[Effects of terazosine and atenolol on serum lipids in essential hypertension]. / Effekte von Terazosin und Atenolol auf die Serumlipide bei essentieller Hypertonie.

BACKGROUND: Only a few studies have evaluated the efficacy of alpha-blocking agents in combination with other classes of antihypertensive agents, especially in patients not adequately controlled by monotherapy. As alpha-blockers have an additional beneficial effect on serum lipids, it seems reasonable to use them instead of beta-blockers or diuretics in insufficiently treated hypertensive patients with hyperlipidemia. MATERIALS AND METHODS: All patients with insufficient blood pressure control with either a calcium channel blocker or an ACE inhibitor and evidence of hyperlipidemia (total serum cholesterol > 5.69 mmol/L) were included into an open, randomized and prospective study to evaluate the effects of terazosin and atenolol on lipid profile in hypertensive patients. The patients received either terazosin (n = 26; dose 1 to 10 mg) or atenolol (n = 28; dose 25 to 100 mg). Blood pressure was assessed by 24-hour ambulatory blood pressure measurement and serum lipids were evaluated at the time of inclusion and 12 weeks later. RESULTS: Blood pressure was similar after 12 weeks of treatment (atenolol: 129 (9)/75 (7) mm Hg; terazosin: 128 (11)/75 (9) mm Hg) and total cholesterol was significantly reduced after 12 weeks of treatment (atenolol: Diff 0-12 weeks: 7.29 (1.32) versus 6.62 (1.14 mmol/L, p = 0.006; terazosin: 7.34 (0.93) versus 6.67 (0.85) mmol/L, p = 0.002). In the terazosin group, HDL-cholesterol increased and triglycerides decreased significantly (Diff 0-12 weeks: HDL-chol: 1.55 (0.31) versus 1.63 (0.44) mmol/L, p = 0.04; TG: 1.93 (1.17) versus 1.34 (0.64) mmol/L, p = 0.03). Comparing both groups a significant difference was found with regard to HDL-cholesterol and triglycerides (atenolol versus terazosin: HDL-chol: -0.05 (0.12) versus +0.08 (0.1) mmol/L, p = 0.04; TG: -0.18 (0.61) versus--0.59 (0.6), p = 0.03). CONCLUSIONS: The alpha-blocker terazosin is as effective as atenolol when combined with either an ACE inhibitor or a calcium-channel blocker as a part of a multidrug regimen to achieve sufficient blood pressure control. In addition, terazosin is superior to atenolol with regard to the effect on the lipid profile of hypertensive and hyperlipidemic patients and seems therefore a reasonable alternative to beta-blockers in hypertensive patients with hyperlipidemia.

Out-of-hospital diagnosis of cerebral infarction versus intracranial hemorrhage.

OBJECTIVE: To establish a model based on clinical and anamnestic data easily available in the out-of-hospital setting, which facilitates the differential diagnosis between cerebral infarction and intracranial hemorrhage. DESIGN: Retrospective study that simulates a prospective approach. SETTING: Emergency Department of the University Hospital in Vienna, Austria. PATIENTS AND PARTICIPANTS: Data of 224 patients with either intracranial hemorrhage or cerebral infarction were prospectively collected. Uni-and multivariate analysis was performed to identify neurological symptoms and anamnestic data, which were associated with either intracranial hemorrhage or cerebral infarction. MEASUREMENTS AND RESULTS: Unilateral weakness or sensory loss was observed more frequently in patients with infarction compared to hemorrhage (69.8 % vs 11.9 %, P < 0.001). The frequency of patients with impaired level of consciousness was significantly higher in the hemorrhage group compared to the infarction group (59.3 % vs 3.8 %, P < 0.001). A multivariate logistic regression analysis showed that hypertension (OR = 0.31, 95 % CI = 0.12-0.76, P = 0.01), diabetes (OR = 0.17, 95% CI = 0.04-0.68, P = 0.01), and unilateral weakness or sensory loss (OR = 0.10, 95 % CI = 0.04-0.26, P < 0.001) were significantly associated with cerebral infarction. Impaired level of consciousness was significantly related to hemorrhage (OR = 13.41, 95 % CI = 3.92-45.91, P < 0.001). On the basis of the logistic regression analysis, we generated a scoring system for the out-of-hospital diagnosis between infarction and hemorrhage. The values of the score lay between -3 and +3. The probability of infarction increases when the score becomes negative, and the probability for hemorrhage increases when the score becomes positive. CONCLUSION: Our model is a useful guideline for the differential diagnosis between cerebral infarction and intracranial hemorrhage in the out-of-hospital setting, as it is based on easily available clinical and anamnestic parameters.

