Receiving Angiotensin-converting Enzyme Inhibitors Research Articles

Renin-Angiotensin System (RAS) Blockade Reduces Proteinuria in Heart Transplant Recipients: An Observational, Longitudinal Analysis

Purpose No data exist regarding the incidence of proteinuria and the impact of RAS blockade on proteinuria in heart transplant recipients. The International Society for Heart and Lung Transplantation does not address the evaluation or treatment of proteinuria following heart transplantation. We calculated the 3-year cumulative incidence of proteinuria in heart transplant recipients receiving and not receiving angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) therapy, as well as, the risk of proteinuria in those receiving an ACE-I/ARB. Methods and Materials This study is as an observational, longitudinal analysis of heart transplant recipients managed at the University of Colorado Hospital Heart Transplant Program beginning January 1, 2000 with continued care for a minimum of three years. Proteinuria was defined as a urine albumin/creatinine ratio ≥ 30 mg/g. Data variables, including urine albumin/creatinine ratio and ACE-I/ARB use, were collected at baseline and at years 1, 2, and 3 post-transplant. Comparison between groups involved a t -test for normally distributed variables. A difference-in-differences estimator was used to account for temporal proteinuria trends between 1 and 3 years between groups. Kaplan-Meier analyses were used to compare time to proteinuria. Results 56 heart transplant recipients met inclusion criteria; 21 (37.5%) did not receive an ACE-I/ARB and 35 (62.5%) received an ACE-I/ARB. The cumulative 3-year incidence of proteinuria was 15%. In the unadjusted analysis, the rate of change in development of proteinuria at 1 to 3 years was lower with ACE-I/ARB therapy compared to those not receiving these therapies (5.5% vs 10%, p Conclusions RAS blockade appears to reduce the development of proteinuria in heart transplant recipients.

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GenTAC registry report: gender differences among individuals with genetically triggered thoracic aortic aneurysm and dissection.

Previous data suggest women are at increased risk of death from aortic dissection. Therefore, we analyzed data from the GenTAC registry, the NIH-sponsored program that collects information about individuals with genetically triggered thoracic aortic aneurysms and cardiovascular conditions. We performed cross-sectional analyses in adults with Marfan syndrome (MFS), familial thoracic aortic aneurysm or dissection (FTAAD), bicuspid aortic valve (BAV) with thoracic aortic aneurysm or dissection, and subjects under 50 years of age with thoracic aortic aneurysm or dissection (TAAD <50 years). Women comprised 32% of 1,449 subjects and were 21% of subjects with BAV, 34% with FTAAD, 22% with TAAD <50 years, and 47% with MFS. Thoracic aortic dissections occurred with equal gender frequency yet women with BAV had more extensive dissections. Aortic size was smaller in women but was similar after controlling for BSA. Age at operation for aortic valve dysfunction, aneurysm or dissection did not differ by gender. Multivariate analysis (adjusting for age, BSA, hypertension, study site, diabetes, and subgroup diagnoses) showed that women had fewer total aortic surgeries (OR = 0.65, P < 0.01) and were less likely to receive angiotensin converting enzyme inhibitors (ACEi; OR = 0.68, P < 0.05). As in BAV, other genetically triggered aortic diseases such as FTAAD and TAAD <50 are more common in males. In women, decreased prevalence of aortic operations and less treatment with ACEi may be due to their smaller absolute aortic diameters. Longitudinal studies are needed to determine if women are at higher risk for adverse events.

Abstract P246: Heart Failure Performance Measures: Eligibility and Implementation In the Community

Background: The goal of heart failure (HF) performance measures is to improve the quality of care by enabling the practice implementation of guidelines. The guidelines define the population eligible for each measure. Little is known about the proportion of eligible patients to which these measures are applicable in the community. Methods: We determined the eligibility for and the adherence to performance measures and beta-blocker therapy in a community-based cohort of hospitalized patients diagnosed with incident HF from January 2005 to April 2011. Results: Of 294 inpatients with first ever HF (mean age 72 ± 15 years, 48% men), ejection fraction was measured in 292 (99%) patients during hospitalization. Of these, 97 (33%) had an ejection fraction &lt;40% and were thus candidates for beta-blocker and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) therapy. After excluding individuals with absolute contraindications, 71 patients were eligible to receive ACE inhibitors or ARB, and 86 were eligible to receive beta-blockers (figure). Among those eligible, 83% received ACEI/ARB and 91% received beta-blockers. Excluding those with relative contraindications, 70 patients were eligible for beta-blockers and 90% of them received it. Among the 139 (47%) individuals with HF and atrial fibrillation, 35 were eligible for warfarin and 49% received it. Of the 36 current smokers, 22 (61%) received cessation counseling during hospitalization. Conclusions: In the community, among patients hospitalized with HF eligible for performance measures, the implementation of performance measures varies by measure and can be improved for some. However, most community HF patients are not eligible for performance measures and other approaches should be identified to improve their care and outcomes.

