19 research outputs found
How to select a drug for the long-term treatment of chronic heart failure
Abstract
First-line drugs for the treatment of chronic congestive heart failure should produce immediate symptomatic benefit, improve exercise tolerance, and thereby improve the quality of life. They should preferentially be active as monotherapy or at least reduce the need for comedication. The drugs must be safe and well tolerated by patients and change, in the end, the natural history of the disease, so that sudden death will be prevented and life expectancy improves. None of the currently available drugs satisfies all these criteria. Diuretics, digitalls, converting-enzyme inhibitors, and ibopamine come close to the described ideal
Congenitale dopamine Beta-hydroxylase deficientie : een nieuw orthostatisch syndroom
Sinds decennia wordt chronische autonome dysfunctie herkend
als een belangrijk klinisch probleem hoewel het relatief
zeldzaam is. Bradbury en Eggleston beschreven in 1925
het sindsdien naar hen genoemde syndroom als "primary
postural hypotension", ook bekend als . "idiopathische
orthostatische hypotensie" en "idiopathische autonome
dysfunctie" (1). Sindsdien zijn medici zich bewust van het
feit, dat een groot aantal medicamenten en systeemziekten
het door Bradbury en Eggleston beschreven syndroom kunnen
nabootsen. De combinatie van orthostatische hypotensie,
hypohydrosis, een relatief gefixeerde polsfrequentie,
impotentie en dysfunctie van de urinewegen en het maagdarmkanaal
is een complex van symptomen, dat gemakkelijk
herkend wordt als dysfunctie van het autonome zenuwstelsel
Congenitale dopamine Beta-hydroxylase deficientie : een nieuw orthostatisch syndroom
Sinds decennia wordt chronische autonome dysfunctie herkend
als een belangrijk klinisch probleem hoewel het relatief
zeldzaam is. Bradbury en Eggleston beschreven in 1925
het sindsdien naar hen genoemde syndroom als "primary
postural hypotension", ook bekend als . "idiopathische
orthostatische hypotensie" en "idiopathische autonome
dysfunctie" (1). Sindsdien zijn medici zich bewust van het
feit, dat een groot aantal medicamenten en systeemziekten
het door Bradbury en Eggleston beschreven syndroom kunnen
nabootsen. De combinatie van orthostatische hypotensie,
hypohydrosis, een relatief gefixeerde polsfrequentie,
impotentie en dysfunctie van de urinewegen en het maagdarmkanaal
is een complex van symptomen, dat gemakkelijk
herkend wordt als dysfunctie van het autonome zenuwstelsel
Comparison of N-terminal pro-atrial natriuretic peptide and atrial natriuretic peptide in human plasma as measured with commercially available radioimmunoassay kits
Atrial natriuretic peptide (ANP) has become an important parameter for assessing the condition of patients with cardia disease. Recently, attention has also focused on N-terminal pro-atrial natriuretic peptide (NtproANP) in this context. NtproANP circulates in plasma in higher concentration, is more stable ex vivo, and may be a better parameter for cardiac function over time. We have evaluated a new commercially available radioimmunoassay kit for NtproANP and compared results and method withthose of ANP measurements. The NtproANP kit was found to be reliable and easy to use (no plasma extraction step is necessary), with good reproducibility (coefficients of variation 7-15%). Normal values in 15 healthy laboratory workers, 25 healthy elderly subjects and 25 patients with heart failure were 207 ± 70, 368 ± 134 and 1206 ± 860 pmol/l, respectively, 8.3, 11.8 and 13.0 times higher, respectively, than corresponding ANP concentrations. NtproANP correlated well with ANP (r 0.64-0.78). We conclude that plasma NtproANP measurement may be a good alternative to plasma ANP measurement: technically, it is easier to perform, and NtproANP is more stable in plasma. Whether NtproANP is a better diagnostic and prognostic parameter than ANP remains to be further established
Beneficial effects of conversion from cyclosporine to azathioprine on fibrinolysis in renal transplant recipients
Cyclosporin A (CsA) has been implicated as one of the factors contributing
to the high cardiovascular morbidity and mortality after renal
transplantation. This may be mediated by either a high prevalence of
conventional risk factors for atherosclerosis, such as hypertension,
hypercholesterolemia, and diabetes mellitus, or by impairment of the
fibrinolytic activity evoked by CsA, possibly through interference with
