[Mean systolic annular velocity and strain score index: new and non-invasive parameters for the evaluation of acute myocardial infarction patients]. / Ortalama sistolik anüler velosite ve strain skor indeksi: akut miyokart enfarktüsü hastalarinin degerlendirilmesinde yeni ve invazif olmayan parametreler.

OBJECTIVE: To evaluate the diagnostic value of mean annular velocity (MAV) and strain score index (SSI) for determination of the left ventricular systolic dysfunction in patients with first acute myocardial infarction (AMI). METHODS: Seventy-one patients (55 male, mean age: 59+/-12 years) with first acute ST-elevation myocardial infarction and 30 healthy subjects were included in this cross-sectional and observational study. Echocardiography with tissue Doppler and strain analysis was performed during initial hospital admission. Peak systolic myocardial velocities were recorded from 4 different sites on the mitral annulus. A MAV value was calculated and the peak systolic strain values of 12 segments were measured and a mean SSI was calculated. ROC curve analysis was used in order to determine cut-off values for MAV and SSI. RESULTS: The patients with AMI had a significantly reduced MAV compared with healthy subjects (5.52+/-1.78 cm/s vs 9.80+/-1.13 cm/s, p<0.001). In ROC analysis, a cut-off value of 8.41 cm/s (AUC 0.915, 95%CI 0.887-0.952, p<0.001) for MAV differentiated AMI patients from controls with 97.2% sensitivity and 93.3% specificity. The patients with AMI have also decreased SSI (11.23+/-2.83 vs 19.11+/-2.05, p<0.001). A cut-off value of 15.35% differentiated AMI patients from controls with 94.4% sensitivity and 100% specificity (ROC AUC 0.945, 95%CI 0.901-0.972, p<0.001). There was a good correlation between left ventricular EF and MAV (r=0.73, p<0.001) and SSI (r=0.66, p<0.001). CONCLUSION: The patients with first myocardial infarction have decreased mean systolic annular velocity and mean systolic strain score index.

Comparison of strain doppler echocardiography and radiologic left ventriculography for quantitative assessment of regional myocardial function.

OBJECTIVE: We aimed to study the comparison of strain and strain rate parameters with conventional left ventriculography derived regional function. METHOD: Forty patients were included in the study. The study group was selected from patients who had undergone left ventriculography and coronary angiography for clinical indications. Regional myocardial function was assessed using the centerline method via ACOM PC Quantcor LVA measurement system. Patients were also evaluated with echocardiography. Strain and strain rate Doppler echocardiographic measurements were compared with conventional left ventriculography at anterobasal, anterolateral, inferior and posterobasal segments. RESULTS: Radiological left ventricular radial shortening was found to correlate with longitudinal strain shortening in all ventriculographic segments examined (anterobasal, r = 0.771, P < 0.0001; anterolateral, r = 0.790, P < 0.0001; posterobasal, r = 0.861, P < 0.0001; inferior, r = 0.815, P < 0.0001). Correlation was persistent both in patients with or without coronary artery disease. The sensitivity of a peak systolic longitudinal strain >12.5% for prediction of patients with radial shortening >or=20% was 75%, with a specificity of 100%. However, no relationship could be demonstrated between radiological left ventricular radial shortening and strain rate measurements. CONCLUSIONS: In our study it was shown that regional wall motion can be measured quantitatively via strain Doppler echocardiography with the left ventriculography as reference.

Effects of acute exercise on fibrinolysis and coagulation in patients with coronary artery disease.