Treatment patterns and risk factor control in patients with and without metabolic syndrome in cardiac rehabilitation

AimMetabolic syndrome (MetS) is a clustering of factors that are associated with increased cardiovascular risk. We aimed to investigate the proportion of patients with MetS in patients undergoing cardiac rehabilitation (CR), and to describe differences between patients with MetS compared to those without MetS with regard to (1) patient characteristics including demographics, risk factors, and comorbidities, (2) risk factor management including drug treatment, and (3) control status of risk factors at entry to CR and discharge from CR.MethodsPost-hoc analysis of data from 27,904 inpatients (Transparency Registry to Objectify Guideline-Oriented Risk Factor Management registry) that underwent a CR period of about 3 weeks were analyzed descriptively in total and compared by their MetS status.ResultsIn the total cohort, mean age was 64.3 years, (71.7% male), with no major differences between groups. Patients had been referred after a ST elevation of myocardial infarction event in 41.1% of cases, non-ST elevation of myocardial infarction in 21.8%, or angina pectoris in 16.7%. They had received a percutaneous coronary intervention in 55.1% and bypass surgery (coronary artery bypass graft) in 39.5%. Patients with MetS (n = 15,819) compared to those without MetS (n = 12,085) were less frequently males, and in terms of cardiac interventions, more often received coronary artery bypass surgery. Overall, statin use increased from 79.9% at entry to 95.0% at discharge (MetS: 79.7% to 95.2%). Patients with MetS compared to those without MetS received angiotensin converting enzyme inhibitors, angiotensin receptor blockers, oral antidiabetics, and insulin at entry and discharge more frequently, and less frequently clopidogrel and aspirin/clopidogrel combinations. Mean blood pressure was within the normal range at discharge, and did not differ substantially between groups (124/73 versus 120/72 mmHg). Overall, between entry and discharge, levels of total cholesterol, low density lipoprotein cholesterol, and triglycerides were substantially lowered, in particular in MetS patients. Thus, control rates of lipid parameters improved substantially, with the exception of high density lipoprotein cholesterol. Low density lipoprotein cholesterol rates <100 mg/dL increased from 38.7% at entry to 73.8% at discharge (MetS: from 39.4% to 74.6%) and triglycerides control rates (<150 mg/dL) from 58.1% to 70.4% (MetS: 43.7% to 62.2%). Physical fitness on exercise testing improved substantially in both groups.ConclusionPatients with and without MetS benefited substantially from the participation in CR, as their lipid profile, blood pressure, and physical fitness improved. Treatment effects were similar in the two groups.

Incidence of adverse events with telmisartan compared with ACE inhibitors: evidence from a pooled analysis of clinical trials

Telmisartan is indicated for the prevention of cardiovascular events in high-risk patients, based on comparable efficacy to the angiotensin-converting enzyme (ACE) inhibitor, ramipril, in the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET®) trial. However, tolerability must be considered when selecting treatments. This analysis compared the tolerability of telmisartan and ACE inhibitors using data pooled from 12 comparative, randomized studies involving 2564 telmisartan-treated patients and 2144 receiving ACE inhibitors (enalapril, lisinopril, or ramipril). Incidence rates of adverse events for the combined ACE inhibitor treatments and for telmisartan were similar (42.8% vs 43.9%, respectively) as were the rates of serious adverse events (1.8% vs 1.7% for telmisartan, respectively). Patients receiving ACE inhibitors had more cough (8.6% vs 2.6% with telmisartan, P < 0.0001). Results were similar irrespective of age, gender, or ethnicity. The adverse event of angioedema was observed in four patients (0.2%) receiving ACE inhibitors versus none with telmisartan (P = 0.043). There were small, numerical differences in serious adverse events. A total of 107 patients (5.0%) receiving ACE inhibitors and 93 patients (3.6%) receiving telmisartan discontinued treatment because of adverse events (P = 0.021); of these, 32.7% and 5.4%, respectively, were discontinuations due to cough (relative risk reduction of 88% [P < 0.0001] with telmisartan). Telmisartan and ACE inhibitors produced comparable blood pressure reductions at marketed doses. Telmisartan and ACE inhibitors are suitable for the prevention of cardiovascular events in high-risk patients, but telmisartan is better tolerated, particularly with regard to cough.