prostanoid metabolism. We therefore assessed the impact of conversion of
CsA to azathioprine immunosuppressive treatment on parameters of
fibrinolytic activity and plasma concentration of the prostanoids
prostaglandin E2 and thromboxane B2 in 18 stable renal transplant
recipients. During CsA, mean arterial pressure and serum creatinine were
significantly higher than during azathioprine (116+/-15 mm Hg versus
106+/-13 mm Hg, P=0.0003; and 147+/-34 micromol/L versus 127+/-35
micromol/L, P=0.002; mean+/-SD). On conversion, the plasma tissue
plasminogen activator activity increased from 1.2 (1.1 to 1.7; median, 95%
CI) to 1.8 (1.6 to 2.0) IU/mL (P=0.011), without a significant change of
the plasminogen activator antigen concentration. This was associated with
a substantial decrease in plasminogen activator inhibitor-1 activity from
10.4 (8.5 to 16.7) to 6.4 (5.6 to 9.2) IU/mL (P=0.009). Furthermore,
plasma levels of prostaglandin E2 and thromboxane B2 markedly decreased
(from 9.7 [7.4 to 12.9] to 4.6 [4.3 to 8.1] pg/mL, P=0.0006; and from
106.1 [91.7 to 214.2] to 70.2 [50.3 to 85.6] pg/mL, P=0.002,
respectively). During CsA, but not azathioprine, plasma tissue plasminogen
activator antigen and plasminogen activator inhibitor-1 levels correlated
significantly with prostaglandin E2 (r=0.53, P=0.02; and r=0.60, P=0.008,
respectively), and thromboxane B2 (r=0.75, P=0.0001; and r=0.77, P=0.0001,
respectively) levels. In conclusion, CsA induced substantial impairment of
fibrinolytic activity, which recovered after conversion to azathioprine.
The impaired fibrinolysis observed during CsA treatment may be caused by
modulation of eicosanoid production or metabolism in vascular endothelial
cells and possibly contributes to the high incidence of cardiovascular
disease after kidney transplantation
Human renal and systemic hemodynamic, natriuretic, and neurohumoral responses to different doses of L-NAME
Experimental evidence indicates that the renal circulation is more
sensitive to the effects of nitric oxide (NO) synthesis inhibition than
other vascular beds. To explore whether in men the NO-mediated vasodilator
tone is greater in the renal than in the systemic circulation, the effects
of three different intravenous infusions of NG-nitro-L-arginine methyl
ester (L-NAME; 1, 5, and 25 microg. kg-1. min-1 for 30 min) or placebo on
mean arterial pressure (MAP), systemic vascular resistance (SVR), renal
blood flow (RBF), renal vascular resistance (RVR), glomerular filtration
rate (GFR), and fractional sodium and lithium excretion (FENa and FELi)
were studied in 12 healthy subjects, each receiving randomly two of the
four treatments on two different occasions. MAP was measured continuously
by means of the Finapres device, and stroke volume was calculated by a
model flow method. GFR and RBF were estimated from the clearances of
radiolabeled thalamate and hippuran. Systemic and renal hemodynamics were
followed for 2 h after start of infusions. During placebo, renal and
systemic hemodynamics and FENa and FELi remained stable. With the low and
intermediate L-NAME doses, maximal increments in SVR and RVR were similar:
20.4 +/- 19.6 and 23.5 +/- 16.0%, respectively, with the low dose and 31.4
+/- 26.7 and 31.2 +/- 14.4%, respectively, with the intermediate dose
(means +/- SD). With the high L-NAME dose, the increment in RVR was
greater than the increment in SVR. Despite a decrease in RBF, FENa and
FELi did not change with the low L-NAME dose, but they decreased by 31.2
+/- 11.0 and 20.2 +/- 6.3%, respectively, with the intermediate dose and
by 70.8 +/- 8.1 and 31.5 +/- 15.9% with the high L-NAME dose,
respectively. It is concluded that in men the renal circulation is not
more sensitive to the effects of NO synthesis inhibition than the systemic
circulation and that the threshold for NO synthesis inhibition to produce
antinatriuresis is higher than the threshold level to cause renal
vasoconstriction
Stent placement for renal arterial stenosis: where do we stand? A meta-analysis
PURPOSE: To perform a meta-analysis of renal arterial stent placement in
comparison with renal percutaneous transluminal angioplasty (PTA) in
patients with renal arterial stenosis. MATERIALS AND METHODS: Studies
dealing with renal arterial stent placement (14 articles; 678 patients)
and renal PTA (10 articles; 644 patients) published up to August 1998 were
selected. A random-effects model was used to pool the data. RESULTS: Renal
