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PubMed1996

[Are beta-blockers generally contraindicated in patients with peripheral arterial occlusive disease?].

Ninety patients with chronic ischemic heart disease and stage IIb peripheral arterial occlusive disease were investigated to determine the effect of celiprolol, atenolol and isosorbide dinitrate on peripheral arterial blood flow. Walking distance and the resistance index in the femoral artery were measured before and after 3 months medication and compared with the findings in controls (30 patients with chronic ischemic heart disease and stage IIb peripheral arterial occlusive disease) who received placebo. Patients with peripheral arterial occlusive disease who were treated with atenolol 50 mg/day demonstrated significant decreases in both pain-free and maximal walking distance. In contrast, the walking distances in those given celiprolol 200 mg/day and those who received isosorbide dinitrate 80 mg/day did not differ from the distances in control subjects. The Doppler flow through the femoral artery, as measured by color duplex sonography, showed a significant decrease in resistance index, both in patients given celiprolol and in those given isosorbide dinitrate. In patients treated with atenolol the resistance index rose significantly. The results of this study confirm that the beta-adrenoceptor blocker celiprolol exerts a supplementary vasodilatory action resembling that of nitrates and hence can be used in patients with chronic ischemic heart disease and impaired peripheral arterial perfusion.

Adrenergic beta-Antagonists↗
PubMed1987

Preoperative myocardial ischaemia: its relation to perioperative infarction.

One hundred consecutive patients undergoing coronary artery bypass surgery were randomly allocated to a preoperative (24 h) intravenous infusion of isosorbide dinitrate (1.5-15 mg/hr) (50 patients) or to placebo (50 patients). The characteristics of the two groups were similar. Evidence of acute myocardial ischaemia was sought by continuous electrocardiographic Holter recordings and acute myocardial infarction by the appearance of new Q waves and increased activity of the creatine kinase MB isoenzyme. Episodes of acute myocardial ischaemia were found in 18% of patients in the control group and in none of those who received isosorbide dinitrate. None the less, the frequency of perioperative myocardial infarction was similar (22% and 18% respectively) in the two groups. Perioperative infarction was significantly more common in women, in patients with unstable angina or poor left ventricular function, in those who had coronary endarterectomy, and in those in whom the aortic clamping time was greater than 50 minutes. These factors may have obscured any effect that prevention of preoperative ischaemia had on perioperative infarction. Preoperative infusion of isosorbide dinitrate eliminated preoperative ischaemia but did not influence the occurrence of perioperative infarction. The probable benefits of prevention of preoperative ischaemia on postoperative left ventricular function, which is a determinant of long term survival, remain to be established.

Acute Disease↗
PubMedDate not supplied

The cytoprotective effect of a nitric oxide donor drug on gastric mucous membrane of rats treated with ketoprofen, a non-steroidal anti-inflammatory drug.

BACKGROUND: Non-steroidal anti-inflammatory drugs are considered today a very important group of medication, with a wide variety of therapeutic use, in different areas of modern medicine. Despite their beneficial effects on the patient, these drugs show a high incidence of side effects, mainly in the gastrointestinal tract. The physiopathological mechanisms of non-steroidal anti-inflammatory drugs induced lesions and the gastric mucosa defense mechanism became an important source for medical research, especially those which try to evaluate the role of nitric oxide as a cytoprotective agent. AIM: To define a possible cytoprotective effect of a nitric oxide donor, isosorbide dinitrate, on the gastric mucous of rats submitted to non-steroidal anti-inflammatory drugs ketoprofen treatment. METHODS: Adult male Wistar rats, previously submitted to starvation for 24 hours and divided in three groups: group I (standard): animals that received isotonic saline solution intragastric by gavage and intravenous. Group II (control-ketoprofen): animals that received isotonic saline solution intragastric by gavage and ketoprofen intravenous. Group III (nitrate/ketoprofen): animals that received 2mM solution of isosorbide dinitrate intragastric by gavage and ketoprofen intravenous. Later on, these animals were sacrificed and had their stomach removed and submitted to macroscopical, microscopical and biochemical studies. The evaluated parameters were: a) gastric lesion index; b) gastric mucous layer thickness; c) gastric tissue nitrate/nitrite (NOx) concentration and d) gastric tissue malondialdehyde concentration. RESULTS: a) Gastric lesion index evaluation showed a smaller statistically significant incidence on the animals of group III; b) group III showed a thicker mucous layer, which also was statistically significant, when compared to group II; c) the variation on tissue nitrate/nitrite concentration was similar in all three groups, without statistical significance when compared to each other. CONCLUSION: Isosorbide dinitrate has a cytoprotective activity on the gastric mucosa of rats submitted to ketoprofen action.

