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Query: UMLS:C0020538 (hypertension)
 170,190 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Angiotensin-converting enzyme inhibitors are proved, effective agents for the treatment of hypertension and congestive heart failure. New data suggest that angiotensin-converting enzyme inhibitors may be effective therapy for patients following acute myocardial infarction. Results from clinical trials, such as the Survival and Ventricular Enlargement trial, have demonstrated that captopril attenuates left ventricular enlargement, minimizes and/or prevents the subsequent development of overt congestive heart failure, and improves survival in patients with asymptomatic left ventricular dysfunction after myocardial infarction. Clinical reinfarctions and need for subsequent revascularization procedures were also reduced with captopril. In the Acute Infarction Ramipril Efficacy study, patients with clinically evident heart failure following acute myocardial infarction who received ramipril demonstrated a significant reduction in mortality and cardiovascular events. The mortality benefit in this study was evident within 30 days, possibly reflecting differences in patients studied (ie, population with high-risk heart failure in the Acute Infarction Ramipril Efficacy study as opposed to population with asymptomatic left ventricular dysfunction in the Survival and Ventricular Enlargement trial). Contrary results have been reported in another major postmyocardial infarction trial, the Cooperative New Scandinavian Enalapril Survival Study, which evaluated enalaprilat/enalapril maleate in unselected patients with acute myocardial infarction. This article reviews the recent trials using angiotensin-converting enzyme inhibition after myocardial infarction and will explore the reasons why angiotensin-converting enzyme inhibition seems to be beneficial in this clinical setting.
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PMID:Comparing angiotensin-converting enzyme inhibitor trial results in patients with acute myocardial infarction. 788 63

Ramipril is a long-acting nonsulfhydryl angiotensin converting enzyme (ACE) inhibitor introduced for clinical use about a decade ago. Ramipril is a prodrug that undergoes de-esterification in the liver to form ramiprilat, its active metabolite. Ramipril rapidly distributes to all tissues, with the liver, kidneys and lungs showing markedly higher concentrations of the drug than the blood. After absorption from the gastrointestinal tract, rapid hydrolysis of ramipril occurs in the liver. In the therapeutic concentration range, protein binding of ramipril and ramiprilat is 73 and 56%, respectively. Ramiprilat binds to ACE with high affinity at concentrations similar to that of the enzyme and establishes equilibrium slowly. Although ramipril is metabolised by hepatic and renal mechanisms to both a glucuronate conjugate and a diketopiperazine derivative, most of the drug is excreted in the urine as ramiprilat and the glucuronate conjugate of ramiprilat. Elimination from the body is characterised by a relatively rapid initial phase with a half-life of 7 hours and a late phase with a half-life of about 120 hours. No clinically significant pharmacokinetic interactions between ramipril and other drugs have been reported. The drug has been generally well tolerated with the most prevalent adverse effects being dizziness (3.4%), headache (3.2%), weakness (1.9%) and nausea (1.7%). Ramipril is an effective and well tolerated drug for the treatment of hypertension and congestive heart failure in all patients, including those with renal or hepatic dysfunction, and the elderly.
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PMID:Clinical pharmacokinetics of ramipril. 813 99

We have studied the pharmacodynamic effects of ramipril, propranolol, and their combination, as well as the effect of propranolol on the pharmacokinetics of ramipril in 12 healthy men (age 24 (SD 6) y, weight 72 (7) kg). Propranolol and placebo, ramipril and placebo, or propranolol and ramipril were given orally for four days in a crossover, double-blind fashion. The pharmacokinetics of ramipril and ramiprilat were investigated on day 4. Effects on plasma renin activity, ACE activity, and heart rate and blood pressure both before and after a standardized exercise test were measured on days 1 and 4. On day 4 the combination reduced the mean arterial pressure by 2.8 mmHg compared with propranolol alone and by 3.7 mmHg compared with ramipril alone. Ramipril had no effect on the bradycardia induced by propranolol. Propranolol reduced exercise mean arterial pressure by 9 mmHg (day 4) and heart rate by 7 beats.min-1 (day 4) compared with ramipril; this was not affected by co-administration of ramipril. On day 4 the average plasma renin activity was not significantly higher than after the combination. ACE activity was not affected by propranolol. The pharmacokinetics of ramipril and ramiprilat were not influenced by propranolol. The combination of ramipril and propranolol has additive pharmacodynamic effects that may be useful in the treatment of hypertension.
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PMID:The pharmacokinetic and pharmacodynamic interactions of ramipril with propranolol. 827 50

