Angiotensin-converting enzyme inhibition with quinapril improves endothelial vasomotor dysfunction in patients with coronary artery disease. The TREND (Trial on Reversing ENdothelial Dysfunction) Study.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors may exert some of their benefits in the therapy of hypertension, congestive heart failure, and acute myocardial infarction by their improvement of endothelial dysfunction. TREND (Trial on Reversing ENdothelial Dysfunction) investigated whether quinapril might improve endothelial dysfunction in normotensive patients with coronary artery disease and no heart failure, cardiomyopathy, or major lipid abnormalities so that confounding variables that affect endothelial dysfunction could be minimized. METHODS AND RESULTS: Using a double-blind, randomized, placebo-controlled design, we measured the effects of quinapril (40 mg daily) on coronary artery diameter responses to acetylcholine using quantitative coronary angiography. The primary response variable was the net change in the acetylcholine-provoked constriction of target segments between the baseline (prerandomization) and 6-month follow-up angiograms. The constrictive responses to acetylcholine were comparable in the placebo (n = 54) and quinapril (n = 51) groups at baseline. After 6 months, only the quinapril group showed significant net improvement in response to incremental concentrations of acetylcholine (4.5 +/- 3.0% [mean +/- SEM] versus -0.1 +/- 2.8% at 10(-6) mol/L and 12.1 +/- 3.0% versus -0.8 +/- 2.9% at 10(-4) mol/L, quinapril versus placebo, respectively; overall P = .002). CONCLUSIONS: TREND shows that ACE inhibition with quinapril improved endothelial dysfunction in patients who were normotensive and who did not have severe hyperlipidemia or evidence of heart failure. These benefits of ACE inhibition are likely due to attenuation of the contractile effects and superoxide-generating effects of angiotensin II and to enhancement of endothelial cell release of nitric oxide secondary to diminished breakdown of bradykinin.

Primary cardiac tumors. Diagnosis and management in 14 cases.

In our experience over a 10-year period at Westchester County Medical Center (Valhalla, NY), we diagnosed 11 left atrial myxomas and three primary cardiac malignancies in ten females and four males, aged 18-74 years. Two-dimensional echocardiography enabled the correct diagnosis of these lesions. Detailed characteristics of the cardiac tumors were provided by magnetic resonance imaging (MRI) scanning in five patients. Two of three malignancies were only biopsied; the myxomas were completely excised. We emphasized removal of tumor and its attachments to the atrial wall, accomplished by left or biatrial incision, full-thickness excision of the area of attachment, and pericardial patch closure of the atrial or free-wall defects. Associated procedures included mitral valve repair (three) and coronary artery bypass grafting (two). There was no mortality associated with the surgery. Two patients with malignancy died three and 36 months after surgery; a third is alive at 30 months after surgery. No patients with myxoma has had recurrence from 16 to 100 months. Preoperative diagnosis of cardiac tumors is enhanced by MRI scanning and may help in planning the surgical procedure. Complete and timely removal of these tumors contributes to long-standing patient survival.

Identification of calcified intracardiac lesions using gradient echo MR imaging.

Gradient echo signal imaging (GEI) has expanded the clinical role of magnetic resonance (MR) imaging of the heart. The role of GEI to evaluate intracardiac calcified lesions was studied. All patients were imaged with both conventional spin echo (SE) techniques and GEI. The GEI demonstrated that calcific cardiac lesions exhibit magnetic susceptibility differences and produce marked hypointensity throughout the calcified area. All patients had echocardiographic and fluoroscopic evidence of cardiac calcification and surgical confirmation of calcified lesions. The SE MR was unable to define the intracardiac calcification. Gradient echo imaging may be a helpful adjunct in the complete definition of intracardiac calcific lesions. When profound signal void areas are detected on cardiac GEI studies, calcification should be suspected.

MR imaging in the definition of coronary artery anomalies.

Coronary angiography remains the standard imaging technique to study coronary artery anatomy. Coronary artery aneurysms and fistulas are often incompletely visualized with routine angiography. Magnetic resonance (MR) imaging of such coronary anomalies is presented. The MR images improve the preoperative assessment of patients with coronary artery aneurysms and fistulas.

Postoperative evaluation of ascending aortic prosthetic conduits by magnetic resonance imaging.

Operative repair of ascending thoracic aortic dissection and aneurysm often involves the placement of prosthetic aortic conduits and stents with wrapping of the native aorta around the prosthetic device. Postoperative assessment has been clinical because of the absence of an adequate noninvasive imaging modality and a reluctance to perform invasive contrast aortography. Magnetic resonance imaging was performed on ten patients after operative placement of a prosthetic ascending aortic graft. The MR images were reviewed and a grading system was devised based on appearance of the operative site. An increase in MR signal was noted in some patients between the graft and wrapped native vessel. In 20 percent of patients vascular lumen compromise was noted. Magnetic resonance imaging offers a noninvasive technique to assess postoperative complications and offers a viable alternative to invasive contrast aortography.