Relationship Between Hyperuricemia and Chronic Kidney Disease

Because approximately 70% of uric acid is excreted from the kidney, hyperuricemia occurs when renal function deteriorates. Until now, it has not been clear if the hyperuricemia seen in such renal diseases plays a role in the progression of renal disease. However, recent clinical studies show that the serum uric acid value is closely associated with hypertension in hyperuricemic patients (cross-sectional study), and also with the onset of hypertension (longitudinal study). Furthermore, one interesting report shows that treatment of hyperuricemia with allopurinol lowers blood pressure in juvenile essential hypertension patients with hyperuricemia. In addition, it is well known that hyperuricemia is closely associated with chronic kidney disease (CKD), is a risk factor for renal insufficiency in general populations, and is a poor prognostic factor of renal function in patients who also have IgA nephropathy. On the other hand, in intervention studies on hyperuricemia, the treatment of hyperuricemia with allopurinol in CKD has resulted in a fall in blood pressure and inhibition of the progression of renal damage. Conversely, the cessation of allopurinol treatment in CKD was followed by a rise in blood pressure and the development of renal damage. Furthermore, the rise of blood pressure and development of renal damage following cessation of allopurinol treatment are only seen in patients not receiving angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB). This suggests that the renin angiotensin (RA) system plays an important role in the development of hypertension and renal damage from hyperuricemia.

The Treatment of Pulmonary Hypertension in The Children with Chronic Obstructive Pulmonary Disease

Background and Aims: Improving the treatment of pulmonary hypertension in children with chronic obstructive pulmonary disease. Methods: A survey of 70 children, mean age 9,8±4,5 months with chronic obstructive pulmonary disease. Pulmonary artery pressure (?LA) was determined before treatment. The 45 patients (main group) received phosphodiesterase inhibitors (FOS) (2 mg/kg/day), the control group (25 children) - angiotensin-converting enzyme (ACE) (dose 0.5 mg/kg/day). In 30, 60, 90 days after initiation of therapy ?LA was defined again. Results: In children of main group ?LA was 31,7±2,3 mmHg, in the control group -31,5±1,98 mmHg. Patients treated with inhibitors of FOS in 30 days ?LA decreased to 9,2±0,7%, which was significantly better than children who received ACE inhibitors (p< 0,05). After 60 days in children treated with inhibitors of FOS ?LA was 24,47±1,9 mmHg. In the control group ?LA was 28,68±1,9 mmHg (p < 0,05). On the 90 day treatment in children of main group ?LA was 23,67±1,6 mmHg, in the control group - 26,98±2,3 mmHg. Conclusions: In children with chronic obstructive pulmonary disease to effectively reduce the pressure in the pulmonary artery, preventing the progression of hypoxia and fibrosis the phosphodiesterase inhibitors may be used in a dose of 2 mg/kg/day.

The Impact of Renin-Angiotensin-Aldosterone System Blockade on Heart Failure Outcomes and Mortality in Patients Identified to Have Aortic Regurgitation: A Large Population Cohort Study