Use of an age-adjusted Doppler E/A ratio in patients with moderate to severe hypertension.

OBJECTIVE: To assess the ratio of early (E) to late atrial (A) mitral Doppler peak flow velocity (Doppler E/A ratio) before and after adjustment for age in patients with moderate to severe hypertension, in whom left ventricular diastolic dysfunction is an early finding. Mitral flow patterns can be used to assess diastolic filling characteristics, and the Doppler E/A ratio is the parameter most commonly used, although it is known to be strongly age dependent. There are no established normal values for this ratio. DESIGN: Retrospective data analysis. SETTING: A 2000-bed tertiary-care teaching hospital. PATIENTS: We studied 190 patients (99 women and 91 men; ages 55 +/- 13 years) with moderate to severe hypertension. INTERVENTIONS: The ratio of early (E) to late atrial (A) mitral Doppler peak flow velocity was measured. As this ratio depends on age, a Z score was calculated to control for this influence. The Z score is the standardized normal deviation of the mean, with a normal value of 0 +/- 2. MAIN OUTCOME MEASURES: Sensitivities and specificities for detecting an age-dependent reduction in Doppler E/A score (Z score less than -2) with a non-age-dependent Doppler E/A ratio (less than 1) were calculated. RESULTS: In 106 of the patients (56%) the Doppler E/A ratio was less than 1.0. Only nine patients (4.7%) had a Z score less than -2. The sensitivity of the Doppler E/A ratio threshold of 1.0 for detecting a Z score less than -2 was 0.89 and the specificity was 0.46. A Z score less than -2 was found only in patients younger than 45 years. CONCLUSIONS: The Doppler E/A ratio was reduced in a large proportion of our patients. However, after correction for age it was decreased in only 4.7% of these patients. The use of a single Doppler E/A ratio threshold value has a weak diagnostic power to detect age-independent changes in mitral flow patterns.

G-protein beta3 subunit gene (GNB3) polymorphism 825C-->T in patients with hypertensive crisis.

OBJECTIVE: The polymorphism 825C-->T in exon 10 of the gene GNB3 encoding the beta3 subunit of heterotrimeric guanine nucleotide binding regulatory proteins (G-proteins) results in a splicing variant (GNB3-s) in which the nucleotides 498-620 of exon 9 are deleted. The T allele has been shown to be overrepresented in patients with essential hypertension. Because GNB3-s may support the development of severe elevation of blood pressure, we hypothesized that GNB3 825C-->T may be present more frequently in patients with hypertensive crisis. DESIGN: Case control study. SETTING: Department of Emergency Medicine at the University Hospital of Vienna, Vienna, Austria. PATIENTS: A total of 174 patients admitted to an emergency department for treatment of hypertensive crisis diagnosed as suffering from essential hypertension. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were genotyped for the 825C-->T transition in GNB3. An equal number of age- and gender-matched normotensive, healthy individuals served as the control population. The allele frequency of 825C-->T in the GNB3 gene was 0.310 in patients with hypertensive crisis and 0.342 in the control group. There was no difference in genotype distribution and allele frequency between the patients and the age- and gender-matched control group or between the observed prevalence and the occurrence rate expected from the Hardy-Weinberg principle within each group. CONCLUSIONS: GNB3 825C-->T is not associated with the phenotype of hypertensive crisis in patients suffering from essential hypertension. Furthermore, our data do not support the concept that the 825C-->T transition in the GNB3 gene is associated with essential hypertension.

Simultaneous comparison of thoracic bioimpedance and arterial pulse waveform-derived cardiac output with thermodilution measurement.