arterial stent placement proved highly successful, with an initial
adequate performance in 98% and major complications in 11%. The overall
cure rate for hypertension was 20%, whereas hypertension was improved in
49%. Renal function improved in 30% and stabilized in 38% of patients. The
restenosis rate at follow-up of 6-29 months was 17%. Stent placement had a
higher technical success rate and a lower restenosis rate than did renal
PTA (98% vs 77% and 17% vs 26%, respectively; P <.001). The complication
rate was not different between the two treatments. The cure rate for
hypertension was higher and the improvement rate for renal function was
lower after stent placement than after renal PTA (20% vs 10% and 30% vs
38%, respectively; P <.001). CONCLUSION: Renal arterial stent placement is
technically superior and clinically comparable to renal PTA alone
Hemodynamic changes, plasma catecholamine responses, and echocardiographically detected contractile reserve during two different dobutamine-infusion protocols
We studied hemodynamic changes, catecholamine responses, and the occurrence of improved wall thickening by echocardiography during two different dobutamine-infusion protocols. Forty-three patients were studied by using a stepwise incremental dobutamine dose-infusion protocol (10-40 μg/kg/min, 3-min intervals); a subgroup of 11 patients also underwent a continuous dobutamine-infusion protocol (10 μg/kg/min for 12 min) in random order. No patient used β-blockers. At 3-min intervals, blood pressure, heart rate, and plasma concentrations of dobutamine, epinephrine, and norepinephrine were measured. The echocardiographic improvement of wall thickening was analyzed only in paired protocols by visual assessment in left ventricular regions with normal wall motion at rest. The mean heart rate increased in the continuous and stepwise protocols from 73 to 99 and 74 to 132 beats/min. There was no significant change in blood pressure response between the two protocols. The mean plasma dobutamine concentrations during the continuous and stepwise protocols at 0, 3, 6, 9, and 12 min were 0/0; 31/38; 80/203; 106/448; and 120/692 ng/ml, respectively. In each patient, a response curve was constructed for the plasma dobutamine concentration versus heart rate. The heart rate increment and dobutamine concentration at which wall thickening was detected were similar with both protocols (14 ± 5 vs. 12 ± 7 beats/min) and (8) ± 40 vs. 92 ± 48 ng/ml; mean ± SD). Wall thickening was noted in two of 11 patients b
Time Course and Mechanism of Myocardial Catecholamine Release During Transient Ischemia In Vivo
BACKGROUND: Elevated concentrations of norepinephrine (NE) have been
observed in ischemic myocardium. We investigated the magnitude and
mechanism of catecholamine release in the myocardial interstitial fluid
(MIF) during ischemia and reperfusion in vivo through the use of
microdialysis. METHODS AND RESULTS: In 9 anesthetized pigs, interstitial
catecholamine concentrations were measured in the perfusion areas of the
left anterior descending coronary artery (LAD) and the left circumflex
coronary artery. After stabilization, the LAD was occluded for 60 minutes
and reperfused for 150 minutes. During the final 30 minutes, tyramine (154
nmol. kg(-1). min(-1)) was infused into the LAD. During LAD occlusion, MIF
NE concentrations in the ischemic region increased progressively from 1.
0+/-0.1 to 524+/-125 nmol/L. MIF concentrations of dopamine and
epinephrine rose from 0.4+/-0.1 to 43.9+/-9.5 nmol/L and from <0.2
(detection limit) to 4.7+/-0.7 nmol/L, respectively. Local uptake-1
blockade attenuated release of all 3 catecholamines by >50%. During
reperfusion, MIF catecholamine concentrations returned to baseline within
120 minutes. At that time, the tyramine-induced NE release was similar to
that seen in nonischemic control animals despite massive infarction.
Arterial and MIF catecholamine concentrations in the left circumflex
coronary artery region remained unchanged. CONCLUSIONS: Myocardial
ischemia is associated with a pronounced increase of MIF catecholamines,
which is at least in part mediated by a reversed neuronal reuptake
mechanism. The increase of MIF epinephrine implies a (probably neuronal)
cardiac source, whereas the preserved catecholamine response to tyramine
in postischemic necrotic myocardium indicates functional integrity of
sympathetic nerve terminals