Animals↗
PubMed1997

Beta-blockers and nitrates in patients with peripheral arterial occlusive disease: long-term findings.

METHODS: The effect of 6 months' administration of celiprolol, atenolol and isosorbide dinitrate on peripheral arterial occlusive disease (PAOD), double-blind and placebo-controlled, was investigated in 56 patients with chronic ischaemic heart disease and stage IIb PAOD, using as criteria the walking distance and the change in resistance index in the femoral artery. The placebo group consisted of 14 patients with chronic ischaemic heart disease and the same stage of PAOD. RESULTS: Patients on 50 mg/day atenolol showed a significant reduction in both pain-free and maximal walking range compared with the controls. In contrast, those taking 200 mg/day celiprolol and those on 80 mg/day isosorbide dinitrate demonstrated significant increases in pain-free and maximal, walking distance compared with the control group. The colour duplex sonographically measured Doppler flow through the femoral artery showed a significant decrease both in the patients taking celiprolol and in those on isosorbide dinitrate, while in those receiving atenolol the resistance index increased significantly. CONCLUSIONS: The study shows that the beta-adrenoceptor blocker celiprolol also possesses a nitrate-like vasodilatory property and can be used in patients with chronic ischaemic heart disease and impaired peripheral arterial blood flow.

Adrenergic beta-Antagonists↗
PubMed1983

Development of tolerance during nitrate therapy: dissociation of arterial and venous effects. A doppler echocardiographic study.

Using pulsed Doppler echocardiography as a noninvasive method to assess central venous return, nine healthy volunteers were studied before and after isosorbide dinitrate given four times daily for 8 days. First dose isosorbide dinitrate led to a drop in heart rate and mean arterial pressure, and right ventricular inflow velocities decreased. With sustained treatment effects on systemic venous return remained unaltered, whereas reduction in heart rate and in mean arterial pressure was lost. Regarding this disappearing response as indicating a form of tolerance, venous hemodynamic nitrate effects were unaltered by development of tolerance on the arterial side.

Adult↗
PubMed1997

Changing the oxygen tension alters the ability of bronchodilators to protect against methacholine-induced challenge in bovine isolated bronchial rings.

The ability of atrial natriuretic peptide, salbutamol, sodium nitroprusside and isosorbide dinitrate to protect against challenge with methacholine in bovine isolated bronchi was compared in different O2 tensions. Perfusing the Krebs-Henseleit solution with gas mixtures containing 95% O2 (hyperoxia), 20% O2 (approximately normoxia) and 0% O2 (hypoxia) produced O2 tensions in the organ-baths of 524, 147 and 26 mm Hg, respectively. In hyperoxia, pre-incubation of atrial natriuretic peptide at concentrations of 3 x 10(-7) M and 10(-6) M significantly attenuated responses to methacholine, whereas in normoxia, these concentrations of atrial natriuretic peptide had no effect. Furthermore, in hypoxia, 3 x 10(-7) M and 10(-6) M atrial natriuretic peptide significantly enhanced responses to methacholine. Salbutamol, at concentrations of 3 x 10(-7) M and 10(-6) M significantly attenuated responses to methacholine in hyperoxia, whereas in normoxia and hypoxia, pre-incubation of salbutamol did not alter the methacholine response. Pre-incubation of 10(-5) M sodium nitroprusside significantly attenuated methacholine-induced contractions in hyperoxia and when the oxygen tension in the gas mixture was lowered to 20% or 0%, the ability of sodium nitroprusside to protect against methacholine challenge was enhanced. In hyperoxia, isosorbide dinitrate, at the 10(-4) M level, evoked a rightward shift of the methacholine response curve. Lowering the oxygen tension to either 20% or 0% enhanced the protectant effect of isosorbide dinitrate, with the effect being greater in 20% O2. Thus, the effect of these bronchodilators on methacholine-induced challenge in hyperoxia O2 differed from those in normoxia and hypoxia, although the direction of the changes varied among the agents used. This suggests that the responses evoked by bronchodilators in 95% O2 may not necessarily predict those in the physiological range of oxygen tensions and that the relative effectiveness of bronchodilators may vary between normoxic and hypoxic conditions.