OBJECTIVE: To compare the accuracy and reliability of thoracic electrical bioimpedance (TEB) and the arterial pulse waveform analysis with simultaneous measurement of thermodilution cardiac output (TD-CO) in critically ill patients. DESIGN: Prospective data collection. SETTING: Emergency department and critical care unit in a 2,000-bed inner-city hospital. PATIENTS: A total of 29 critically ill patients requiring invasive hemodynamic monitoring for clinical management were prospectively studied. INTERVENTIONS: Noninvasive cardiac output was simultaneously measured by a TEB device and by analysis of the arterial pulse waveform derived from the finger artery. Invasive cardiac output was determined by the thermodilution technique. MEASUREMENTS AND MAIN RESULTS: A total of 175 corresponding TD-CO and noninvasive hemodynamic measurements were collected in 30-min intervals. They revealed an overall bias of 0.34 L/min/m2 (95% confidence interval, 0.24-0.44 L/min/m2; p < .001) for the arterial pulse waveform analysis and of 0.61 L/min/m2 (95% confidence interval, 0.50-0.72 L/min/m2; p < .001) for the TEB. In 39.4% (n = 69) of all measurements, the discrepancy between arterial pulse waveform analysis and TD-CO was >0.50 L/min/m2. The discrepancies of the arterial pulse waveform analysis correlated positively with the magnitude of the cardiac index (r2 = 0.29; p < .001). In 56.6% (n = 99) of all measurements, the discrepancy between TEB and TD-CO was >0.50 L/min/m2. The magnitude of the discrepancies of the TEB was significantly correlated with age (r2 = 0.17; p = .02). Measurements were in phase in 93.2% of all arterial pulse waveform analysis and in 84.9% of all TEB readings (p < .001). CONCLUSIONS: The arterial pulse waveform analysis exhibits a greater accuracy and reliability as compared with the TEB with regard to overall bias, number of inaccurate readings, and phase lags. The arterial pulse waveform analysis may be useful for the monitoring of hemodynamic changes. However, both methods fail to be a substitute for the TD-CO because of a substantial percentage of inaccurate readings.

Increased blood pressure response to the cold pressor test in pregnant women developing pre-eclampsia.

OBJECTIVES: Recent data indicate an increased vascular reactivity due to an overactivity of the sympathetic nervous system in women with pre-eclampsia. We therefore evaluated whether this increased vascular reactivity can be detected prior to the clinical manifestation of preeclampsia by the use of a physiological stimulus. DESIGN: Prospective data collection. SETTING: Clinic of Obstetrics and Gynecology in a 2000 bed tertiary care hospital. PARTICIPANTS: One hundred and twenty-three pregnant women between the 16th to 20th week of gestation. INTERVENTIONS: A cold pressor test was performed by positioning an ice-bag on the forehead of the woman for 3 min. Blood pressure and heart rate were monitored by a continuous, noninvasive blood pressure measurement device during the stimulus and after removal of the icebag. A clinical follow-up was carried out by review of the charts after delivery to identify those women who have developed pre-eclampsia. RESULTS: Ten (8%) out of 123 pregnant women developed pre-eclampsia. During the cold pressor test systolic as well as diastolic blood pressure increased significantly and was more pronounced in women developing pre-eclampsia compared with healthy pregnant women (systolic blood pressure: 14.2 +/- 5.5 versus 8.5 +/- 7.2 mmHg, P= 0.02; diastolic blood pressure: 7.3 +/- 4.9 versus 3.9 +/- 4.7 mmHg, P=0.03). The change in heart rate was similar between both groups (8 +/- 2.6 versus 10.4 +/- 6.4 beats/min, not significant). CONCLUSIONS: An increased vasoconstrictive response to a physiological stimulus is present in women with pre-eclampsia as a sign of an increased vascular reactivity prior to clinical manifestation of the disease. The cold pressor test may be a suitable diagnostic tool to identify women, who will develop pre-eclampsia. However, future studies in larger cohorts are required to establish the final value of this test.

Accuracy of oscillometric blood pressure measurement according to the relation between cuff size and upper-arm circumference in critically ill patients.

