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Biomedical subjects

J E Udelson

Publications and source records attributed to J E Udelson.

At least 37 records · Page 2Linked to original sources
PubMed1998

Warfarin anticoagulation and survival: a cohort analysis from the Studies of Left Ventricular Dysfunction.

OBJECTIVES: We sought to evaluate the relation between warfarin anticoagulation and survival and morbidity from cardiac disease in patients with left ventricular (LV) dysfunction. BACKGROUND: Warfarin anticoagulation plays a major role in the management of patients who have had a large myocardial infarction and in those with atrial fibrillation. However, its use in patients with LV systolic dysfunction has been controversial. METHODS: We reviewed data on warfarin use in 6,797 patients enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trial and analyzed the relation between warfarin use and all-cause mortality, as well as the combined end point of death or hospital admission for heart failure. We used Cox regression to adjust for differences in baseline characteristics and to test for the interaction between warfarin use and selected patient variables in relation to outcome. RESULTS: On multivariate analysis, use of warfarin was associated with a significant reduction in all-cause mortality (adjusted hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.65 to 0.89, p = 0.0006) and in the risk of death or hospital admission for heart failure (HR 0.82, 95% CI 0.72 to 0.93, p = 0.0002). Risk reduction was observed when each trial or randomization arm was analyzed separately, as well as in both genders. It was not significantly influenced by the presence of atrial fibrillation, age, ejection fraction, New York Heart Association functional class or etiology. CONCLUSIONS: In patients with LV systolic dysfunction, warfarin use is associated with improved survival and reduced morbidity. This association is primarily due to a reduction in cardiac events and does not appear to be limited to any particular subgroup.

Angina, Unstable↗
PubMed1998

Antiplatelet agents and survival: a cohort analysis from the Studies of Left Ventricular Dysfunction (SOLVD) trial.

OBJECTIVES: This study sought to evaluate the relation between antiplatelet agent (APA) use and survival and morbidity from cardiac disease in patients with left ventricular (LV) systolic dysfunction. BACKGROUND: APAs play an important role in the prevention and treatment of coronary disease. Their effects in patients with LV systolic dysfunction are unknown. METHODS: We reviewed data on APA use in 6,797 patients enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trial and analyzed the relation between their use and all-cause mortality as well as the combined end point of death or hospital admission for heart failure (HF). We used Cox regression to adjust for differences in baseline characteristics and to test for the interaction between APA use and selected patient variables in relation to outcome. RESULTS: APA use (46.3% of patients) was associated with significantly reduced mortality from all causes (adjusted hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.73 to 0.92, p = 0.0005) and reduced risk of death or hospital admission for HF (adjusted HR 0.81, 95% CI 0.74 to 0.89, p < 0.0001) but was not influenced by trial assignment, gender, LV ejection fraction, New York Heart Association class or etiology. A strong interaction was observed among APA use, randomization group and all-cause mortality. The association between APA use and survival was not observed in the enalapril group, nor was an enalapril benefit on survival detectable in patients receiving APAs at baseline. However, randomization to enalapril therapy significantly reduced the combined end point of death or hospital admission for HF in APA users. CONCLUSIONS: In patients with LV systolic dysfunction, use of APAs is associated with improved survival and reduced morbidity. This association is retained after adjustment for baseline characteristics. APA use is associated with retained but reduced benefit from enalapril.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1998

Factors influencing exercise performance in patients with left ventricular dysfunction. SOLVD Investigators. Studies of Left Ventricular Dysfunction.