Acute physical exertion may trigger an acute coronary syndrome. Furthermore, acute physical exercise may influence hemostatic markers in healthy individuals. However, the effect of acute exercise on blood fibrinolysis and coagulation in patients with coronary artery disease (CAD) is still not well understood. Nineteen untrained patients with angiographically proven CAD (age, 58 +/- 9 years, 12 males), and 25 age- and sex-matched controls without CAD (age, 56 +/- 6 years, 16 males) underwent a treadmill exercise test. Global fibrinolytic capacity (GFC) and prothrombin fragment 1 + 2 (F 1 + 2) levels were measured before exercise, at peak exercise, and 2 hours after recovery. There were no differences between the groups with respect to left ventricular ejection fraction, history of hypertension, body mass index, and serum lipids. Before exercise, GFC was significantly lower in patients with CAD when compared with controls (1.40 +/- 0.43 versus 3.28 +/- 1.19 microg/mL, respectively; P < 0.001). In patients with CAD, F 1 + 2 levels were significantly higher than those of controls (1.15 +/- 0.43 versus 0.79 +/- 0.10 nmol/L, respectively; P = 0.002). In both study groups, GFC levels increased significantly at peak exercise and decreased to baseline values 2 hours after recovery. At peak exercise, F 1 + 2 levels significantly increased in both study groups. However, while F 1 + 2 levels of controls decreased to baseline values 2 hours after recovery (0.79 +/- 0.10 versus 0.80 +/- 0.10 nmol/L; P > 0.05), F 1 + 2 levels of patients with CAD were still significantly elevated (1.15 +/- 0.43 versus 1.84 +/- 0.06 nmol/L; P = 0.002). Acute exercise increases coagulation and fibrinolysis both in untrained subjects with and without CAD. However, in patients with CAD, the equilibrium between fibrinolysis and coagulation during peak exercise is disturbed in favor of coagulation after recovery.

Plasma osteopontin levels are elevated in non-ST-segment elevation acute coronary syndromes.

BACKGROUND: The regions of ruptured atherosclerotic plaques have numerous macrophages. Osteopontin that modulates macrophage function has been shown in atherosclerotic plaques. We aimed to study the plasma levels of osteopontin in patients with unstable angina or non-ST-seg ment elevation myocardial infarction (NSTEMI) and the rela tionship between osteopontin and the extent of the coronary artery disease (CAD). METHODS: We studied 65 patients with unstable angina or NSTEMI, 25 patients with stable angina and 18 patients as the control group. The extent of coronary artery stenosis was determined by the number of vessels with >50% stenosis. Plasma osteopontin concentrations were measured from the blood samples that were drawn immediately after admission to the emergency department in unstable angina/NSTEMI patients and before the coronary angiograph in the stable angina and control groups. RESULTS: The plasma osteopontin concentration was (495 118 ng/ml) significantly higher in the patients with unstable angina/NSTEMI compared to the stable angina group (319 106 ng/ml) and control group (125+/-54 ng/ml) (p=0.0001 The plasma osteopontin levels were lower in the patients with stable angina pectoris who had one-vessel disease compared to those with two-vessel disease (p=0.01). How ever, in the unstable angina/NSTEMI group, the plasma osteopontin levels were statistically not different among the patients with one-vessel, and two-vessel and three-vessel disease (p=NS). There was no correlation between the plasma osteopontin levels and the extent of coronary stenosis. CONCLUSIONS: The plasma osteopontin levels are elevatedin patients with unstable angina/NSTEMI, but there appears to be no correlation with the extent of CAD. These results ma suggest that osteopontin may have a role in the pathobiology of ACS.

Management and in-hospital outcome of patients with first episode of acute myocardial infarction: impact of diabetes mellitus.

The aim of this study is to compare clinical characteristics, management, complications, in-hospital outcome and mortality of diabetic and nondiabetic patients after the first episode of acute myocardial infarction (MI). This retrospective case-matched study included 60 diabetic and 55 non-diabetic patients. Medical information about patients was retrieved from the hospital recordings. Diabetic patients were older, were more hypertensive and had more coronary artery disease history than nondiabetic patients. The frequency of use of acute reperfusion therapy modalities was not statistically different between the two groups. Diabetes was a significant determinant against the use of beta blockers (OR=0.26; 95% CI 0.06-0.95) but in favor of angiotensin converting enzyme inhibitors (OR=3.3; 95% CI 1.17-9.36), whereas diabetes did not influence the use of other drugs. Diabetic patients had more complications than nondiabetic patients (40.0% and 16.3%, respectively, p=0.005). In-hospital mortality rate for diabetic patients was comparable to nondiabetic patients (16.7% and 10.9%, respectively, p=0.373). Pharmaceutical treatment regimens, particularly beta blockers, are underutilized after acute MI in diabetic patients. More frequent use of these regimens will improve the high complication and mortality rates in diabetic patients as well as in nondiabetic patients.

Plasma soluble osteopontin concentrations are increased in patients with rheumatic mitral stenosis and associated with the severity of mitral valve calcium.