OBJECTIVE: To evaluate the accuracy of oscillometric blood pressure measurement according to the relation between cuff size and upper-arm circumference in critically ill patients. DESIGN: Prospective data collection. SETTING: Emergency department in a 2,000-bed inner city hospital. PATIENTS: Thirty-eight patients categorized into three groups according to their upper-arm circumference (group I: 18-25 cm; group II: 25.1-33 cm; and group III: 33.1-47.5 cm) were enrolled in the study protocol. INTERVENTIONS: In each patient, all three cuff sizes (Hewlett-Packard Cuff 40401 B, C, and D) were used to perform an oscillometric blood pressure measurement at least within 3 mins until ten to 20 measurements for each cuff size were achieved. Invasive mean arterial blood pressure measurement was done by cannulation of the contralateral radial artery with direct transduction of the systemic arterial pressure waveform. The corresponding invasive blood pressure value was obtained at the end of each oscillometric measurement. MEASUREMENT AND MAIN RESULTS: Overall, 1,494 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 38 patients (group I, n = 5; group II, n = 23; and group III, n = 10) over a total time of 72.3 hrs. Mean arterial blood pressure ranged from 35 to 165 mm Hg. The overall discrepancy between oscillometric and invasive blood pressure measurement was -6.7+/-9.7 mm Hg (p<.0001), if the recommended cuff size according to the upper-arm circumference was used (539 measurements). Of all the blood pressure measurements, 26.4% (n = 395) had a discrepancy of > or =10 mm Hg and 34.2% (n = 512) exhibited a discrepancy of > or =20 mm Hg. No differences between invasive and noninvasive blood pressure measurements were noted in patients either with or without inotropic support (-6.6 + 7.2 vs. -8.6 + 6.8 mm Hg; not significant). CONCLUSION: The oscillometric blood pressure measurement significantly underestimates arterial blood pressure and exhibits a high number of measurements out of the clinically acceptable range. The relation between cuff size and upper-arm circumference contributes substantially to the inaccuracy of the oscillometric blood pressure measurement. Therefore, oscillometric blood pressure measurement does not achieve adequate accuracy in critically ill patients.

Hypertension in patients presenting with epistaxis.

STUDY OBJECTIVE: We sought to evaluate whether patients with epistaxis in the emergency department have a higher arterial blood pressure compared with patients with other medical emergencies and to study the association of elevated blood pressure during epistaxis with sustained arterial hypertension. METHODS: In a prospective, cross-sectional, prevalence study we compared arterial blood pressure on admission in the ED in 213 consecutive patients treated for epistaxis with that of 213 sex- and age-matched control subjects. In 33 of those patients with elevated blood pressure during epistaxis, we evaluated the prevalence of sustained arterial hypertension. Main outcome measures were arterial blood pressure during epistaxis and evidence of sustained arterial hypertension, as determined by 24-hour ambulatory blood pressure measurement. RESULTS: Patients with epistaxis had significantly higher blood pressure values compared with those of control patients (systolic blood pressure 161+/-30 versus 144+/-22 mm Hg, P<.001; diastolic blood pressure 84+/-19 versus 75+/-15 mm Hg, P <.001). Of 33 (30%) of 108 patients with elevated blood pressure during epistaxis who were further evaluated, 26 (79%) patients were classified as having sustained arterial hypertension. Nine (27%) patients with sustained arterial hypertension were unaware of a history of hypertension. Patients with sustained arterial hypertension had significantly more episodes of epistaxis compared with patients with elevated blood pressure during epistaxis and no sustained arterial hypertension (mean 5 versus 1; P=.004). CONCLUSION: Patients with epistaxis have a higher blood pressure compared with that of control patients. Twenty-six (79%) of 33 patients with elevated blood pressure during epistaxis had sustained arterial hypertension. Nine (27%) of these patients were unaware of a history of hypertension. Continued management of patients with epistaxis and high blood pressure should include confirmation or exclusion of sustained arterial hypertension by 24-hour ambulatory blood pressure recording.

[Acute coronary syndromes: physiopathology and therapeutic aspects]. / Akute Koronarsyndrome: Pathophysiologie und therapeutische Aspekte.