The aim of this study was to investigate the effect of renin-angiotensin system blockade on outcomes in patients with aortic regurgitation (AR). Angiotensin-converting enzyme (ACE) inhibitors have the potential to reduce afterload, blunt left ventricular wall stress, and limit left ventricular dilation and hypertrophy. However, long-term studies have yielded inconsistent results, and very few have assessed clinical outcomes. The Health Informatics Centre dispensed prescription and morbidity and mortality database for the population of Tayside, Scotland, was linked through a unique patient identifier to the Tayside echocardiography database. Patients diagnosed with at least moderate AR from 1993 to 2008 were identified. Cox regression analysis was used to assess differences in all-cause mortality and cardiovascular (CV) and AR events (heart failure hospitalizations, heart failure deaths, or aortic valve replacement) between those treated with and without ACE inhibitors or angiotensin receptor blockers (ARBs). A total of 2,266 subjects with AR (median age 74 years; interquartile range: 64 to 81 years) were studied, with a mean follow-up period of 4.4 ± 3.7 years. Seven hundred and five patients (31%) received ACE inhibitor or ARB therapy. There were 582 all-cause deaths (25.7%). Patients treated with ACE inhibitors or ARBs had significantly lower all-cause mortality and fewer CV and AR events, with adjusted hazard ratios of 0.56 (95% confidence interval [CI]: 0.64 to 0.89; p < 0.01) for all-cause mortality, 0.77 (95% CI: 0.67 to 0.89; p < 0.01) for CV events, and 0.68 (95% CI: 0.54 to 0.87; p < 0.01) for AR events. This large retrospective study shows that the prescription of ACE inhibitors or ARBs in patients with moderate to severe AR was associated with significantly reduced all-cause mortality and CV and AR events. These data need to be confirmed by a prospective randomized controlled outcome trial.

A Propensity-Matched Study of the Comparative Effectiveness of Angiotensin Receptor Blockers Versus Angiotensin-Converting Enzyme Inhibitors in Heart Failure Patients Age ≥65 Years

The comparative effectiveness of angiotensin-converting enzyme (ACE) inhibitors versus angiotensin II type 1 receptor blockers (ARBs) in real-world older heart failure (HF) patients remains unclear. Of the 8,049 hospitalized HF patients aged ≥ 65 years discharged alive from 106 Alabama hospitals, 4,044 received discharge prescriptions of either ACE inhibitors (n = 3,383) or ARBs (n = 661). Propensity scores for ARB use, calculated for each of 4,044 patients, were used to match 655 (99% of 661) patients receiving ARBs with 661 patients receiving ACE inhibitors. The assembled cohort of 655 pairs of patients was well balanced on 56 baseline characteristics. During >8 years of follow-up, all-cause mortality occurred in 63% and 68% of matched patients receiving ARBs and ACE inhibitors, respectively (hazard ratio [HR] associated with ARB use 0.86, 95% confidence interval [CI] 0.75 to 0.99, p = 0.031). Among the 956 matched patients with data on the left ventricular ejection fraction (LVEF), the association between ARB (vs ACE inhibitor) use was significant in only 419 patients with LVEFs ≥ 45% (HR 0.65, 95% CI 0.51 to 0.84, p = 0.001) but not in the 537 patients with LVEFs < 45% (HR 1.00, 95% CI 0.81 to 1.23, p = 0.999; p for interaction = 0.012). HRs for HF hospitalization associated with ARB use were 0.99 (95% CI 0.86 to 1.14, p = 0.876) overall, 0.80 (95% CI 0.63 to 1.03, p = 0.080) in those with LVEFs ≥45%, and 1.14 (95% CI 0.91 to 1.43, p = 0.246) in those with LVEFs <45% (p for interaction = 0.060). In conclusion, in older HF patients with preserved LVEFs, discharge prescriptions of ARBs (vs ACE inhibitors) were associated with lower mortality and a trend toward lower HF hospitalization, findings that need replication in other HF populations.

Acute Kidney Injury After Cardiac Surgery in Infants and Children: Evaluation of the Role of Angiotensin-Converting Enzyme Inhibitors

