Is aliskiren superior to inhibitors of angiotensin-converting enzyme and angiotensin receptor blockers in renin-angiotensin system blockade?

The renin-angiotensin system (RAS) plays a crucial role in development of hypertension, heart failure, as well as in the whole process of nephropathy, particularly of diabetic nephropathy, with or without proteinuria. Blockade of RAS plays the key role in the management of hypertension and other cardiovascular diseases. Angiotensin-converting enzyme (ACE) inhibitors do not provide the full blockade of angiotensin II because it is produced through alternative pathways. Angiotensin receptor blockers (ARBs) also block the negative feedback of angiotensin II upon renin like ACE inhibitors, leading to a several fold increase in angiotensin II levels. Aliskiren is an orally-active, nonpeptidic, direct inhibitor of renin which simultaneously reduces angiotensin I, angiotensin II and plasma renin activity (PRA). This is the main point of action of aliskiren, making it completely different from ACE inhibitors and ARBs. Aliskiren introduces a new concept into the management of hypertension. However, the question concerning its real role in the management of heart failure and its place in the existing therapeutic schemes with ACE inhibitors, ARBs, beta blockers and antagonists of aldosterone receptor, will be answered by numerous ongoing studies and clinical trials. Aliskiren shows renoprotective and antiproteinuric effects similar to those of ACE inhibitors and ARBs. The available results demonstrate that aliskiren provides a new approach to the antagonism of the RAS, offering possibilities of a more efficacious and effective treatment of hypertension, heart failure and proteinuria in diabetic patient.

Clinical, echocardiographic and echophonocardiographic characteristics of the atrial myxomas in 22 years period.

INTRODUCTION: Atrial myxomas are the most frequent benign tumors of the heart. Left atrial myxomas are about 3-4 times more frequent then right. Clinical findings reveal atrioventricular obstruction symptoms and signs, symptoms and signs of peripheral arteries or pulmonary artery embolisation and/or nonspecific symptoms. AIM: Review of atrial myxomas diagnosed at the Clinic of Cardiology in 20 years period and analysis of clinical characteristics, transthoracic echocardiographic (TTE), transesophageal echocardiographic (TEE), and M-mod echophonographic findings. METHODS: TTE is performed in all, but TEE in 16 patients. Simultaneous M-mod echophonocardiographic examination were performed in 11 patients, when optional equipment was applicable. RESULTS: We found 24 atrial myxomas: 19 (79.2%) in left and 5 (20.810%) in right atrium. 21(87.5%) patients had some of the symptoms, but 3 (12.5%) were asymptomatic. TTE was performed in all patients, but we found 1 (2.4%) false negative result. TEE was performed in 14 (58.3%) patients. Echophonocardiographic recordings showed early diastolic tumor "plop" in 10 patients and unusual late diastolic tumor "plop" in one right atrial myxoma, which has not yet been described. CONCLUSIONS: TTE is a reliable method in diagnosis of atrial myxomas, but not in all cases, while TEE has been found as always reliable. Echophonocardiographic recording is useful for confirmation and understanding of auscultatory finding when applicable.