Although the severity of valvular calcification is an important prognostic indicator, the cellular mechanisms of the calcification process are unknown. Osteopontin modulates inflammation and biomineralization, and increased osteopontin expression has been demonstrated in calcified degenerative or rheumatic cardiac valves. The present study evaluated soluble plasma osteopontin in 32 patients with echocardiographically determined rheumatic mitral stenosis and compared the results to those of a control group of 22 healthy patients. Patients were evaluated with routine echocardiographic techniques, Wilkins scoring, and 2-dimensional echocardiographic calcium scoring. Patients with rheumatic involvement other than in the mitral valve were excluded. Plasma osteopontin and high-sensitivity C-reactive protein levels in patients with mitral stenosis were significantly higher those of the control group (p = 0.006 and p = 0.0001, respectively). A significant correlation was found between plasma osteopontin levels and the severity of mitral valve calcification (p = 0.003) and also between high-sensitivity C-reactive protein levels and Wilkins score (p = 0.009). There was a stepwise and statistically significant increase in soluble plasma osteopontin levels in association with the severity of mitral valve calcification. In conclusion, increased osteopontin levels were correlated with the severity of mitral valve calcification in patients with rheumatic mitral stenosis, suggesting an important role of osteopontin in the modulation of valvular calcification. Elevated levels of high-sensitivity C-reactive protein concentrations suggest the presence of ongoing inflammation in those patients.

Echocardiographic predictors of left atrial appendage spontaneous echocontrast in patients with stroke and atrial fibrillation.

OBJECTIVE: The presence of spontaneous echocontrast (SEC) in the left atrium (LA) or LA appendage (LAA) has been associated with a higher risk of thromboembolism and cerebrovascular accidents. The purpose of this study was to define the new transesophageal echocardiographic predictors of SEC for patients with stroke and atrial fibrillation. METHODS: We studied 47 patients with stroke and atrial fibrillation who were undergoing transesophageal echocardiography for the evaluation of source of cardiac emboli. Patients were divided into two groups based on the absence (group 1) or presence (group 2) of SEC in the LAA. RESULTS: Compared with group 1, group 2 had larger LA, larger LAA minimum and maximum areas, and decreased LAA flow velocity, LAA wall velocity, LAA tissue intensity, and intensity ratio. In the stepwise discriminate analysis tissue intensity of LAA, minimum LAA area, LAA flow velocity, and LAA wall velocity were found as independent predictors of LAA SEC. LAA wall velocity had the greatest area under the receiver operating characteristic curve, indicating that the most powerful parameter for SEC is LAA wall velocity. CONCLUSION: Decreased LAA flow velocity and LA wall velocity, increased LAA size, and less negative LAA tissue intensity are associated with SEC in patients with nonvalvular atrial fibrillation. Strain and strain measurements of LAA give no more benefit.

Doppler tissue evaluation of intra-atrial and interatrial electromechanical delay and comparison with P-wave dispersion in patients with mitral stenosis.

OBJECTIVE: The aim of our study was to: (1) measure atrial electromechanical delay in patients with mitral stenosis (MS) and in a control group; (2) find the echocardiographic parameters that affect atrial electromechanical delay; and (3) examine the correlation between atrial electromechanical delay and P-wave dispersion (PWD). METHODS: A total of 25 patients with pure MS (age 43 +/- 10 years; 18 women, 7 men) and 16 control subjects (age 41 +/- 8 years; 9 women, 7 men) were studied. Interatrial and intra-atrial electromechanical delay was measured with Doppler tissue echocardiography. From the 12-lead electrocardiograms, PWD was calculated. RESULTS: Interatrial electromechanical delay was 71.2 +/- 33 in the MS group and 40.5 +/- 21.0 in the control group (P = .01). In the MS group, PWD was 50 +/- 7 and in the control group it was 29 +/- 5 (P = .03). A positive correlation was detected between interatrial electromechanical delay and PWD (r = 0.6, P = .03). CONCLUSION: This study shows that interatrial electromechanical delay gets longer in MS and is correlated with PWD. Atrial electromechanical delay is related with left atrial size but not with severity of MS.

An unusual case of recurrent mass in the right atrium: intravenous leiomyomatosis.