Children with congenital heart disease who undergo cardiac surgery are vulnerable to acute kidney injury (AKI). This study sought to evaluate the role of angiotensin-converting enzyme (ACE) inhibitors and other nephrotoxic medications in the risk for the development of AKI in neonates and children undergoing cardiac surgery. A retrospective review of all patients younger than 2 years admitted to the cardiac intensive care unit after cardiac surgery from March 2007 to September 2008 was conducted. Patients were included in the review if they received furosemide alone or in combination with an ACE inhibitor. Creatinine clearance was calculated, and the patient's maximal degree of AKI was classified by pRIFLE. A P value less than 0.05 was considered significant. Of the 319 patients who met the inclusion criteria, 149 (47%) received furosemide therapy alone and 170 (53%) received a combination of furosemide and an ACE inhibitor. Patients in the furosemide-only group (age, 5 months) were older than the patients who received both furosemide and an ACE inhibitor (age, 3.8 months; P = 0.024). Despite statistically higher Aristotle scores in the ACE-inhibitor group, the intraoperative variables did not differ between the two groups. Postoperatively, the ACE-inhibitor group had a decreased creatinine clearance (55.3 ml/min/1.73 m(2)) compared with the furosemide group (64.4 ml/min/1.73 m(2); P = 0.015) and an increased incidence of a pRIFLE maximal score of "F" (odds ratio [OR], 1.75; P = 0.033). However, after adjustment for additional risk factors, no difference in the occurrence of AKI resulted (OR, 0.939; P = 0.85) when patients received an ACE inhibitor. More than half of the study population received ACE inhibitors, but this treatment was not associated with an increase in AKI.

Engagement of Renin-Angiotensin System in Prostate Cancer

Angiotensin II (Ang-II) plays a role not only as a vasoconstrictor in controlling blood pressure and electrolyte and fluid homeostasis, but also as a mitogenic factor through the Ang-II type-1 (AT1) receptor in cardiovascular cells. Since a low prevalence of cancer in hypertensive patients receiving angiotensin converting enzyme inhibitors has been reported, the molecular mechanisms of the renin-angiotensin system (RAS) in cancer cells have been elucidated. Interestingly, there is increasing evidence that the RAS is implicated in the development of prostate cancer. As previously reported, AT1 receptor blockers (ARBs), a class of antihypertensive agent, have the potential to inhibit the growth of prostate cancer cells and tumors through the AT1 receptor. This review highlights that the RAS plays a potential role in various aspects of prostate cancer, and ARBs could be useful for treatment of prostate cancer or its chemoprevention.

Age Dependendent Efficacy of Ace Inhibitors Among Chinese Cardiovascular Patients During Hospitalization Phase

Objective: Cardiac failure is a global burden among cardiovascular diseases, and major cause of morbidity and mortality especially among elderly age group. Angiotensin Converting Enzyme(ACE) inhibitors, remained the choice of treatment as they inhibit the renin angiotensin aldosterone system along with reduction in levels of pro-inflammatory cytokines, both of them are key factors in progression and complications of heart failure. The aim of this study was to rule out the effect of aging and efficacy of ACE inhibitor, Captopril, among Chinese cardiovascular patients with acute myocardial infarction (MI) during the hospitalization phase of therapy. Material &amp; Methods: Randomized control trial at hospital of Tongji Medical College Wuhan, China over a period of more than 1 year from April 2009 till July 2010 recruiting patients in two stages. A total of 260 patients with mean age 65±8 years were recruited. All suffered from first time myocardial infarction and arrived in Cardiac emergency within 72 hours of the event. The participants were then randomly divided in study and control groups which were then further classified in sub-groups depending upon their age. Study group received ACE inhibitor Captopril in addition to standardized therapy while control group just received the conventional therapy for the event. Statistical analyses were done to formulate the corre-lation between multi-variables. Results: Participants were divided in Study group (N=150) (A and C, Young and Old) and the control group (N=110) (B and D, Young and Old). Survival rate was better among elderly on captopril in comparison to younger ones during the hospitalization. The Systolic blood pressure among study group was significantly lower than control group (132.9±16.3mmHg/84.7 ±9.1mmHg vs. 147.1±17.4mmHg/85.1 ±10.9mmHg, P&lt;0.05).Patient’s survival was statistically significant with respect to age (P&lt;0.001). Conclusion: Treatment with Captopril is definitely associated with improved short as well as long term cardiac prognosis and markedly. Captopril therapy is associated with improved long term prognosis and reduced cardiac mortality during the hospitalization phase of the therapy and recovery period. But the most significant finding is that the increased survival after taking Captopril was higher in elderly patients than in younger patients. ACE inhibitors like Captopril in proper dosage play a real vital beneficial role among elderly patients as compared to the younger ones, but still there is need to recruit a large cohort in different ethnic groups with different genetic makeup. Key Words: Myocardial infarction (MI); Ace-inhibitor; Aging DOI: 10.3126/ajms.v1i2.2947Asian Journal of Medical Sciences 1 (2010) 59-63