BACKGROUND: The determinants of exercise performance are multifactorial and incompletely understood in patients with symptomatic left ventricular (LV) dysfunction, with much less information regarding asymptomatic LV dysfunction. This study assessed the hemodynamics and neurohormonal factors influencing exercise performance in patients with LV ejection fractions > or =0.35, both symptomatic and asymptomatic, enrolled in Studies of LV Dysfunction. METHODS AND RESULTS: We studied 103 patients enrolled prospectively in Studies of LV Dysfunction before randomized therapy; 38 were symptomatic and 65 had no or minimal symptoms. By using rest-exercise gated equilibrium radionuclide ventriculography and cuff blood pressure, we assessed the heart rate, LV and right ventricular (RV) volumes and ejection fractions, total peripheral resistance, the LV peak systolic pressure/end systolic volume ratio as an index of contractility, and plasma renin and norepinephrine at rest and during maximal graded supine bicycle ergometer exercise. Changes between rest and exercise were evaluated as indices of cardiovascular reserve. The cumulative workload ranged from 120 to 2,100 watt-min. At rest, the LV ejection fraction was 0.30 in asymptomatic patients and 0.25 in symptomatic patients, respectively (P < .0004). During exercise, asymptomatic patients had greater increases in heart rate, systolic blood pressure, LV ejection fraction, and cardiac output than symptomatic patients (P > or = .05). Combining all patients, the strongest univariate correlates of exercise workload were the ability to increase heart rate (r = 0.70), the pressure/volume ratio (r = 0.63), and systolic blood pressure (r = 0.55), and to decrease the total peripheral resistance (r = -0.47) with moderate correlations for the ability to increase LV and RV ejection fractions (r = 0.33 and 0.35, respectively) (P < .0008). By multivariate analysis, workload was modeled best by the changes in four factors: heart rate, systolic blood pressure, and the LV and RV ejection fractions (R2 = 0.54, P < .001). CONCLUSION: Exercise performance and its hemodynamics differed in patients with symptomatic and asymptomatic LV dysfunction. Rather than features at rest, the reserve capacities for increasing heart rate, systolic blood pressure, and the LV and RV ejection fractions were the predominant cardiac mechanisms related to greater exercise performance.

Adult↗
PubMed1998

Ventricular remodeling and its prevention in the treatment of heart failure.

Ventricular remodeling refers to changes in left ventricular (LV) geometry, mass, and volume in response to myocardial injury or alterations in load. The extent of LV dilatation or remodeling after myocardial infarction (MI) or in patients with heart failure is a strong predictor of both morbidity and mortality. Based on these observations, it is clear that LV remodeling is a maladaptive process. Two classes of drugs appear to inhibit LV remodeling. A large amount of data support the use of angiotensin-converting enzyme (ACE) inhibitors to improve survival and to prevent progressive remodeling. In addition, recent studies suggest that beta-adrenergic blockers have a beneficial effect on both survival and remodeling. These data support a causative role of the renin-angiotensin system and perhaps the sympathetic nervous system in this process. Thus, ACE inhibitors and possibly beta-blockers should be part of the pharmacologic regimen for the treatment of patients with LV dysfunction to prevent progressive LV remodeling.

Adrenergic beta-Antagonists↗
PubMed1997

Acute and long-term effects of the angiotensin-converting enzyme inhibitor, enalapril, on adrenergic activity and sensitivity during exercise in patients with left ventricular systolic dysfunction.

Patients with heart failure and left ventricular systolic dysfunction exhibit increased adrenergic activity but blunted adrenergic responsiveness. We studied patients enrolled in the Studies of Left Ventricular Dysfunction, examining exercise responses of heart rate (HR) and plasma norepinephrine (PNE). Eighty-seven patients were studied before randomization; 65 of these were examined 1 year after randomization to placebo or enalapril. Compared with prevention trial (asymptomatic) patients, patients in the treatment trial (symptomatic) had higher resting HR and PNE levels and less increase in HR with a greater increase in PNE with exercise. Acute administration of enalapril increased the resting HR in patients in the prevention trial only but had no significant effect on PNE. After 1 year of therapy, patients in the prevention trial exhibited no change. Within the treatment trial, the placebo group displayed both a higher peak PNE and increase in PNE with exercise than did the enalapril group, whose HR response was maintained in spite of a reduction of exercise PNE. We conclude that (1) compared with asymptomatic patients, symptomatic patients with reduced left ventricular ejection fraction manifest greater resting and exercise adrenergic activity, with blunted HR response; and (2) in symptomatic patients, 1 year of enalapril treatment effected an augmented HR response to adrenergic stimulation, supporting an interaction between the renin/angiotensin and adrenergic nervous systems. Normalization of adrenergic tone and response likely contributes to the benefits of long-term angiotensin-converting enzyme inhibitor therapy.

Aged↗
PubMed1997

Comparative diagnostic accuracy of Tl-201 and Tc-99m sestamibi SPECT imaging (perfusion and ECG-gated SPECT) in detecting coronary artery disease in women.

