) was angiotensin receptor blocker. In myocardial infarction group, the commonest drug was 25% Angiotensin Converting Inhibitor and the least (8%) was diuretic. Discussion and Conclusion. Silent hypertension was high in Iraq. Salt-free diet noncompliance was high in both groups; drug noncompliance was significantly higher in patients with myocardial infarction. Angiotensin 11 receptor blocker use was associated significantly with myocardial infarction more than in stroke.

Assessing renal function - searching for the perfect marker continues!

Assessing renal function - searching for the perfect marker continues!

Survival and echocardiographic evaluation of dogs with idiopathic dilated cardiomyopathy treated with carvedilol

Sixty dogs with idiopathic dilated cardiomyopathy were randomly treated with traditional therapy - digitalis, diuretics, angiotensin-converting inhibitors - (group A) or treated with these drugs plus carvedilol (group B). Echocardiographic variables were measured before and after 3, 13, 26, and 52 weeks of treatment or until death. Comparisons between groups and time were performed. No significant differences between groups were found in the most of the echocardiographic variables. The left ventricular end-systolic diameter indexed to body surface area (LVESDi) increased significantly in the group A dogs compared to the group B animals. The survival of groups A and B dogs were not different (P-value=0.1137). In conclusion, the stability of the LVESDi observed in the group treated with carvedilol may represent the beneficial effect over the ventricular remodeling.

Indicadores de calidad en el síndrome coronario agudo para el análisis del proceso asistencial pre e intrahospitalario

We present a map of 27 indicators to measure the care quality given to patients with acute coronary syndrome attended in the pre- and hospital area. This includes technical process indicators (registration of care intervals, performance of electrocardiogram, monitoring and vein access, assessment of prognostic risk, hemorrhage and in-hospital mortality, use of reperfusion techniques and performance of echocardiograph), pharmacological process indicators (platelet receptors inhibition, anticoagulation, thrombolysis, beta-blockers, angiotensin converting inhibitors and lipid lowering drugs) and outcomes indicators (quality scales of the care given and mortality).