Intravenous leiomyomatosis with a cardiac extension is an extremely rare condition. In this report, a case of a 43-year-old female patient is described: she was operated for right atrial mass protruding into the inferior vena cava, which was later diagnosed as leiomyoma. After a 3-year symptom-free period, recurrence of the extension through the inferior vena cava was observed. After abdominal ultrasonographic examination, which revealed bilateral ovarian and retroperitoneal mass, bilateral oopherectomy, retroperitoneal, and right atrial mass excision was done. The retroperitoneal and right atrial mass was reported as leiomyoma. On her last admission, she had complaints of dizziness, abdominal pain, and bilateral leg edema; and right atrial mass extending through the common iliac vein was noted, but the patient did not accept any further treatment modality.

Meigs' syndrome with highly elevated ca. 125 levels in a patient with Takayasu arteritis: a case report.

A 56-year-old post-menopausal woman presented with abdominal swelling and shortness of breath. An evaluation of abdomen and pelvis showed ascites and a solid mass. Serum CA-125 level was elevated (509 IU/ml). A computerized tomography-angiography was performed since the pulses of upper extremities could not be palpated. The patient was diagnosed to be suffering from Takayasu arteritis. The exploratory laparotomy revealed a fibroma of the ovary.

Right ventricular outflow tract thrombus in a case of Behcet's disease.

Behcet's disease is known as a chronic systemic vasculitic syndrome, the hallmark of which is recurrent oral aphthous and genital ulcerations and uveitis. Vascular involvement, mainly thrombosis, reportedly affects as many as one-third of patients. Cardiac involvement, however, is very rare. We present in this report a young female patient developing right ventricular thrombus while being treated medically.

Left ventricular long-axis function is reduced in patients with rheumatic mitral stenosis.

Left ventricular long-axis function evaluated by M-mode or tissue Doppler echocardiography has been shown to be useful indexes of left ventricular systolic function; however it has not been evaluated in patients with mitral stenosis. We examined the left ventricular long-axis function of the patients with pure mitral stenosis and normal global systolic function as assessed by fractional shortening of the left ventricle (LV). Fifty-two patients with pure mitral stenosis and twenty-two healthy controls were evaluated by echocardiography. Although there was no statistically significant difference in global systolic function, M-mode derived systolic motion of the septal side and (12 +/- 3 vs 14.4 +/- 1.5 mm, P = 0.016) the lateral side of mitral annulus (13.2 +/- 3 vs 16.8 +/- 2 mm, P = 0.001) were both significantly lower in the patients with mitral stenosis than control subjects. Similarly tissue Doppler systolic velocity of the septal annulus (7.6 +/- 1.1 vs 10.4 +/- 3.2 cm/s, P = 0.03) and lateral mitral annulus (7.6 +/- 1.1 vs 10.4 +/- 3.2 cm/s, P = 0.003) were also significantly lower in patients with mitral stenosis than in controls. There was a statistically significant correlation between septal annular motion and annular velocity (r = 0.643, P = 0.002). Septal annular motion and annular velocity were also correlated with left atrial ejection fraction (r = 0.338, P = 0.005 and r = 0.676, P = 0.001, respectively). Thus, patients with mitral stenosis had significantly impaired long-axis function evaluated by M-mode or tissue Doppler echocardiography despite normal global systolic function.

Detection of patients with hypertrophic cardiomyopathy at risk for paroxysmal atrial fibrillation during sinus rhythm by P-wave dispersion.

BACKGROUND: Paroxysmal atrial fibrillation (PAF) in hypertrophic cardiomyopathy (HCM) is associated with poor prognosis. Previous studies have shown good correlation between P-wave dispersion (Pd) and occurrence of PAF. However, Pd in patients with HCM for predicting PAF has not been studied. HYPOTHESIS: The aim of the study was to determine whether Pd could identify patients with HCM who are likely to suffer from PAF. METHODS: Twenty-two patients with HCM with a history of PAF (Group 1) and 26 patients with HCM without a history of PAF (Group 2) were studied. Maximum (Pmax) and minimum (Pmin) P-wave durations, as well as P-wave dispersion (Pd = Pmax - Pmin) were calculated from 12-lead surface electrocardiograms (ECG). RESULTS: P-wave dispersion was significantly different between the groups (Group 1: 55 +/- 6 ms vs. Group 2: 37 +/- 8 ms; p<0.001), while Pmax (Group 1: 134 +/- 11 ms vs. Group 2: 128 +/- 13 ms; p = 0.06) and Pmin (Group 1: 78 +/- 9 ms vs. Group 2: 81 +/- 7 ms; p = 0.07) was not significantly different. Patients with a history of PAF had higher left atrial diameter than the patients without PAF (Group 1: 52 +/- 8 mm vs. Group 2: 48 +/- 10 mm; p = 0.02). A cut-off value of 46 ms for Pd had a sensitivity of 76% and a specificity of 82% in discriminating between patients with and without PAF. CONCLUSION: This study suggests that P-wave dispersion could identify patients with HCM who are likely to develop PAF.