OBJECTIVES: This prospective study was conducted in 115 women to directly compare the sensitivity and specificity of thallium-201 (Tl-201), technetium-99m (Tc-99m) sestamibi perfusion and Tc-99m sestamibi electrocardiographic (ECG)-gated single-photon emission computed tomographic (SPECT) studies for detection of coronary artery disease (CAD). BACKGROUND: Data on the comparative diagnostic accuracy of Tl-201 and Tc-99m sestamibi perfusion imaging for the detection of CAD, specifically in women, are very limited. METHODS: Eighty-five patients with suspected CAD, scheduled for coronary angiography, and 30 volunteers with a pretest likelihood of < or = 5% for CAD were evaluated. Within 1 week, each patient underwent Tl-201 and Tc-99m sestamibi SPECT imaging procedures (both perfusion and gated SPECT imaging). Treadmill stress testing was used in 78 patients and dipyridamole in the remaining 37 patients. All images were interpreted by three observers in a blinded manner (consensus reading). Technetium-99m sestamibi SPECT studies were read without and then with ECG gating. Technetium-99m sestamibi gated SPECT studies were used to differentiate scar tissue from soft tissue attenuation artifact. RESULTS: The overall sensitivities for detecting > or = 50% and > or = 70% stenoses were 75.0% and 84.3%, respectively, for Tl-201, and 71.9% and 80.4%, respectively, for Tc-99m sestamibi perfusion studies (p = 0.48). The specificity for lesions > or = 50% was 61.9% for Tl-201 and 85.7% for Tc-99m sestamibi perfusion (p = 0.07), whereas for lesions > or = 70% it was 58.8% for Tl-201 and 82.4% for Tc-99m sestamibi perfusion (p = 0.01). When the 34 patients with a normal coronary angiogram were added to the group of 30 normal volunteers, the "specificity" for lesions > or = 70% was 67.2% for Tl-201, 84.4% for Tc-99m sestamibi SPECT perfusion (p = 0.02) and 92.2% for Tc-99m sestamibi gated SPECT (p = 0.0004). CONCLUSIONS: Both Tl-201 SPECT and Tc-99m sestamibi SPECT perfusion studies had a similar sensitivity for the detection of CAD in women. However, Tc-99m sestamibi SPECT perfusion imaging shows a significantly better specificity, which is further enhanced by the use of ECG gating.

Case-Control Studies↗
PubMed1997

Cost implications of selective preoperative risk screening in the care of candidates for peripheral vascular operations.

The preoperative identification that patients are at high risk for adverse postoperative outcomes is the first step toward preventing costly in-hospital complications. The economic implications of noninvasive screening strategies in the care of patients undergoing peripheral vascular operations must be clarified. A decision model was developed from the peer-reviewed literature on patients undergoing preoperative screening by means of dipyridamole myocardial perfusion imaging, dobutamine echocardiography, or cardiac catheterization before vascular operations (n = 23 studies). Routine versus selective screening strategies were compared for patients with an intermediate likelihood of having coronary artery disease on the basis of clinical history of coronary disease or typical symptoms. Median costs (1994 US dollars) of preoperative screening strategies were derived with two microcosting approaches: adjusted Medicare charges (top-down approach) and a bottom-up approach with Duke University Center direct cost estimate data. In-hospital cost was 11% higher for preoperative screening by means of routine cardiac catheterization ($27,760) than for routine pharmacologic stress imaging ($24,826, P = 0.001). The total cost of a do-nothing strategy, that is, no preoperative testing, was 5.9% less than that of routine preoperative pharmacologic stress imaging and 15.9% lower than that of cardiac catheterization (P = 0.001). Selective screening among patients with a history of coronary disease or typical angina resulted in further reduction of the cost of care to a level comparable with that of a do-nothing strategy (52.5% reduction in cost with pharmacologic stress imaging, P > 0.20). Use of noninvasive testing for preoperative risk stratification was cost effective for patients 60 to 80 years of age. Cost per life saved ranged from $33,338 to $21,790. However, coronary revascularization after an abnormal noninvasive test was cost effective only for patients older than 70 years. In this economic decision model, substantial cost savings were predicted when selective noninvasive stress imaging was added to preoperative screening for patients about to undergo vascular operations. With a selective screening approach, the economic impact of initial diagnostic testing may be minimized without compromising patient outcomes.

Decision Trees↗
PubMed1996

Double-blind, placebo-controlled study of the effects of carvedilol in patients with moderate to severe heart failure. The PRECISE Trial. Prospective Randomized Evaluation of Carvedilol on Symptoms and Exercise.

