Demetrios J. Beldekos

Comparison of spirapril, isradipine, or combination in hypertensive patients with left ventricular hypertrophy: effects on LVH regression and arrhythmogenic propensity.

This study was designed to evaluate in 45 hypertensive patients with left ventricular hypertrophy (LVH) the effects of a 6-month course with one of three different antihypertensive regimens (the calcium channel blocker isradipine, the angiotensin converting enzyme inhibitor spirapril in monotherapy, or a combination of the two drugs, n = 15 per group) on blood pressure, LVH regression, and various functional correlates of LVH. All three treatment modalities decreased significantly LV mass index by an average of 10%, although the combination had the greatest blood pressure-lowering effect and spirapril had the least, as assessed by office resting pressures, ambulatory monitoring, and isometric grip testing. There was no correlation between magnitude of blood pressure lowering and degree of LVH regression. The effects of treatment on pressor hormone profiles differed among groups, as spirapril tended to suppress angiotensin II and norepinephrine, whereas isradipine had opposite effects. Exercise tolerance was prolonged by all three regimens, but significantly more by the combination. All three regimens decreased significantly the double product by 10% to 15%. Indices of electrophysiologic stability calculated from analysis of ambulatory electrocardiogram exhibited significant improvement in several parameters such as QRS duration, presence of late potentials, and measures of heart rate variability, resulting in fewer episodes of simple or complex ventricular arrhythmia. We conclude that all three regimens produce significant LVH regression associated with improved functional capacity and electrical stability. These results reflect the sum of the differential hemodynamic and hormonal effects exerted by each treatment modality.

Hemodynamic and Humoral Correlates in Essential Hypertension: Relationship Between Patterns of LVH and Myocardial Ischemia

While evaluating 45 hypertensive patients with left ventricular hypertrophy (LVH) for enrollment in a clinical research protocol, we had the opportunity to compare anatomic and functional characteristics of those with LVH and ischemia on an exercise tolerance test (ETT), but without coronary artery disease by angiography (group I, n=8), versus those with a normal ETT (group II, n=37). There were no differences in age, sex, severity, and duration of hypertension between the two groups, but group I patients were significantly more overweight and had a worse lipid profile. Blood pressure at peak ETT was higher in group I despite shorter exercise duration, although resting and ambulatory pressures were similar. Group I patients had evidence of more pronounced cardiac enlargement and LVH by both ECG and echo criteria and a characteristic pattern of more pronounced thickening at the apex, but both groups had equally good systolic function and similar degrees of mild diastolic dysfunction. Analysis of 24-hour ambulatory ECG showed a significantly greater propensity to ventricular arrhythmias in group I, as shown by the presence of late potentials in 4 patients, the presence of couplets in 3, runs of ventricular tachycardia in 2 (while none of group II patients had late potentials or complex arrhythmias), and an average frequency of isolated premature ventricular contractions approximately three times higher in group I than group II patients. Our data demonstrate that hypertensives with LVH associated with myocardial ischemia at stress but with normal coronary arteriograms tend to be more overweight, attain a higher systolic blood pressure at ETT despite a shorter duration, have a higher propensity for severe arrhythmias, and have an adverse lipid profile. LVH in these subjects is more pronounced by both ECG and echo criteria and is characterized by predominantly apical hypertrophy with left atrial and ventricular dilatation rather than overall LV wall thickening.

Effect of intravenous insulin administration on left ventricular performance during non-ST-elevation acute coronary events in patients with diabetes mellitus.