Recent studies indicate that norepinephrine-induced contractile oscillations in the tail artery from stroke-prone spontaneously hypertensive rats (SHRSP) may be a vascular phenomenon independent of blood pressure level. The objectives of this study were: (1) to characterize pharmacologically the alpha-adrenoceptor mediating norepinephrine-induced oscillations in tail artery; and (2) to investigate the relationship between blood pressure level, altered by treatments with hydralazine/hydrochlorothiazide or the angiotensin converting enzyme inhibitor ramipril, and the observation of norepinephrine-induced oscillations in tail artery. The alpha 2-adrenoceptor agonists clonidine and guanabenz potently stimulated oscillatory contractions in the tail artery while the alpha 1-adrenoceptor agonists phenylephrine and methoxamine were considerably less potent. Yohimbine, an alpha 2-adrenoceptor antagonist, but not the alpha 1-adrenoceptor antagonist prazosin demonstrated high affinity for the receptor mediating norepinephrine-induced oscillatory contractions. These results support the hypothesis that norepinephrine-induced oscillatory contractions in the tail artery from SHRSP occur primarily through stimulation of alpha 2-adrenoceptors. Ramipril lowered blood pressure in SHRSP after 4 weeks of treatment during 6-10 weeks of life but did not alter the ability of the alpha 2-adrenoceptor agonist clonidine (10(-5) M) to induce contractile oscillations in tail arteries from SHRSP, indicating these oscillations are not a secondary effect of high blood pressure. These studies suggest that norepinephrine-induced oscillations in tail artery from SHRSP may be a vascular trait separate and distinct from blood pressure level and angiotensin II expression early in life.
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PMID:Effect of ramipril on alpha-adrenoceptor-mediated oscillatory contractions in tail artery of hypertensive rats. 828 89

Angiotensin-converting enzyme (ACE) inhibitors are now established drugs in the treatment of hypertension and heart failure. However, their use in patients after a myocardial infarction has occurred remains controversial. The major clinical question regarding ACE inhibitors is whether they should be given to all patients immediately after thrombolysis or whether their use should be restricted to a particular subgroup. This question has now been addressed in several large-scale trials of mortality after myocardial infarction, and no important new information seems likely to emerge on the issue. Clinicians must therefore decide what their practice will be on the basis of data that are currently available. The authors of the recently published Gruppo italiano per lo Studio delta Sopravvlvenza nell' infarcto Miocardico (GISSI-3) and Fourth International Study of Infarct Survival (ISIS-4) mega-trials advocate a policy of widespread and early use of ACE inhibitors in all patients after myocardial infarction occurs. However, the small mortality benefit observed from use of ACE inhibitors in these studies lacks certainly and may prove difficult to reproduce in the general population of patients who have had an infarct outside the setting of a trial. Although patients were essentially not selected apart from the exclusion of those with marked hypotension, the low 6-month and 1-year mortality figures indicate "selection" compared with the typical population of patients who have had a myocardial infarction. Furthermore, a significant long-term mortality benefit was not observed with the short-term (4- to 6-week) use of ACE inhibitors in these trials. In contrast, in the Survival and Ventricular Enlargement (SAVE), Acute Infarction Ramipril Efficacy (AIRE), and Trandopril Cardiac Evaluation (TRACE) trials, where evidence of impairment of ventricular function was used to select patients, both a marked and certain benefit regarding mortality was apparent from long-term prescription of these drugs. Importantly, the marked benefit observed in these selected patients may have been "diluted out" in the larger scale trials of unselected patients where the majority may have gained little and some may have been harmed by treatment or its withdrawal. In most of the large mortality trials the rationale for use of ACE inhibitors after myocardial infarction was stated to be their likely beneficial effect on "remodeling" of the heart after "Infarct expansion." Because adverse remodeling occurs in only a proportion of patients after a heart attack, the benefits of ACE inhibitor therapy might be predicted to be largely limited to this group, which would favor a selective policy. However, strong claims have been made that ACE inhibitors have other important actions, including prevention of myocardial infarction. If this is confirmed in a number of ongoing large-scale trials. then an even ore widespread use of these agents can be expected.
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PMID:Who should be treated with angiotensin-converting enzyme inhibitors after myocardial infarction? 867 63