Treatment of mild-to-moderate hypertension with calcium channel blockers: a multicentre comparison of once-daily nifedipine GITS with once-daily amlodipine.

BACKGROUND: Hypertension is one of the most important causes of cardiovascular disease, and treatment of hypertension leads to a significant reduction in cardiovascular mortality and morbidity. Although calcium channel blockers are regarded as an important part of the therapeutic armamentarium against cardiovascular diseases, and are among the most frequently prescribed antihypertensive medications, concern has been aroused about these drugs, particularly the short-acting dihydropyrldine derivatives. However, the value of nifedipine GITS(Adalat-Crono), the long-acting dihydropyrldine, is in need of being re-established. OBJECTIVE: To compare the effectiveness, safety and tolerability of once-daily nifedipine and amlodipine treatment in patients with mild-to-moderate essential hypertension. DESIGN: Randomised multicentre trial with an open comparison of treatments for 12 weeks, with a preceding placebo run-in period of 2 weeks (patients on beta-blockers at the time of enrollment entered a mandatory 2-week wash-out period before being allowed In the placebo run-in period;this wash-out period was one week for patients using any antihypertensive medication other than beta-blockers). SETTING: Nine centres (all university hospitals) in Turkey. PATIENTS: 155 patients with essential hypertension(diastolic blood pressure 95-109 mmHg). INTERVENTIONS: Initial treatment (step 1) consisted of 30 mg nifedipine GlTS (n = 76; (Adalat-Crono tablets), or 5 mg amlodipine (n = 79; Norvasct5-mg tablets), either administered once daily, as a morning dose, or f the blood pressure was not below 140/90 mmHg, or the reduction In diastolic blood pressure was lower than 10 mmHg after a treatment period of 6 weeks, the dose was increased (Step 2) to 60 mg once daily in the nifedipine group, or 10 mg once daily in the amlodipine group. MAIN EFFICACY PARAMETER: Diastolic blood pressure at trough after 12 weeks of active compound therapy adjusted to baseline. RESULTS: After 12 weeks of treatment, the mean diastolic blood pressure was 83.1 and 81.9 mmHg,in the nifedipine and amlodipine groups, respectively (p = 0.436). The mean decrease in systolic blood pressure (28.5 +/- 11.9 and 28.2 +/- 11.2 mmHg in the nifadipine and amlodipine groups, respectively) and the mean decrease in diastolic blood pressure (16.4A +/- 7.0 and 17.5 +/- 6.9 mmHg in the nifedipine and amlodipine groups, respectively), as well as the responder rates (88.1%and 92.1%, in the nifediplne and amlodipine groups, respectively) were comparable at the end of the study. No significant differences between groups were detected In the efficacy parameters assessed in this study. Both drugs were well tolerated. The overall incidence of adverse events was 7.9% in the nifadipine group and 10.1% In the amlodipine group. However, more patients discontinued treatment prematurely in the amlodipine group (13 patients; 19.7%), than in the nifedipine group (four patients; 5.6%). CONCLUSIONS: The results of this study demonstrated that once-daily nifedipine in GITS formation and amlodipine are comparably safe and effective treatment options in patients with mild-to-moderate essential hypertension.

Assessment of heart rate turbulence in the acute phase of myocardial infarction for long-term prognosis.