A Case of Angiotensin Converting Enzyme Inhibitor-Induced Systemic Lupus Erythematosus

Drug-induced lupus erythematosus is defined as a lupus-like syndrome related to continuous drug exposure which resolves after discontinuation of the offending drug. Here we report a case of a 70-year-old man who developed drug-induced lupus erythematosus after receiving angiotensin converting enzyme inhibitor medication for unstable angina pectoris, for 5 years. He was hospitalized with arthralgia, edema, and newly developed pleural effusion. The serum analysis revealed an elevated level of antinuclear

Beta-Blockade Restores Muscle Sympathetic Rhythmicity in Human Heart Failure

Muscle sympathetic nerve firing rate increases as chronic heart failure (CHF) progresses, yet its oscillation, particularly within the frequency range encompassing 0.13 Hz, diminishes. The current study tested the hypothesis that chronic therapy with lipophilic β-adrenoceptor antagonists augments the modulation of muscle sympathetic nerve activity variability (MSNAV) at this frequency range. In 21 CHF angiotensin converting enzyme (ACE) inhibitor-treated patients (age: 53 ± 2, ejection fraction: 20 ± 2%), MSNA was recorded before and after 4 months of β-blockade with either metoprolol (up to 50mg b.i.d.) or carvedilol (up to 25mg b.i.d.). Harmonic MSNAV was assessed by coarse graining spectral analysis. Both drugs lowered heart rate similarly (-13 ± 2 beats/min; P < 0.001) but neither affected MSNA burst frequency (-7 ± 4 bursts/min, not significant). Before β-blockade, harmonic MSNA power in the region encompassing 0.13 Hz was essentially absent. Beta-blockade increased the mean values for total power (from 0.00 to 0.50 Hz; 5.2 ± 0.8 to 6.8 ± 1.2U(2); P < 0.001) and for harmonic MSNA spectral power across the 0.1-0.22 Hz frequency range (from 0.48 ± 0.10 to 1.50 ± 0.32 U(2), F = 12.2; P < 0.001). Both carvedilol and metoprolol had a similar effect. In patients with CHF receiving ACE inhibitors, adding a β-adrenoceptor antagonist restores low and high frequency harmonic oscillations in MSNA. Beta-1 antagonism is sufficient to achieve this response. Augmented modulation of sympathetic outflow could contribute to the beneficial effects of β-blockade in CHF on sudden death and disease progression.

O uso de inibidores da enzima conversora de angiotensina e sua relação com eventos no pós-operatório de cirurgia de revascularização miocárdica

Angiotensin-converting enzyme (ACE) inhibitors reduce the chance of death, myocardial infarction (MI) and cerebrovascular accident (CVA) in patients with coronary disease. However there is no consensus as to its indication in patients undergoing coronary artery bypass grafting (CABG). To assess the relationship between preoperative use of ACE inhibitors and clinical outcomes after CABG. Retrospective cohort study. We included data from 3,139 consecutive patients undergoing isolated CABG in Brazilian tertiary care hospital between January 1996 and December 2009. Follow-up was until discharge or death. Clinical outcomes after surgery were analyzed between users and nonusers of ACE inhibitors preoperatively. Fifty-two percent (n=1,635) of patients received ACE inhibitors preoperatively. The use of ACE inhibitors was an independent predictor of need for inotropic support (OR 1.24, 95% CI 1.01 to 1.47, P = 0.01), acute renal failure (OR 1.23, 95% CI 1.01 to 1.73, P = 0.04) and progression to atrial fibrillation (OR 1.32, 95% CI 1.02 to 1.7, P = 0.03) postoperatively. The mortality rate among patients receiving or not preoperative ACE inhibitors was similar (10.3% vs. 9.4%, P = 0.436), as well as the incidence of myocardial infarction and stroke (15.6% vs. 15.0%, P = 0.694 and 3.4% vs. 3.5%, P = 0.963, respectively). The use of preoperative ACE inhibitors was associated with increased need for inotropic support and higher incidence of acute renal failure and postoperative atrial fibrillation, not associated with increased rates of myocardial infarction, stroke or death.