BACKGROUND: Carvedilol has improved the symptomatic status of patients with moderate to severe heart failure in single-center studies, but its clinical effects have not been evaluated in large, multicenter trials. METHODS AND RESULTS: We enrolled 278 patients with moderate to severe heart failure (6-minute walk distance, 150 to 450 m) and a left ventricular ejection fraction < or = 0.35 at 31 centers. After an open-label, run-in period, each patient was randomly assigned (double-blind) to either placebo (n = 145) or carvedilol (n = 133; target dose, 25 to 50 mg BID) for 6 months, while background therapy with digoxin, diuretics, and an ACE inhibitor remained constant. Compared with placebo, patients in the carvedilol group had a greater frequency of symptomatic improvement and lower risk of clinical deterioration, as evaluated by changes in the NYHA functional class (P = .014) or by a global assessment of progress judged either by the patient (P = .002) or by the physician (P < .001). In addition, treatment with carvedilol was associated with a significant increase in ejection fraction (P < .001) and a significant decrease in the combined risk of morbidity and mortality (P = .029). In contrast, carvedilol therapy had little effect on indirect measures of patient benefit, including changes in exercise tolerance or quality-of-life scores. The effects of the drug were similar in patients with ischemic heart disease or idiopathic dilated cardiomyopathy as the cause of heart failure. CONCLUSIONS: These findings indicate that, in addition to its favorable effects on survival, carvedilol produces important clinical benefits in patients with moderate to severe heart failure treated with digoxin, diuretics, and an ACE inhibitor.

Adrenergic beta-Antagonists↗
PubMed1996

Calcium channel blockers in heart failure: help or hindrance?

Since their development, calcium channel blocking agents have stimulated interest in their potential benefit for a variety of cardiovascular disorders, including heart failure. The rationale for the potential benefit of calcium channel blockers in heart failure is multi-factorial, including vasodilation, correction of perturbed diastolic relaxation, anti-ischemic action, and potential for inhibiting myocyte hypertrophy and injury. Despite these potential benefits, the degree of salutary influence has remained controversial, and a number of studies have suggested potential adverse action in patients with heart failure, perhaps linked to either negative inotropic action or to reflex neurohormonal activation. Diversity among different agents, particularly with regard to tissue selectivity and pharmacokinetics may imply substantial differences in the relative benefits and risks in various subgroups of patients with heart failure. One trial with the newer dihydropyridine agent, amlodipine, indicates benefit to survival in patients with moderate to severe heart failure and reduced ejection fraction. The reproducibility of this finding and the mechanism for this benefit deserves further investigation.

Calcium Channel Blockers↗
PubMed1995

Enhanced hepatic uptake of thallium-201 in patients with severe narrowing of the right coronary artery.

To assess the hepatic uptake of thallium-201 after exercise treadmill testing and to investigate whether hepatic uptake of thallium-201 may be a useful marker of right coronary artery (RCA) disease, 43 patients were studied: 17 with RCA disease (9 with 1-vessel disease, 8 with multivessel disease including the RCA), 8 with left coronary system disease alone, and 18 with a low probability (< 5%) of coronary disease. All subjects were studied with symptom-limited exercise and redistribution thallium-201 single-photon emission computed tomographic (SPECT) scintigraphy. Two indexes of hepatic uptake were derived: a liver-to-heart ratio after stress, and a stress-to-rest hepatic ratio. The low-probability group had a liver/heart ratio of 0.48 +/- 0.02. In the group with RCA disease alone, liver/heart ratio was 1.29 +/- 0.20 (p < 0.005 vs low-probability group). Patients with multivessel coronary artery disease involving the RCA had a ratio of 1.19 +/- 0.16 (p < 0.005 vs low-probability group), and patients with only left coronary system disease had a liver/heart ratio of 0.87 +/- 0.15 (p < 0.05 vs low-probability group). The stress/rest ratio of the low-probability group was 0.83 +/- 0.04. Patients with RCA disease alone had a stress/rest ratio of 1.49 +/- 0.25 (p < 0.05 vs low-probability group), and patients with multivessel disease involving the RCA had a stress/rest ratio of 1.16 +/- 0.08 (p < 0.005 vs low-probability group).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

Severe reversible global and regional ventricular dysfunction associated with high-dose interleukin-2 immunotherapy.