This article discusses recent developments in the field of acute coronary syndromes including pathophysiological mechanisms as well as therapeutic strategies. A plaque disruption is caused by different stimuli in a plaque prone to rupture, i.e. a plaque with a lipid-rich core and high local concentration of inflammatory cells (T-cells, monocytes/macrophages, mast cells). These cells are capable of producing matrix degradation products and can reduce stability of a plaque. Thrombus formation, based on platelet activation and aggregation as well as fibrin formation, is the main consequence of plaque disruption. Depending on the degree of thrombus formation occlusion is followed clinically by unstable angina (subtotal occlusion) or by acute myocardial infarction (total occlusion). Accompanying vasoconstriction may further aggravate the situation. Principles of therapy are thrombus dissolution as well as prevention of new thrombus formation: main goals of thrombolytic therapy in acute myocardial infarction are a prompt (less than 3 hours), complete, and sustained (prevention of early thrombotic reocclusion) reperfusion.

[Sublingual nitroglycerin or intravenous enalaprilat in preclinical treatment of hypertensive patients with pulmonary edema]. / Sublinguales Nitroglyzerin oder intravenöses Enalaprilat in der präklinischen Behandlung von hypertensiven Patienten mit Lungenödem.

In a prospectively designed randomized study, we compared the efficacy of sublingual nitroglycerine and intravenous enalaprilat in the out-of-hospital treatment of 46 hypertensive patients with pulmonary edema (defined as rales over both lungs and systolic blood pressure > 200 mm Hg and diastolic blood pressure > 100 mg). The out-of-hospital treatment consists of oxygen (6 Ll/min) via a face mask, furosemide 80 mg i.v., opioids 10 mg s.c., and either sublingual nitroglycerine (n = 23; initial dose: 0.8 mg; repetitive application of 0.8 mg every 10 min until a cumulative dose of 3.2 mg) or intravenous enalaprilat (initial dose: 2.5 mg; repetitive application of 2.5 mg every 30 min until a cumulative dose of 10 mg). The aim of the antihypertensive treatment was a reduction of systolic blood pressure below 160 mm Hg and diastolic blood pressure below 90 mm Hg until admission to the emergency department. In the emergency room, an arterial and venous blood sample was taken to determine the respiratory (pO2, pCO2) and metabolic status (pH value; base-excess; serum lactate) of the patient. Successful antihypertensive treatment was observed in 13/23 (57%) patients of the enalaprilat group and 15/23 (65%) patients of the nitroglycerine group (p = 0.54). Systolic and diastolic blood pressure on admission were similar in both treatment groups (systolic RR: enalaprilat: 179 [31] mm Hg; nitroglycerine: 184 [38] mm Hg; p = 0.59; diastolic RR: enalaprilat: 96 [14] mm Hg; nitroglycerine: 101 [14] mm Hg; p = 0.12). No significant differences were observed between the enalaprilat and the nitroglycerine groups concerning respiratory and metabolic parameters on admission (pO2: 67 [15] vs. 64 [17] mm Hg; p = 0.50; pCO2: 46 [9] vs. 47 [13]; p = 0.75; pH value: 7.27 [0.12] vs. 7.27 [0.09]; p = 0.98; BE: -4.2 [3.7] vs. -5.7 [4.1]; p = 0.23; lactate: 4.2 [3.3] vs. 4.2 [2.7]; p = 0.98). Intravenous enalaprilat did not exhibit any advantage compared to nitroglycerine in terms of blood pressure reduction or respiratory and metabolic parameters on admission to the emergency room. We conclude that enalaprilat is no substitute for nitroglycerine in the out-of-hospital treatment of hypertensive patients with pulmonary edema.

The nitura study--effect of nitroglycerin or urapidil on hemodynamic, metabolic and respiratory parameters in hypertensive patients with pulmonary edema.

