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Query: UMLS:C0018801 (heart failure)
 72,216 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Angiotensin-converting enzyme inhibitors (ACEIs) are an important class of drugs in cardiovascular disease. As their name suggests, they act by blocking angiotensin converting enzyme, thereby limiting the production of angiotensin II, the most active component of the renin-angiotensin- aldosterone system. This system plays an important role in maintenance of blood pressure and electrolyte and fluid balance. Therefore, by blocking this system, the ACEIs have wide ranging effects. Recent trials have reaffirmed their place in the management of hypertension, congestive cardiac failure, in the prevention of renal complications in diabetes and the prevention of strokes in 'at risk' patients. There are still many ongoing trials using the ACEIs. These trials are mainly aimed at comparing their efficacy with 'older' drugs (such as betablockers) and 'newer' drugs such as the angiotensin receptor blockers and calcium antagonists in different indications, such as heart failure and diabetic nephropathy. The impact of these drugs on the prevention of macro- and micro vascular complications in diabetes is also being investigated. The results of all these trials, when available, are expected to reaffirm the important role of this class of drugs in our modern day medical armamentarium. In this review, the ongoing clinical trials involving ACEIs, the rationale behind these trials and what impact they hope to have on our current understanding of the role of this important class of drug in medical practice, will be discussed.
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PMID:Ongoing trials involving angiotensin-converting enzyme inhibitors. 1243 9

To evaluate the current status of the management of hypertensive patients in Japan, we investigated 907 treated hypertensive patients (486 females and 421 males; mean age, 66.7 years) followed by cardiologists. According to the guidelines for the management of hypertensive patients in Japan in 2000 (JSH-2000), only 41.5% of the subjects achieved the target blood pressure, with a mean systolic blood pressure of 140.0+/-14.9 mmHg and a mean diastolic blood pressure of 80.0+/-10.7 mmHg. There were no differences between patients with and without concurrent disease or among age groups (<60, 60-69, 70-79, and 80 years and over) in systolic blood pressure levels achieved. However, the diastolic blood pressure decreased with age, indicating an increase of the pulse pressure. Overall, the prescription rates were: calcium channel blockers (CCBs), 73.0%; angiotensin converting enzyme inhibitors (ACE-inhibitors), 31.3%; angiotensin receptor blockers (ARBs), 18.9%; beta-blockers, 16.2%; and diuretics, 10.1%. Although some selection of antihypertensive drugs was based on evidence from previous trials on hypertensive patients with diabetes mellitus, chronic heart failure and renal insufficiency, overall, CCBs were selected in all age groups and in all comorbid conditions. In conclusion, Japanese cardiologists do not appear to consider age and comorbidity when choosing antihypertensive managements. Based on current evidence, the management of hypertension should be individualized, with the blood pressure target level and antihypertensive medications chosen on the basis of age and comorbidity.
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PMID:The status of hypertension management in Japan in 2000. 1245 24

The most important advance in heart failure during the past decade has been the recognition that medications inhibiting neurohormonal activation relieve symptoms, reduce hospitalizations, and prolong survival in patients with heart failure from left ventricular systolic dysfunction. Recent trials with angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, aldosterone antagonists, and beta blockers have provided valuable information regarding the uses, dosing, and extent of therapeutic benefits of neurohormonal inhibition.
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PMID:Heart failure: recent advances in prevention and treatment. 1245 49

Numerous hypertension treatment trials have been reported during the past several years. In comparative studies it has been shown that the use of diuretics or diuretics/beta blockers has resulted in a reduction in morbidity/mortality equivalent to the use of other antihypertensive medications. This is true in both young and elderly patients. In one large 8-year study in diabetics, the use of a beta blocker/diuretic combination was shown to be as effective in reducing overall cardiovascular events as an angiotensin-converting enzyme (ACE) inhibitor/diuretic treatment program. Although most data indicate that the degree of blood pressure lowering accounts for most of the benefit, there are some differences in outcome that may be explained by different mechanisms of drug action. For example: 1) diuretics are more effective in preventing heart failure and overall cardiovascular events than alpha blockers; 2) an ACE inhibitor-based program is more effective in the elderly in reducing myocardial infarctions and heart failure than a calcium channel blocker-based program; and 3) a nondihydropyridine is more effective in reducing strokes, but less effective in preventing myocardial infarctions or heart failure, than a program based on diuretic therapy. There is also abundant evidence that the use of ACE inhibitors may prevent the occurrence of diabetes in hypertensive individuals and will reduce cardiovascular events in diabetics. Finally, the angiotensin receptor blockers have been shown to slow the progression of renal disease and prevent the occurrence of end-stage renal disease when compared to treatment regimens that do not include an angiotensin receptor blocker or ACE inhibitor. Updated treatment recommendations should include an ACE inhibitor and possibly an angiotensin receptor blocker along with diuretics and beta blockers as initial therapy. In addition, recommendations for the use of multiple-drug therapy have been reinforced by recent trials. Goal pressures are not readily achieved with monotherapy, especially in high-risk patients.
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PMID:Update on the management of hypertension: do recent clinical trial results indicate a change in national recommendations for therapy? 1246 17