Cardiac toxicity and hemodynamic alterations are frequently associated with high-dose interleukin-2 (IL-2) immunotherapy in cancer patients. Serious cardiac events including myocardial infarction, ischemia, and noninfectious myocarditis have been observed. We document two cases of unusually severe but reversible cardiac abnormalities related to IL-2 therapy: one patient with a profound form of global myocardial hypocontractility and a second patient with regional aneurysmal and dyskinetic changes of the left ventricle. These cases exhibit unique features not previously described in IL-2-treated patients. The possible pathophysiologic mechanisms underlying these global and regional forms of cardiomyopathy, including the production of secondary-messenger molecules such as nitric oxide and myocardial stunning, are discussed. Both patients remain disease free of their cancer (> 3 years since completing therapy), are without residual cardiac dysfunction or recurrent related symptoms, and have not experienced any additional cardiac events. The report demonstrates the complexity of the cardiac toxicities associated with IL-2-based immunotherapy and recognizes a need for treating physicians to be familiar with their management.

Carcinoma, Renal Cell↗
PubMed1994

Physiologic significance of chronic coronary aneurysms in patients with Kawasaki disease.

OBJECTIVES: The aim of this study was to determine whether persistent coronary aneurysms in patients with Kawasaki disease are associated with altered myocardial perfusion and function. BACKGROUND: Some patients with Kawasaki disease have died suddenly because of severe coronary artery stenosis; others have chronic coronary aneurysms. METHODS: Eleven patients with chronic coronary aneurysms were enrolled in the study. The size of the aneurysms and the degree of associated stenosis were determined by angiography in nine patients and by echocardiography in two. All patients underwent simultaneous function and myocardial perfusion assessment during symptom-limited exercise by echocardiography and technetium-99m sestamibi imaging, respectively. RESULTS: Of 33 vascular territories, 18 contained coronary aneurysms measuring 3.5 to 10 mm. Three aneurysms were associated with significant stenosis as detected by angiography. Of the 18 vascular territories, 13 were normal, and 5 manifested stress-induced perfusion defects; of the latter 5 areas, 4 had associated wall motion abnormalities. The three territories supplied by stenotic coronary arteries had both abnormal regional function and perfusion demonstrated during exercise. CONCLUSIONS: Patients with chronic coronary aneurysms may have associated stenosis, as detected by angiography, with a subjacent myocardium that is subject to abnormal perfusion and function. However, the majority of coronary aneurysms are associated with normal regional coronary flow reserve, as assessed by myocardial perfusion imaging, and even giant coronary aneurysms may be associated with normal coronary flow reserve and preserved regional myocardial function during stress.

Adolescent↗
PubMed1994

An assessment of the positive predictive value and cost-effectiveness of dipyridamole myocardial scintigraphy in patients undergoing vascular surgery.

PURPOSE: The approach to cardiac risk stratification of patients undergoing vascular surgery continues to be controversial. The success of algorithms that use clinical risk factors to determine cardiac risk have been inconsistent. Dipyridamole myocardial scintigraphy (DMS) has been accepted as a sensitive, noninvasive approach to risk stratification with excellent negative predictive value. Low positive predictive value (PPV) of abnormal DMS scans is a shortcoming that contributes to extensive preoperative cardiac evaluation and intervention with associated morbidity, mortality, and cost in most patients who undergo uncomplicated vascular procedures, regardless of DMS results. METHODS: Over 6 years, 237 patients underwent DMS before surgical management of infrarenal aortic aneurysm, aortoiliac, or infrainguinal occlusive disease. The value of multiple clinical factors and DMS were assessed retrospectively for the prediction of perioperative myocardial infarction (MI), heart-related death, or preoperative selection for myocardial revascularization. Only congestive heart failure and two or more reversible defects on DMS were statistically significant on logistic regression analysis. RESULTS: The PPV of DMS was 19% for all patients with reversible defects, 12% for patients with one reversible defect, and 36.7% for patients with two or more reversible defects. The rates of cardiac death and MI were 1.3% and 5.9%, respectively. Perioperative echocardiography revealed unchanged postinfarction ejection fraction in most patients who experienced MI. Cost-effectiveness of DMS screening was evaluated. CONCLUSIONS: The costs per MI and cardiac death averted suggest a decline in cost-effectiveness of screening with DMS over time, assuming improving cardioprotective strategies of patient care. Clinical risk factors were minimally useful in the prediction of perioperative MI, heart-related death, or need for myocardial revascularization. The PPV of DMS is low, and the majority of MIs may be clinically insignificant. The cost-effectiveness of cardiac screening with DMS may not be justifiable given current trends of health care reform.

Aged↗
PubMed1994

Predicting recovery of severe regional ventricular dysfunction. Comparison of resting scintigraphy with 201Tl and 99mTc-sestamibi.