OBJECTIVE: To assess the effects of nitroglycerin or urapidil on hemodynamic, respiratory and metabolic parameters in hypertensive patients with pulmonary edema. DESIGN: Open, randomized and prospective clinical study. SETTING: Out-of-hospital setting and Emergency Department in a 2000-bed hospital. PATIENTS: Hundred twelve patients with evidence of hypertensive crises with pulmonary edema (systolic blood pressure (SBP) > 200 mmHg and/or diastolic blood pressure (DBP) > 100 mm Hg and rales over both lungs) at the time when the emergency physician arrived. INTERVENTIONS: The out-of-hospital treatment consisted of oxygen via face mask, 80 mg furosemide i.v., 10 mg morphium s.c., and either nitroglycerin sublingually (initial dose: 0.8 mg; repetitive administration of 0.8 mg every 10 min to a cumulative dose of 3.2 mg) or urapidil (initial dose: 12.5 mg i.v.; repetitive administration every 15 min to a cumulative dose of 50 mg). If SBP was more than 180 mm Hg and/or DBP more than 90 mm Hg on admission, antihypertensive treatment was continued with nitroglycerin (0.3-3 mg/h) or urapidil (5-50 mg/h). MEASUREMENTS AND RESULTS: Blood pressure (BP) was measured every 5 min with the use of an automatic oscillometric device. Serum lactate, PO2, pH value, and base excess (BE) were evaluated on admission and 6 h later. Blood pressure, serum lactate and BE on admission were significantly lower (SBP: 155 +/- 30 vs 179 +/- 33 mm Hg; p = 0.0002; DBP: 82 +/- 17 vs 93 +/- 19 mmHg; p = 0.001; lactate: 2.2 +/- 1.6 vs 3.9 +/- 2.7; p = 0.0001; BE: -1.9 +/- 3.9 vs -4.4 +/- 1.7; p = 0.0005) and PO2 and pH values were significantly higher in the urapidil group compared to the nitroglycerin group (PO2: 75 +/- 25 vs 66 +/- 17; p = 0.036; pH: 7.33 +/- 0.08 vs 7.29 +/- 0.09; p = 0.042). After 6 h no differences between the two groups were observed. CONCLUSION: The more pronounced BP reduction in the urapidil group was associated with an improved respiratory and metabolic situation in hypertensive patients with pulmonary edema. Therefore, urapidil is a valuable alternative to nitroglycerin in patients with pulmonary edema and systemic hypertension.

Course of blood pressure within the first 12 h of hypertensive urgencies.

OBJECTIVE: To evaluate the course of blood pressure within 12 h of a hypertensive urgency with or without oral antihypertensive treatment prior to discharge of patients from hospital. DESIGN: A prospective, double-blinded, placebo-controlled and randomized clinical trial. SETTING: Department of Emergency Medicine in a 2000-bed inner city hospital. PATIENTS: Forty patients successfully treated for a hypertensive urgency with intravenous administration of urapidil. INTERVENTIONS: We administered 60 mg urapidil orally or placebo prior to discharge of patients from hospital and evaluated the course of blood pressure within 12 h of the urgency by use of an ambulatory blood pressure measurement unit. MAIN OUTCOME MEASURES: Mean systolic and diastolic blood pressures within the first 12 h of a hypertensive urgency and the number of hypertensive and hypotensive episodes. RESULTS: Mean systolic and diastolic blood pressures were significantly lower in members of the urapidil group than they were in members of the placebo group (132 +/- 14 versus 147 +/- 18 mmHg, P = 0.003; 79 +/- 12 versus 87 +/- 14 mmHg, P = 0.047, respectively). The number of hypotensive episodes was similar for these two groups (three versus one, P = 0.32), whereas the number of hypertensive episodes was significantly lower for the urapidil group (13 versus 34, P = 0.001). CONCLUSIONS: Oral medication with urapidil prior to discharge results in lower overall blood pressure levels and reduces the risk of hypertensive episodes recurring within 12 h of a hypertensive urgency. Therefore, we recommend this therapeutic approach for patients with hypertensive urgencies, who are treated with an intravenous antihypertensive drug.

Attenuation of thrombolysis-induced increase of plasminogen activator inhibitor-1 by intravenous enalaprilat.

