Angiotensinergic versus nonangiotensinergic hemodynamic effects of converting enzyme inhibition in patients with chronic heart failure. Assessment by acute renin and converting enzyme inhibition.

BACKGROUND: The contribution of nonangiotensinergic effects of converting enzyme inhibitors to their hemodynamic effects in patients with chronic heart failure is not clear. A comparison of the effects of renin and converting enzyme inhibition should help to clarify this issue. METHODS AND RESULTS: Thirty-six patients with chronic heart failure (New York Heart Association class II or III) were randomly assigned to receive double-blind either intravenous placebo, the renin inhibitor remikiren, or the converting enzyme inhibitor enalaprilat followed by coinfusion of a second placebo infusion, the addition of remikiren to enalaprilat, or the addition of enalaprilat to remikiren, respectively. Systemic hemodynamics (Swan-Ganz and radial artery catheters) were measured before (rest and submaximal recumbent bicycle ergometry), during (rest), and at the end (rest and exercise) of each 45-minute single- or combination-infusion period. Placebo did not change hemodynamics or renin activity. Effective inhibition of the renin-angiotensin system by remikiren and enalaprilat was indicated by increases of plasma immunoreactive renin together with rapid and complete inhibition of renin activity after remikiren and an increase after enalaprilat (all P < or = .05). Remikiren and enalaprilat rapidly and to a similar extent reduced resting blood pressure through a reduction of systemic vascular resistance, and these changes were significantly correlated to baseline plasma renin activity. Both compounds also decreased pulmonary artery, pulmonary capillary wedge, and right atrial pressures to a similar extent (P < .05). During exercise, pulmonary capillary wedge and right atrial pressures were equally reduced and stroke volume index was increased with remikiren and enalaprilat (P < .05) for both). The combination of converting enzyme with renin inhibition or vice versa did not cause additional hemodynamic changes. CONCLUSIONS: Specific renin inhibition in patients with chronic heart failure produces short-term hemodynamic effects that are almost indistinguishable from those of converting enzyme inhibition. This finding and the lack of additional effects of converting enzyme inhibition added to renin inhibition suggest that nonangiotensinergic effects of converting enzyme inhibitors do not play a significant role in their short-term hemodynamic effects in patients with chronic heart failure.

[Clinical assessment of the patient with suspected dissecting aneurysm]. / Die Abklärung des Patienten mit Verdacht auf Aneurysma dissecans.

The clinical picture of aortic dissection is dominated by severe pain. In differential diagnosis the far more frequent acute myocardial infarction should chiefly be considered. Further evaluation is therefore only indicated when, in addition to pain, there are no signs of infarction in the ECG, additional aortic incompetence, pericardial effusion or history of hypertension. In recent years, in addition to contrast angiography, three non-invasive methods for this diagnosis have been developed: computer tomography, biplane esophageal echocardiography and magnetic resonance imaging. The sensitivity, specificity, advantages and disadvantages of these four methods are compared. In the individual center, according to the availability and expertise of the investigators, one method should be used as the first diagnostic tool. Only in a minority of patients should a second method be necessary until the diagnosis is confirmed or excluded, as is shown in our own series. A limitation to one, and in difficult situations possibly two, methods is not only important from the economic point of view but also to save time, since in aortic type A dissection surgery should be performed without delay.

Clinical risk assessment after first myocardial infarction--is additional noninvasive testing necessary?

In order to assess whether the outcome of MI can be predicted by clinical data alone or whether and how much noninvasive testing is necessary to predict cardiac events or death, 361 patients were prospectively evaluated and followed for up to five years. A recursive partitioning analysis indicated that high-risk patients can be identified clinically after MI with a high degree of accuracy; to separate low-risk patients who need no further investigation or therapy, however, one additional noninvasive test is necessary which allows quantification of myocardial damage as well as exercise-induced ischemia. Additional tests added little to this risk prediction, indicating that multiple noninvasive testing should not be performed.

Ambulatory scintigraphic assessment of transient changes in left ventricular function: a new method for detection of silent myocardial ischaemia.

Demonstration of ischaemic left ventricular dysfunction in the absence of chest pain should provide important confirmation of silent myocardial ischaemia in patients with asymptomatic ST segment changes. For this purpose, a new portable scintillation probe (VEST) similar to a miniaturized nuclear stethoscope combined with a Holter ECG was evaluated. After standard equilibrium radionuclide angiocardiography with technetium-99m labelled red blood cells, the VEST was positioned under gamma-camera control and data were recorded from 1-12 h in 61 unselected patients. Ejection fraction (LVEF), relative changes in volumes, heart rate and ST segment changes were determined. Reproducibility of LVEF at rest (r = 0.91; variability 3.8 +/- 3%, N = 19) and during exercise (r = 0.98; variability 3.2 +/- 2%, N = 19) was good. In 15 asymptomatic exercise tests four different patterns of LVEF and ST segment responses were identified: (1) decrease in LVEF followed by significant ST depression (five times); (2) ST depression followed by decrease in LVEF (three times); (3) decrease in LVEF without significant ST changes (three times); and (4) ST depression without significant LVEF change (four times). In this still small series, patterns (1) to (3) corresponded to patients with documented coronary artery disease, which was not the case for pattern (4). For detection of silent ischaemia at rest, a decrease in LVEF of greater than 5% lasting for greater than 1 min was defined as ischaemic LV dysfunction. Using this definition, four spontaneous episodes of silent LV dysfunction could be demonstrated in two of three CCU patients with unstable angina during 160-680 min of data recordings without simultaneous ST changes.(ABSTRACT TRUNCATED AT 250 WORDS)