Angioedema is a well-known side effect of treatment with an angiotensin-converting enzyme (ACE) inhibitor and one that we have been willing to accept in view of the incidence of the problem and the clear benefits of this class of agents in numerous clinical situations. Angioedema is also seen with angiotensin receptor blocker (ARB) therapy but much less frequently than with ACE inhibitors. The mechanism for angioedema with ARB therapy remains poorly defined. ACE inhibitor-related angioedema occurs more commonly in black patients. The basis for an increased risk of angioedema in black patients remains unclear. Angioedema can be life-threatening but more times than not it can be managed with conservative treatment measures including specifically the discontinuation of the medication and/or administration of an antihistamine and/or epinephrine. Occasionally, maneuvers to protect the integrity of the airway may be needed. In a heart failure patient having previously experienced ACE inhibitor-related angioedema, ARBs should be used cautiously since angioedema has been reported with ARB therapy in heart failure patients. The need to reduce renin-angiotensin aldosterone system activity in a heart failure patient would seem to justify the small risk of angioedema with ARB therapy in a patient having previously experienced ACE inhibitor-related angioedema.
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PMID:Angioedema in heart failure: occurrence with ACE inhibitors and safety of angiotensin receptor blocker therapy. 1246 24

Results of drug treatment of 51 patients (41 men, 10 women) aged 35-86 years (mean age 62 years) included into COPERNICUS trial are presented. All patients had compensated NYHA class IV chronic heart failure and left ventricular ejection fraction less than 25%. For at least 2 months the patients received therapy with diuretics and angiotensin converting enzyme inhibitors (84%) or angiotensin receptor blockers (16%) and then were randomized to either carvedilol or placebo. Average duration of follow-up was 17 months. Carvedilol was well tolerated both during dose titration and during maintenance therapy. Addition of carvedilol to standard therapy of patients with severe heart failure was associated with increase of average ejection fraction from 21.7 to 30.3%. Rates of cardiovascular and sudden deaths, risk of hospitalization among carvedilol treated patients were 25, 33 and 57% less than among patients subjected only to standard therapy.
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PMID:[Long term use of a non-selective beta-blocker with vasodilating properties carvedilol in patients with severe heart failure]. 1249 64

Angiotensin receptor blockers are a new class of agents that have made a major contribution to the treatment of hypertension. These agents effectively reduce blood pressure and are well tolerated. Other clinical trials have focused, however, on the much wider use of angiotensin receptor blockers in conditions such as congestive heart failure, postmyocardial infarction management, and diabetic nephropathy. Recent studies have provided evidence that these agents might confer target organ protection in hypertension that is equal to, and possibly better than, the benefits provided by conventional antihypertensive agents. Moreover, there is now little doubt that these drugs are effective alternatives to ACE inhibitors in heart failure and will become treatments of choice for patients with type 2 diabetes and nephropathy. Cardiovascular study outcomes have still not determined, however, whether high-risk patients would do better on angiotensin receptor blockers or angiotensin converting enzyme (ACE) inhibitors or a combination of both, except in cases of intolerance to ACE inhibitors.
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PMID:The angiotensin II receptor blockers: opportunities across the spectrum of cardiovascular disease. 1255 52

