Disopyramide for transient high-degree atrioventricular block in a young patient with a history of syncope.

Although high-degree atrioventricular (AV) block in patients with a history of syncope usually requires pacemaker implantation, therapeutic strategies should also be considered. A 35-year-old man presented with complaints of palpitations, nausea and dysgeusia. Since aged 30, the patient had experienced three episodes of syncope. Holter monitoring showed transient high-degree AV block (up to 5:4 block) associated with nausea, eructation and dysgeusia irrelevant to posture as well as ventricular ectopic beats with palpitation. A head-up tilt test revealed neurally mediated vasodepression but electrophysiological study showed no abnormalities. These results indicated that his transient high-degree AV block was functional, and syncope would have been because of neurally mediated vasodepression, not bradycardia. After administration of disopyramide at 300 mg daily, the symptoms subsided and ventricular ectopic beats and AV block disappeared. He has been well for 20 months.

Telmisartan, an angiotensin II type 1 receptor blocker, improves coronary microcirculation and insulin resistance among essential hypertensive patients without left ventricular hypertrophy.

Hypertension and insulin resistance are associated with reduced coronary vasodilatory capacity, possibly caused by structural changes in the coronary resistance vessels. The goal of this study was to compare the effect of an angiotensin receptor blocker (ARB) with that of a calcium channel blocker (CCB) on coronary flow reserve and insulin resistance among essential hypertensive patients without left ventricular hypertrophy. A total of 40 consecutive essential hypertensive patients were randomized to daily 40 mg telmisartan or 20 mg nifedipine coat-core treatment. Coronary flow velocity reserve (CFVR) measurement using transthoracic Doppler echocardiography and blood tests were performed before and after 12 weeks of treatment. At baseline, blood pressure, CFVR, and homeostasis model assessment of insulin resistance (HOMA-IR) were not significantly different between the two groups. At the end of the treatment period, the telmisartan and nifedipine groups exhibited similar declines in blood pressure. CFVR was improved in the telmisartan group (2.4+/-0.4 to 2.9+/-0.4; p<0.01), but there was no difference in the nifedipine group (2.5+/-0.3 to 2.5+/-0.3; n.s.). HOMA-IR was improved in the telmisartan group (3.1+/-1.1 to 1.6+/-0.7; p<0.01), but there was no difference in the nifedipine group (2.8+/-1.1 to 2.4+/-0.7; n.s.). In conclusion, this study demonstrates that antihypertensive therapy with telmisartan, but not nifedipine, has a beneficial effect on coronary microcirculation and insulin resistance among essential hypertensive patients.