[Painless myocardial ischemia at various blood pressure levels in patients with effort angina (J-shaped relationship)].

Blood pressure (BP) elevation is associated with lowered sensitivity to pain and increased risk of painless myocardial ischemia. However relationship between frequency of episodes of symptomless myocardial ischemia and BP level in patients with normal or low BP has not been elucidated. In 74 men with ischemic heart disease and stable class I-III effort angina blood pressure was measured on the day of 24-hour ECG monitoring. Ranges of systolic (S) and diastolic (D) BP values were 93-159 and 65-104 mm Hg, respectively. Episodes of painless ischemia were most frequent in highest (4-th) (SBP>=142, DBP>=93 mm Hg) and least frequent in the 2nd (SBP 120-126, DAD 79-86 mm Hg.) quartile of BP distribution. In patients with lower BP (1st quartile) frequency of episodes of painless ischemia was significantly higher as compared with patients of the 2nd quartile. Thus relationship between frequency of episodes of painless ischemia and BP level in patients with stable effort angina was J-shaped: sensitivity to ischemia was lowered and frequency of painless ischemia increased both at highest and lowest values of BP.

[Clinical value of degree of blood pressure lowering during use of effective doses of antianginal drugs]. / Klinicheskaia znachimost' stepeni snizheniia arterial'nogo davleniia pri peimenenii éffektivnykh doz antianginal'nykh preparatov.

Paired exercise tests with single doses of verapamil, nifedipine, propranolol, buccal nitroglycerin (trinitrolong), sustained release oral nitroglycerin, and placebo were performed in 101 patients with stable class II-III angina and the drug causing longest exercise duration was selected for long term therapy. Efficacy of a selected drug was compared with magnitude of its hypotensive effect. The latter was calculated as difference between blood pressure (BP) before and 2 hours after drug administration. Lower quintile of distribution of BP differences (systolic BP difference >20 mm Hg and/or diastolic BP difference >15 mm Hg) was considered as excessive hypotensive effect of a study drug (EHESD) single dose. Exercise duration before ST-segment depression was significantly shorter (p<0.05) in cases with EHESD compared with those without EHESD. After 1 month of therapy total daily number of episodes of myocardial ischemia decreased by 3.2+/-3.0 and 1.8+/-1.2 in patients without and with EHESD, respectively (p<0.02). At the same time number of episodes of painless ischemia increased more than 2 times in patients with EHESD (p<0.01). Registration of EHESD at initial stages of treatment with short acting antianginal drugs appears to be a reliable marker of increased frequency of painless episodes of myocardial ischemia and low efficacy of regular use of these drugs.

[Decrease in the sensitivity to the anti-ischemic effect of propranolol and prospects for correcting it in patients with stable angina pectoris]. / Snizhennaia chuvstvitel'nost' k antiishemicheskomu éffektu propranolola i vozmozhnost' ee korrektsii u bol'nykh stabil'noi stenokardiei.

AIM: To study incidence of low sensitivity to an antiischemic effect of propranolol and feasibility of its correction with a metabolic drug--trimetazidine. MATERIAL AND METHODS: Paired treadmill and bicycle exercise tests were made until depression of segment ST > 1 mm and a typical angina episode. The trial included 147 men with ischemic heart disease, stable angina pectoris (functional class II-III). The antiischemic effect of propranolol single doses 40 or 80 mg were assessed in 117 patients. Single doses of propranolol 40 mg, trimetazidine 20 mg and their combination were examined for an antiischemic effect in 30 patients. The absence of the above effect of propranolol was stated in 20 patients who participated in a double blind, randomised, placebo-controlled study with conduction of 2-week courses of regular administration of propranolol in a dose 120 mg/day, trimetazidine 60 mg/day and their combination. Echo-CG was made initially and in the end of each course. RESULTS: Propranolol's antiischemic effect of a single dose 40 mg was not found in 45.3% patients, 40-80 mg--in 21%. Among 20 patients without effect of the single propranolol dose, an increment of the threshold load made up 20.7 +/- 15.7 s, after intake of trimetazidine 16.3 +/- 18.6 s. The combination of these drugs significantly increases the increment of the threshold load duration to 90.8 +/- 80.4 s. The same picture was observed in the course treatment. The above increment in the course administration of propranolol was 46.3 +/- 15.3 s, of trimetazidine 22.8 +/- 20.2 s, of their combination 122.7 +/- 21.8 s (p = 0.02). In the absence of propranolol effect, echo-CG registered deterioration of disorder of left ventricular diastolic function. 10 patients with effect of the single propranolol dose this deterioration was not observed in combined use of propranolol and trimetazidine. CONCLUSION: The antiischemic effect of propranolol in a single dose 40 mg was not recorded in about half of the examined anginal patients. Combined use of propranolol and trimetazidine in cases with no propranolol effect provides a synergetic effect both in single and course administration.