We examined the effect of intravenous enalaprilat on the course of PAI-1 plasma levels in 23 patients with acute myocardial infarction undergoing thrombolytic therapy. All patients received 100 mg aspirin, 1000 IU/h heparin, thrombolysis with 100 mg rt-PA within 90 min, and betablockers. Eleven out of 23 patients received 5 mg enalaprilat intravenously prior to thrombolysis. Blood samples for determination of PAI-1 plasma levels were collected on admission, 2, 4, 6, 12, and 24 h after thrombolysis. PAI-1 plasma levels in patients receiving enalaprilat were similar to those of the control patients before thrombolysis (5 ng/ml, 95% confidence interval: 2-10 vs. 7 ng/ml, 95% confidence interval: 2-10; p = 0.5). The PAI-1AUC was 9 ng/ml/h (95% confidence interval: 5-10) in the enalaprilat group and 19 ng/ml/h (95% confidence interval: 13-26) in the control group (p = 0.0006). The maximum difference was observed 6 h after thrombolysis (enalaprilat: 13 ng/ml, 95% confidence interval: 5-25, control: 42 ng/ml, 95% confidence interval: 18-55; p = 0.003). Our study clearly demonstrates that application of intravenous enalaprilat prior to thrombolysis attenuates the thrombolysis-related increase of PAI-1. This finding may suggest a possible therapeutic approach to influence the fibrinolytic system in patients with acute myocardial infarction after thrombolysis.

Safety and efficacy of urapidil and sodium nitroprusside in the treatment of hypertensive emergencies.

OBJECTIVE: To assess the safety and efficacy of urapidil compared to sodium nitroprusside in the treatment of hypertensive emergencies. DESIGN: Randomized, prospective clinical study. SETTING: Emergency department in a 2000-bed inner city hospital. PATIENTS: Eighty-one patients with hypertensive emergencies defined as elevation of systolic blood pressure above 200 mmHg and/or diastolic blood pressure above 110 mmHg plus evidence of end-organ damage were included in the study protocol. The efficacy of therapy was defined as 1) blood pressure reduction below 180/95 mmHg within 90 min and 2) no re-elevation of blood pressure during a 4-h follow-up period in primary responders. The safety of both drugs was defined as the number of minor and major side effects during treatment. INTERVENTIONS: Patients received either sodium nitroprusside (n = 35; continuous intravenous administration with a starting dose of 0.5 microgram/kg per min; increase in increments of 0.5 microgram/kg per min every 15 min until response to treatment or a maximum of 3 micrograms/kg per min) or urapidil (n = 46; intravenous bolus; starting dose: 12.5 mg; repetitive administration of 12.5 mg every 15 min until response or a maximum dose of 75 mg). MEASUREMENTS AND RESULTS: Blood pressure was measured every 2.5 min by using a non-invasive oscillometric blood pressure measurement unit. Response to treatment within 90 min was observed in 75 (93%) patients (urapidil: n = 41 [89%]; nitroprusside: n = 34 [97%]; p = 0.18). During the follow-up period 8/34 (24%) patients in the nitroprusside group and 1/41 (2%) patients in the urapidil group exhibited blood pressure re-elevation. Major side effects were observed in seven patients receiving nitroprusside and two patients in the urapidil group (p = 0.04). CONCLUSION: Urapidil is equally effective, compared to sodium nitroprusside, in the treatment of hypertensive emergencies. Due to a smaller number of adverse events, urapidil is a reasonable alternative to nitroprusside in the treatment of hypertensive emergencies.

Impact of the renin-angiotensin-aldosterone system on blood pressure response to intravenous enalaprilat in patients with hypertensive crises.