A postmarketing surveillance study was undertaken to confirm the efficacy and safety of the angiotensin-converting enzyme inhibitor ramipril and to extend the findings of controlled clinical trials into real-world conditions. A total of 11,100 patients with mild-to-moderate hypertension treated by primary care physicians were enrolled in this 8-week, open-label study. Ramipril was usually initiated at a dosage of 2.5 mg once daily and titrated to achieve target blood pressure. Efficacy was assessed in 8261 patients for whom blood pressure data were recorded after the start of treatment: safety was assessed in all patients. Of patients with combined systolic and diastolic hypertension, 86.0% achieved a final diastolic blood pressure of < or = 90 mm Hg or a > or = 10 mm Hg decrease from baseline; the highest response was seen in elderly patients (87.2%), and the lowest response was seen in black patients (81.2%). Of patients with isolated systolic hypertension, 70.4% achieved a final systolic blood pressure of < or = 140 mm Hg or a > or = 20 mm Hg decrease from baseline, including 70.6% of women, 70.3% of men, and 69.1% of elderly patients; the highest response was seen in white patients (71.8%), and the lowest response was seen in black patients (64.4%). Adverse events were generally mild; cough (3.0%) was the most frequent. Once-daily ramipril was effective and well tolerated during an 8-week period in a large, diverse population of patients who had mild-to-moderate hypertension and who were treated by primary care physicians.
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PMID:The CARE Study: a postmarketing evaluation of ramipril in 11,100 patients. The Clinical Altace Real-World Efficacy (CARE) Investigators. 887 94

Ramipril, a once-a-day angiotensin-converting enzyme inhibitor, was studied in the treatment of mild-to-moderate hypertension in 240 patients. A total of 194 patients (111 women and 83 men; mean +/- SD age, 46.0 +/- 11.5 years) were considered assessable for study. After a 2-week placebo washout phase, all patients received ramipril 2.5 mg once daily for 4 weeks. At 4 weeks, blood pressure was evaluated for response to therapy. Responders to 2.5 mg were continued on the same dose; nonresponders received 5 mg once daily for another 4 weeks. Results showed that 91% of patients responded after 8 weeks of therapy, 60% to 2.5 mg and 31% to 5 mg. Ramipril was well tolerated and, because of its long half-life, can be considered a true once-a-day angiotensin-converting enzyme inhibitor for the treatment of patients with mild-to-moderate hypertension.
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PMID:An open-label, noncomparative, multicenter study of ramipril in the treatment of patients with mild-to-moderate hypertension. 900 32

A multinational, double-blind, randomised study was conducted to investigate the efficacy and safety of a low-dose combination of the angiotensin converting enzyme inhibitor, ramipril, and the calcium antagonist, felodipine ER, in 642 patients with mild to moderate hypertension [supine diastolic blood pressure (DBP) = 95-115 mm Hg]. After a 4-week single-blind placebo run-in, patients were randomly allocated to once-daily felodipine extended release (ER; 2.5 mg), ramipril (2.5 mg) or felodipine ER/ramipril (2.5/2.5 mg) for 12 weeks. In the intention-to-treat analysis, mean DBP decreased significantly (p < 0.0001) after felodipine ER, ramipril and the combination (-9.1, -9.8 and -11.4 mm Hg, respectively). The decrease was significantly greater with the combination than with felodipine ER monotherapy (p = 0.02). The number of responding patients (final DBP < or = 90 mm Hg or a decrease of > or = 10 mm Hg) was also higher with the combination than with felodipine ER or ramipril monotherapy (65.1%, 53.1%, 55.7%, respectively). There were no differences between the three groups with respect to the incidence of adverse events overall or those considered treatment-related. There were fewer cases of peripheral oedema with combination therapy than with felodipine ER monotherapy. Thirty-three patients (5.1%) withdrew from the study because of adverse events, but there was no clear pattern with regard to the specific events leading to withdrawal. There were no clinically relevant changes in laboratory or clinical safety variables. Ramipril/felodipine ER 2.5/2.5 mg is an appropriate starting dosage when initiating combination antihypertensive therapy.
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PMID:Ramipril and felodipine: a comparison of the efficacy and safety of monotherapy versus combination therapy. 901 Jun 11