Impact of therapy with statins, beta-blockers and angiotensin-converting enzyme inhibitors on plasma myeloperoxidase in patients with coronary artery disease

The present study investigated whether therapy with statins, beta-blockers and angiotensin-converting enzyme (ACE) inhibitors on admission affects the plasma level of myeloperoxidase (MPO) in patients with coronary artery disease (CAD). This study included a consecutive series of 680 patients with angiographically confirmed CAD: 382 patients with stable CAD, 107 patients with unstable angina and 191 patients with ST-segment elevation acute myocardial infarction. Blood samples for MPO measurement were taken before angiography prior to heparin administration. On admission, 316 patients were receiving statins, 432 patients were receiving beta-blockers and 354 patients were receiving ACE inhibitors. MPO level was: 65.5 [48.8-101.6] μg/L among patients on statin therapy versus 86.7 [56.0-159.9] μg/L among patients without statin therapy (P<0.001); 68.1 [50.1-105.1] μg/L among patients on beta-blocker therapy versus 97.3 [56.0-181.9] μg/L among patients without beta-blocker therapy (P<0.001) and 65.5 [49.2-102.0] μg/L among patients receiving ACE inhibitors versus 92.0 [56.1-171.1] μg/L among patients not receiving ACE inhibitors on admission (P<0.001). The MPO-lowering effect of these drugs was observed only in patients with acute coronary syndrome but not in patients with stable CAD. The multivariable analysis, adjusting for cardiovascular risk factors, clinical variables and concomitant therapy identified beta-blockers on admission as an independent correlate of lower MPO levels (P=0.016). In patients with symptomatic CAD, beta-blocker therapy on admission was independently associated with lower levels of plasma MPO. Pre-admission therapy with statins, beta-blockers or ACE inhibitors reduced MPO levels in patients with acute coronary syndromes, but not in patients with stable CAD.

Higher activity of peripheral blood angiotensin-converting enzyme is associated with later-onset of Alzheimer's disease

According to the amyloid theory, the balance between amyloid-β (Aβ) production and degradation is key to the development of Alzheimer 's disease (AD). Several enzymes including angiotensin-converting enzyme (ACE) have been reported as candidate enzymes involved in Aβ degradation. We previously identified the relationship between ACE activity and AD. We present a comparison between AD and non-AD patients in the inpatient care unit of a geriatric hospital and have included the onset age and age at sampling in the comparison. We performed a colorimetric assay to determine ACE activity and a sandwich enzyme-linked immunosorbent assay (ELISA) to quantify blood plasma Aβ 1–40 and 1–42 levels. Our 676 subjects, none of whom had received ACE inhibitor medication, included 147 AD patients. Clinical diagnoses were carried out to separate subjects into the AD and non-AD groups on the basis of the criteria of the International Classification of Diseases (ICD-10) and the Consortium to Establish a Registry for AD (CERAD). We found that the later the onset of AD, the higher the ACE activity, but there was no correlation between ACE activity and the Aβ level in peripheral blood. In this report, we suggest that peripheral ACE activity may affect the age at AD onset.

Lisinopril‐Induced Nightmares

Drug‐induced nightmares have been reported in the literature and are a known adverse effect of certain antihypertensive agents such as α‐agonists and β‐blockers. Data are limited, however, on the association of this adverse effect with angiotensin‐converting enzyme (ACE) inhibitors. We describe a 63–year‐old, obese woman, with no history of illicit drug abuse, alcohol abuse, or psychiatric illness, who developed nightmares after starting lisinopril 10 mg/day for blood pressure control. The drug was discontinued, triamterene‐hydrochlorothiazide was started, and her nightmares ceased. One year later, the patient continued to have no complaints of nightmares. At that time, however, her blood pressure was slightly elevated. Triamterene was discontinued, and lisinopril was restarted at a lower dose of 5 mg/day in addition to hydrochlorothiazide 25 mg/day. Her nightmares returned; however, the patient decided to continue taking the lisinopril and tolerate the nightmares. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6) between the patient's development of nightmares and lisinopril therapy. The exact mechanism by which ACE inhibitors cause this drug reaction is not known. Clinicians should be aware of this potential adverse effect when monitoring patients receiving ACE inhibitors.

Section 5: Management of Asymptomatic Patients with Reduced Left Ventricular Ejection Fraction

Section 5: Management of Asymptomatic Patients with Reduced Left Ventricular Ejection Fraction