This study is designed to assess the value of heart rate turbulence (HRT) in the acute phase of MI for prediction of long-term mortality risk. The study included 128 consecutive acute MI patients with 24-hour Holter recordings to evaluate HRT (turbulence onset and slope), SDNN, mean RR interval, and ventricular premature beat frequency. LVEF was evaluated by two-dimensional echocardiography. Data from 117 patients (mean age 58 +/- 11 years) were available for further analysis. Twelve patients died during follow-up (mean 312 +/- 78 days). Although SDNN < 70 ms was the most powerful predictor of mortality among all presumed risk factors (hazard ratio 20 [95% CI 2.6-158]; P = 0.004) in univariate Cox regression analysis, in multivariate analysis LVEF < or = 0.40 and turbulence slope < or = 2.5 ms/RR interval were the only independent predictors of mortality (hazard ratio 6.9 [95% CI 1.8-26]; P = 0.006, hazard ratio 7.3 [95% CI 1.4-37]; P = 0.016, respectively). Addition of HRT parameters for LVEF increased remarkably the positive predictive value (60%) without any decrease in the negative predictive value (92%). Blunted HRT reaction within the first 24 hours of acute MI is an independent predictor of long-term mortality. Furthermore, its predictive power is comparable and also additive to that of LVEF.

Patients with paroxysmal atrial fibrillation but not paroxysmal supraventricular tachycardia display evidence of platelet activation during arrhythmia.

It is well known that chronic atrial fibrillation (CAF) and paroxysmal atrial fibrillation (PAF) are associated with hypercoagulable state. However, pathological hemostatic changes during the paroxysmal supraventricular tachycardia (PSVT) have not yet been elucidated. To determine platelet activity in patients with PSVT, PAF and CAF, we examined the levels of beta-thromboglobulin (BTG) and platelet factor 4 (PF4) during tachyarrhythmia attacks. We measured the levels of BTG and PF4, as an index of platelet activation in 15 patients with PAF (9 men, mean age 45+/-11), and 14 patients with PSVT (8 men, mean age 40+/-10). Levels were compared to 22 age and sex matched healthy controls in sinus rhythm and with 25 patients with CAF (16 men, mean age 51+/-12). Blood samples were taken during arrhythmia and 24 hours after conversion to sinus rhythm. Patients taking medications or have clinical conditions that may affect the BTG and PF4 levels were excluded. In patients with PAF, BTG and PF4 levels were significantly higher than in controls (p<0.009, and p=0.002, respectively), and in patients with PSVT (p<0.004, and p=0.009, respectively), however, BTG and PF4 levels were significantly lower than CAF patients (p=0.002, and p=0.02, respectively). Moreover, BTG and PF4 levels were significantly decreased 24 hours after conversion to sinus rhythm (p<0.0001), and p=0.004, respectively). Although BTG and PF4 levels in patients with PSVT were significantly lower than in patients with PAF (p=0.04, and p=0.009, respectively) and CAF (p=0.0001, and p=0.0001, respectively), BTG and PF4 levels were similar to controls and did not change significantly after recovery to sinus rhythm (p=NS for all). These results indicate that there was no platelet activation in patients with PSVT during tachyarrhythmia but significantly increased platelet activity in PAF and CAF patients. There was a significant decrement of the platelet activity to a level of control subjects twenty-four hours after cardioversion of PAF.

Radiocontrast-induced nephrotoxicity and urinary alpha-glutathione S-transferase levels: effect of amlodipine administration.

AIMS: The exact pathogenesis and prophylaxis concerning radiocontrast-induced nephrotoxicity (RCIN) was unclear. Short-acting calcium antagonists were used to prevent RCIN. This study was designed to evaluate the role of a long-acting calcium antagonist (amlodipine) administration by determining serum creatinine (SCre) levels and 24 hour urinary excretion rates of glutathione S-transferase alpha (GST-alpha) which has a selective localization only to proximal tubular epithelium. METHODS: In a prospective trial, 29 outpatients (19 M, 10 F) undergoing coronary angiography were randomized and either amlodipine 10 mg/day (n = 15) or placebo (n = 14) were administered prior to angiography and continued thereafter. All patients had normal basal renal function and none of them had any risk factor for RCIN. A low osmolar, nonionic contrast media (iopamidol 76%) was administered to all patients. Creatinine clearance (CCre), SCre and 24-hour urinary GST-alpha levels were measured before, 24 hours and 7 days after angiography. RESULTS: SCre and 24 hour urinary GST-alpha values increased on 24th hour following the angiography in both groups (p < 0.017 and 0.001, respectively). Pretreatment with amlodipine created no difference in both variables (p > 0.05). CONCLUSIONS: A reversible tubular dysfunction occurs following radiocontrast administration which was manifested by an increase in urinary GST-alpha excretion rates. Pretreatment with a long acting calcium antagonist amlodipine has no effect on the course of enzyme excretion and alteration observed in SCre.