1. In the present study the role of angiotensin II (AngII) in the development of cardiac hypertrophy in diabetes combined with hypertension was investigated. 2. Diabetes was induced in 8-week-old male spontaneously hypertensive rats (SHR) by intravenous injection of streptozotocin (45 mg/kg bodyweight). Diabetic SHR were treated with the angiotensin-converting enzyme (ACE) inhibitor ramipril at a dose of 0.4 mg/kg per day. 3. Twelve weeks following the onset of diabetes, hearts were arrested in diastole and were perfusion-fixed. The right ventricle and left ventricle plus septum were weighted and the volume of the ventricular walls was determined using the Cavalieri principle. 4. Induction of diabetes in SHR led to a significant reduction in bodyweight compared with non-diabetic control SHR and this was not affected by ramipril treatment. The development of hypertension was not as great in diabetic SHR compared with controls, such that at 12 weeks following the onset of diabetes systolic blood pressure (SBP) averaged 191 +/- 3 and 230 +/- 4 mmHg in diabetic SHR and controls, respectively. Ramipril treatment significantly lowered SBP in diabetic SHR. 5. The left ventricle plus septum volume:bodyweight ratio (LV vol:BW) was significantly higher in diabetic SHR compared with controls (3.83 +/- 0.19 and 3.26 +/- 0.16 mm3/g, respectively). Ramipril treatment did not affect growth of the left ventricle in diabetic SHR with the LV vol:BW ratio averaging 3.95 +/- 0.14 mm3/g. Similar trends on growth were observed in the right ventricle. 6. In conclusion, the development of cardiac hypertrophy in diabetic SHR appears to occur by mechanisms independent of AngII and the elevation of blood pressure.
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PMID:Cardiac hypertrophy in diabetic spontaneously hypertensive rats: role of angiotensin II? 917 55

1. Cardiovascular effects of submaximal antihypertensive doses of the angiotensin converting enzyme inhibitor, ramipril (0.25 mg kg-1 day-1 in the food), and the calcium channel blocker, felodipine (0.4 mg kg-1 day-1 subcutaneously by osmotic minipump), both alone and in combination, were examined in spontaneously hypertensive rats (SHR) in a four-week study. 2. Both ramipril and felodipine as monotherapy decreased systolic blood pressure. The antihypertensive effect of the drug combination was more than that of ramipril treatment alone, but not significantly better than that of felodipine monotherapy. Ramipril or felodipine treatments did not significantly affect the heart rate, either alone or in combination. 3. The beneficial effect of ramipril monotherapy on left ventricular hypertrophy was more prominent than that of felodipine. The cardioprotective effect of felodipine was improved when combined to ramipril. The systolic blood pressure at the end of the experimental period correlated only weakly with left ventricular hypertrophy. 4. Responses of mesenteric arterial rings in vitro were examined at the end of the four-week study. Ramipril and felodipine monotherapies as well as their combination markedly improved the endothelium-dependent vascular relaxation responses to acetylcholine. The combination of ramipril and felodipine slightly enhanced the endothelium-independent vascular relaxation responses to sodium nitroprusside. Ramipril treatment alone slightly diminished the vascular contractile responses to noradrenaline. Neither ramipril nor felodipine alone or in combination affected the vascular contractile responses to potassium chloride. 5. Ramipril treatment, both alone and in combination with felodipine, caused a three fold increase in plasma renin activity. Serum aldosterone, fasting blood glucose level, serum insulin and the 24 hour urinary excretions of sodium, potassium, magnesium, calcium, phosphorus or protein were not significantly affected by the drug treatments. 6. Our findings suggest that a better overall control of hypertension and end-organ damages, without an increase in adverse effects, can be achieved by the combination of submaximal antihypertensive doses of felodipine and ramipril than by monotherapy with either drug alone.
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PMID:Cardiovascular effects of a low-dose combination of ramipril and felodipine in spontaneously hypertensive rats. 917 93


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