BACKGROUND: Regional 201Tl activity after resting injection, imaged early and after redistribution, reflects viable myocardium and can predict improved isotope uptake as well as regional and global ventricular function after revascularization. 99mTc-sestamibi, a perfusion tracer with favorable imaging characteristics, has distinct kinetics compared with 201Tl, demonstrating minimal redistribution; this property may give 201Tl an advantage for detecting viable myocardium, particularly in segments with resting hypoperfusion. The purpose of this study was to compare regional activities of 201Tl and 99mTc-sestamibi after resting injections in patients with coronary artery disease and regional or global left ventricular dysfunction and to assess their comparative abilities for predicting recovery of severe regional ventricular dysfunction after revascularization. METHODS AND RESULTS: Qualitative and quantitative comparisons of rest and redistribution 201Tl activity and sestamibi activity 1 hour after rest injection were performed in 31 patients with coronary artery disease and left ventricular dysfunction. Quantitative analysis of three short-axis tomograms per patient was performed by use of circumferential profiles that allowed analysis of 12 segments per patient. Two-dimensional echocardiography was used to assess wall motion and thickening in segments corresponding to the single photon emission computed tomography data. Concordance between regional 201Tl activity at redistribution imaging and regional sestamibi activity by semiquantitative visual analysis demonstrated concordant regional activity in 87% of segments; among discordant segments, no significant skew was seen, indicating enhanced uptake of one agent over the other. Quantitative analysis for all segments showed significant correlation (r = .86, P < .001) between quantitative regional 201Tl redistribution activity and 1-hour post-rest injection sestamibi activity in individual segments. Eighteen of these patients were revascularized, and echocardiography was repeated 20 +/- 16 days later; segments exhibiting significant regional ventricular dysfunction before revascularization were classified as having reversible or irreversible dysfunction on the basis of the change in wall motion and thickening. 201Tl and sestamibi regional activities were similar in those segments with reversible (72 +/- 11% [percent of peak activity] versus 75 +/- 9%, respectively, P = NS) as well as irreversible ventricular dysfunction (51 +/- 11% versus 50 +/- 8%, P = NS). Positive (75% versus 80% for 201Tl and sestamibi, respectively) and negative (92% versus 96%, respectively) predictive values for recovery of regional ventricular dysfunction after revascularization were similar for the two agents. CONCLUSIONS: In patients with coronary artery disease and left ventricular dysfunction, quantified sestamibi activity 1 hour after rest injection parallels redistribution 201Tl activity after a resting injection, suggesting that uptake and subsequent handling of sestamibi are more complex than can be explained by a pure flow tracer with no redistribution. Quantitative analysis of regional activities of both 201Tl and sestamibi after resting injections can differentiate viable from nonviable myocardium, and the two agents comparably predict reversibility of significant regional wall motion abnormalities after revascularization in such patients to a similar degree.

Adult↗
PubMed1993

Changes in ventricular volume, wall thickness and wall stress during progression of left ventricular dysfunction. The SOLVD Investigators.

To assess the long-term changes in cardiac function in asymptomatic patients with severe left ventricular dysfunction, left ventricular (cineangiography) and right ventricular (radionuclide angiography) function were assessed at baseline in 49 patients enrolled in the prevention arm of the Studies of Left Ventricular Dysfunction. After an average follow-up period of 12.4 months, 30 patients (11 randomized to the placebo group and 19 to the enalapril group) could be restudied to assess the progression of ventricular dysfunction. After 1 year of follow-up, the changes in heart rate, left ventricular end-diastolic and systolic pressure and right ventricular volumes were comparable in both groups. However, there were modest but opposite changes in left ventricular end-diastolic volume (+9 ml/m2 with placebo vs. -10 ml/m2 with enalapril, p < 0.05) and end-systolic volume (+5 ml/m2 with placebo vs. -13 ml/m2 with enalapril, p < 0.05). Mean systolic wall stress increased insignificantly in both groups, whereas ejection fraction increased from 29% to 31% in the placebo group and from 28% to 32% with enalapril (p = NS, placebo vs. enalapril). Even in asymptomatic patients with severe left ventricular dysfunction, there was a slow progression of left ventricular dilation. Enalapril administration appeared to slow this progression, but wall stress was not normalized by the treatment at the doses used in the study, indicating that at least one of the stimuli for further remodeling remained present.

Adult↗