The purpose of the study was to evalute the impact of the renin-angiotensin-aldosterone (RAA) system on blood pressure (BP) response in patients with hypertensive emergencies and urgencies treated with intravenous enalaprilat. Thirty-five patients with a systolic BP (SBP) >210 mm Hg and/or diastolic BP (DBP) >110 mm Hg received 5 mg enalaprilat intravenously. The extent of systolic and DBP reduction was correlated with pretreatment concentrations of angiotensin II (ANGII) (SBP: r = -0.47; P = 0.006; DBP: r = -0.55; P = 0.001) and plasma renin activity (PRA) (SBP: r = -0.49; P = 0.003; DBP: r = 0.48; P = 0.007). Non-responders to enalaprilat exhibited significant lower pretreatment levels of PRA, angiotensin-converting enzyme (ACE) and ANG II compared to responders (PRA: 5.5 +/- 3.7 vs 1.1 +/- 2.2 ng/ml/h, P < 0.001; ACE: 12.8 +/- 3.5 vs 8.2 +/- 4.8 U/l, P = 0.003; ANG 11:8.7 +/- 6.2 vs 5.0 +/- 3.8 pg/ml, P = 0.04). In patients with severe hypotension following application of enalaprilat ANG II concentrations were significantly higher compared to patients with mean arterial BP reduction <25% (12.3 +/- 6.7 vs 5.6 +/- 4.0 pg/ml,P = 0.013). These data indicate that PRA and ANG II are the major determinants for BP response to enalaprilat. This relation between BP response and RAA system activity have important clinical implications for the treatment of patients with severe hypertension. Primary therapeutic failure indicates that the RAA system contributes very little to the hypertensive status of the patient. Thus, repetitive application on an ACE inhibitor in primary responders is clinically unhelpful and may result in an unnecessary delay of an effective BP reduction. In contrast, high ANG II concentrations are associated with a considerable risk for severe hypotension after enolanalaprilat application. Therefore, the status of the RAA system determines the efficacy as well as the safety of ACE inhibitor treatment in patients with severe hypertension.

Referral of outpatients with non-traumatic conditions for radiographic examinations in an emergency department.

The aim of the study was to evaluate the referral of outpatients with non-traumatic conditions for radiographic examinations and to assess the impact of the radiological report on the patient's management in an emergency department. In a prospectively designed study, 1223 X-ray examinations of 1116 non-trauma outpatients (640 males, 476 females; mean age: 44 +/- 18 years) requested over a 10-month period were evaluated. Patients were classified into four groups according to the presenting complaints (respiratory, abdominal, neurological or non specific symptoms). Analysis of data included the influence of age and presenting symptoms on the likelihood of abnormal radiological findings and the impact of the radiological result on the further management of the patient. In 455 (40.8%) patients an abnormal radiological result was observed. The likelihood of an abnormal radiological findings increased with age (age < 40 years: 33%; age > 40 years; 47%; p < 0.05). Whereas the rate of abnormal radiological findings was high in patients with specific symptoms (respiratory: 69%; abdominal: 37%; neurological: 38%), in patients with non-specific symptoms only 25% of all radiological examinations revealed an abnormality. The radiological result had an impact on the further management in 948 (85%) patients. As 45% of all radiographic examinations revealing a normal radiological result had a clinical impact, normal radiological reports are just as helpful as abnormal radiological findings in the management of non-trauma outpatients in an emergency department. Thus, we assume that the radiological result has a major impact on the management of non-trauma outpatients in the emergency department.

[A protocol for the assessment of patients with coma of unknown origin]. / Ein Protokoll zur Abklärung von Patienten mit Koma unklarer Genese.

OBJECTIVE: Evaluation of the applicability of a protocol designed for the quick and efficient management of patients with coma of unknown origin (CUO). METHODS: Every patient admitted to our Emergency Department with the diagnosis of CUO was evaluated with our diagnostic protocol. The first diagnostic steps included evaluation of the hemodynamic and respiratory situation, Glasgow Coma Scale, basic neurologic and clinical examination, as well as blood withdrawal, for analysis of metabolic and toxicologic parameters. If indicated, cranial computer tomography (CCT) and/or lumbar puncture were performed. RESULTS: Within the study period from 1. 1. 1995 until 30. 9. 1996, 122 patients (65 males, median age 50 years, 25 and 75 percentile: 33; 69) were included. Blood analysis and the toxicological screening were diagnostic effective in 66 patients, clinical examination and body temperature in one case each, CCT in 50 patients and lumbar puncture in 2 patients. By the use of this diagnostic protocol 51 neurologic, 38 toxicologic, 28 metabolic and 2 infectious causes of coma were diagnosed (98%). Etiology of 2 of the comas remained unclear. CONCLUSION: By using our protocol, 98% of the causes of CUO were clarified. The main causes of coma were of neurological, toxicological and metabolic origin. CCT and the blood analysis were the most important procedures leading to a final diagnosis.