Type 2 diabetes is becoming very common and is closely linked to physical inactivity and obesity. It is associated with clustering of coronary risk factors and 60-80% of cases have hypertension. The first therapeutic action is appropriate adjustment of life style. Anti-hypertensive therapies such as diuretics, ACE inhibitors and calcium antagonists have been effective in reducing cardiovascular events in type 2 diabetes, though calcium antagonists may be less effective than older therapies and ACE-inhibitors in reducing the risk of heart attacks and heart failure (but possibly more effective in stroke reduction). Beta-blockers (BBs) have a poor image as a potential therapy due to apparent adverse effects on surrogate end-points such as insulin-resistance. However large, controlled trials have shown BBs to be highly effective in reducing the risk of cardiovascular events and death in post myocardial infarction patients with diabetes. The UKPDS study in type 2 diabetics with hypertension showed first-line beta-blockade to be at least as effective as ACE-inhibition in preventing all primary macrovascular and microvascular end-points. The active ingredient appears to be beta-1 blockade, acting not only to lower blood pressure but also to prevent sudden death and cardiovascular damage stemming from chronic beta-1 stimulation associated with raised noradrenaline activity. By contrast, in the LIFE study atenolol was less effective than the angiotensin receptor antagonist losartan in reducing cardiovascular events and all-cause mortality in mainly elderly hypertensives with diabetes. Thus the best beta-blocker results in reducing hard cardiovascular end-points occur in hypertension studies (including the UKPDS study) involving younger/middle aged (say less than 60-65 years) patients, with relatively high sympathetic activity, relatively compliant/elastic arteries (narrow pulse-pressure) and normally functioning beta-1 receptors. In elderly hypertensive patients beta-blockers may be given as second-line therapy on the back of a low-dose diuretic (but possibly as first line agent in elderly hypertensives with prior myocardial infarction). Thus inappropriate attention to surrogate end-points can lead to faulty prescribing habits. Beta-blockers, currently severely underprescribed, should be considered as a first line therapeutic option for all diabetics with ischaemic heart disease or younger/middle aged diabetics with hypertension (but co-prescribed with low dose diuretic therapy in the elderly). The active ingredient for cardiovascular protection appears to be beta-1 blockade; optimal efficacy in lowering blood pressure and safety e.g. reducing risk of bronchoconstriction, is achieved by choosing an agent with high beta-1 selectivity.
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PMID:Beta-blockers and diabetes: the bad guys come good. 1265 16

Pharmacologic clinical trials in heart failure (HF) have provided substantial advances in effective treatment of this condition, moving us from our focus on short-term symptom relief to an expectation of substantial improvement in long-term clinical outcomes for our patients. Based on an appreciation of the importance of neurohormonal activation in the pathophysiology of HF, clinical trials have demonstrated the value of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers in impeding the progression of HF and in reducing morbidity and mortality for patients with this condition. Clinical trials have further demonstrated the benefits of digoxin in improving symptoms and reducing hospitalization frequency, as well as in aldosterone blockade, at least in patients with severe symptoms. Given the ethical imperative to treat with ACE inhibitors, the angiotensin receptor antagonists have been difficult to study; nevertheless, their value is becoming increasingly clear, particularly for patients intolerant of ACE inhibitors. Trials with several classes of newer agents-cytokine antagonists, endothelin receptor blockers, and vasopeptidase inhibitors-have recently yielded disappointing results. Early results with vasopressin receptor antagonists provide some promise of long-term benefit. Clinical trials have provided significant treatment advances; ongoing and future trials will demonstrate the degree to which we can improve on what we have achieved to date with pharmacologic treatments.
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PMID:Improving clinical outcomes with drug treatment in heart failure: what have trials taught? 1267 Jun 37

Activation of the renin-angiotensin-aldosterone system is associated with unsatisfactory outcomes in patients with hypertension and heart failure in that activation of this system is correlated strongly with both the incidence and extent of end-organ damage. Despite the availability of the angiotensin converting enzyme inhibitors (ACEi) and the angiotensin receptor blockers (ARB), unblocked aldosterone levels remain an important risk factor for cardiovascular disease progression. New preclinical data generated over the last few years strongly supports the hypothesis that aldosterone has important deleterious effects on the cardiovascular system independent of the classical action of this hormone on renal epithelial cells. The new selective aldosterone blocker, eplerenone, has been shown to produce significant cardioprotective and renoprotecive effects in experimental models of cardiovascular disease. Early clinical studies suggests that eplerenone may have important therapeutic benefit in the treatment of hypertension and heart failure post-myocardial infarction (post-MI).
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PMID:Eplerenone, a new selective aldosterone blocker. 1267 58


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