maintaining near-normal glycemia. 5 Group B patients were treated using the usual protocols, with oral hy- poglycemic drugs or 2 daily doses of intermediate- acting insulin. Supplementary small doses of short- acting insulin were administered subcutaneously only if glucose levels were 250 mg/dl. Mean daily plasma glucose levels were assessed in each patient in both groups by employing all the measured glucose values obtained during the study. The mean glucose level in the conservative treatment group was assessed by the 3 standard preprandial glucose values (at 7 A.M., 1 P.M., 6 P.M.), 1 measurement at 12 A.M. hours and any additional measurements that were performed accord- ing to the discretion of the attending physician. All patients were treated with an optimal antianginal reg- imen. Complete 2-dimensional, spectral, and color-fl ow Doppler echocardiographic examinations were per- formed by 2 examiners not involved in the fi nal anal- ysis of data, with a Hewlett-Packard Sonos 1000 Ul- trasound Machine (Andover, Massachusetts) with a 2.5-MHz transducer, while the patients were asymp- tomatic. Images were obtained within 3 hours from ad- mission and 72 hours later and stored on high-quality videotapes for later blinded analysis. A DI designed to determine the combined systolic and diastolic myocar- dial performance, and defi ned as the sum of isovolumet- ric contraction time plus isovolumetric relaxation time divided by ejection time, was estimated from LV outfl ow and mitral infl ow velocity patterns ((IVCT IVRT)/ ET).6 Videotape recordings were analyzed by 1 investi-

Influence of biochemical markers on thrombolysis effectiveness early in the course of ST-segment elevation myocardial infarction

tiveness of monteplase admlnistration prior to emergent PCI in AMI. METHOD: Out of 243 consecutive AMI from 1998 to 2002. we enrolled into the COMA trial 108 patients who were under 75 years of age and had been admitted within 12 hrs after the onset of AMI. Patients were randomly assigned to receive direct PCI (group P, n=57) or PCI followed by pretreatment with intravenous monteplase (27500 IU/kg. group M, 1x51). RESULTS: Primary endpoint of this trial was left ventricular function (EF) at 6 months follow-up. In the initial CAG before PCI, TIMIflow was obtained in 29% of group M, but in only 7% of group P (P=O.O02). There was no significant difference in the PCI success rate, major cardiac or bleeding complications in both groups. No-reflow phenomenon in group P was obselved more frequently than group M (17.5% vs 4.4%. P=O.O4). There were no significant differences EF in both groups. Thus, we divided the group M into subgroups according to whether or not TIMIflow was obsewd at initial CAG. In the group M with TIMIflow, LVEDVI was smaller and the EF was greater than Group P (SS.O+/1.8 vs 5&6+/-l .4, P=O.O02). QCA results showed that the mlnimal lumen diameter was larger in the monteplase group M immediately after PCI, and the difference was even greater at 6 months. CONCLUSION: Intravenous Injection of monteplase can promote rapid repertusion and appears to maintain LV function, to suppress LV remodeling and late restenosis. We propose a combination therapy of PCI with monteplase injection in order to achieve reperfusion as early as possible,

Influence of diabetes mellitus on intravenous thrombolysis effectiveness in patients with ST elevation myocardial infarction

Background-Early resolution of ST-segment elevation is associated with enhanced clinical outcome following ST elevation myocardial infarction (STEMI). Despite the improvements in the management of type 2 diabetic patients with STEMI these patients have unfavorable prognosis. The present prospective study investigated the hypothesis that type 2 diabetic patients may have a delayed ST-segment recovery during administration of intravenous thrombolysis even though within the desirable margin. Methods-The study cohort included 137 consecutive patients with STEMI; 105 were non-diabetic and 32 type 2 diabetic. All patients received thrombolysis in r6 hours from index pain and attained steady 250% ST-segment recovery within 90min. The course of ST-segment recovery was assessed utilizing continuous 12.lead electrocardiographic monitoring. Results-The time required for 250% ST-segment steady resolution was significantly greater in type 2 diabetics (P <O.OOi). Additionally, although there was no difference in the mcidence of TIMI 2 or 3 flow between the two groups, type 2 diabetics had significantly higher values of corrected TIMI frame count in the infarct-related arteries (P <O.OOl). By multwariate linear regression analysis diabetes mellitus was independently and positively related to the time for 150% ST-segment recovery (P ~0.001). Conclusions-The present study implies that type 2 diabetic patients may have delayed recovery of ST-segment elevation even dunng successful thrombolysis.