Albuterol↗
PubMed2004

Effects of nicorandil on cardiac sympathetic nerve activity after reperfusion therapy in patients with first anterior acute myocardial infarction.

PURPOSE: Ischaemic preconditioning (PC) is a cardioprotective phenomenon in which short periods of myocardial ischaemia result in resistance to decreased contractile dysfunction during a subsequent period of sustained ischaemia. Nicorandil, an ATP-sensitive potassium channel opener, can induce PC effects on sympathetic nerves during myocardial ischaemia. However, its effects on cardiac sympathetic nerve activity (CSNA) and left ventricular remodelling have not been determined. In this study, we sought to determine whether nicorandil administration improves CSNA in patients with acute myocardial infarction (AMI). METHODS: We studied 58 patients with first anterior AMI, who were randomly assigned to receive nicorandil (group A) or isosorbide dinitrate (group B) after primary coronary angioplasty. The nicorandil or isosorbide dinitrate was continuously infused for >48 h. The extent score (ES) was determined from 99mTc-pyrophosphate scintigraphy, and the total defect score (TDS) was determined from 201Tl scintigraphy 3-5 days after primary angioplasty. The left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF) were determined by left ventriculography 2 weeks later. The delayed heart/mediastinum count (H/M) ratio, delayed TDS and washout rate (WR) were determined from 123I-meta-iodobenzylguanidine (MIBG) images 3 weeks later. The left ventriculography results were re-examined 6 months after treatment. RESULTS: Fifty patients originally enrolled in the trial completed the entire protocol. After treatment, no significant differences were observed in ES or left ventricular parameters between the two groups. However, in group A (n=25), the TDSs determined from 201Tl and 123I-MIBG were significantly lower (26+/-6 vs 30+/-5, P<0.01, and 32+/-8 vs 40+/-6, P<0.0001, respectively), the H/M ratio significantly higher (1.99+/-0.16 vs 1.77+/-0.30, P<0.005) and the WR significantly lower (36%+/-8% vs 44%+/-12%, P<0.005) than in group B (n=25). Moreover, 6 months after treatment, LVEDV and LVEF were better in group A than in group B. CONCLUSION: These findings indicate that nicorandil can have beneficial effects on CSNA and left ventricular remodelling in patients with first anterior AMI.

3-Iodobenzylguanidine↗
PubMed1983

Analysis of oral molsidomine effects on ventricular function and dimensions in the conscious dog.

The effects of oral administration of molsidomine (50, 100 and 250 micrograms/kg) on left ventricular function, dimensions and hemodynamics were studied in chronically equipped, resting conscious dogs and compared to those of orally administered nitroglycerin (5, 10 and 20 micrograms/kg), as well as isosorbide dinitrate (50, 100 and 250 micrograms/kg). Enteral absorption of molsidomine was similar to that following intravenous administration of the compound, but was delayed in the case of both nitrates, so that restraint hemodynamic effects were noted. Molsidomine significantly decreased ventricular preload and internal heart dimensions. These effects were longer-lasting and more pronounced than those induced by either nitrate compound. Heart rate and LV dP/dtmax remained unaffected by molsidomine but increased in a dose-dependent fashion after administration of the nitrates. Left ventricular ejection phase contractility decreased with all three compounds. This effect was probably due to the reduced ventricular volumes and dimensions caused by molsidomine and isosorbide dinitrate, and to the additional tachycardia with concomitant reduction in ejection phase induced by nitroglycerin. Ejection time and stroke volume fell with all three agents but the effect occurred with a greater delay of onset and was more persistent after molsidomine. Nitroglycerin was found to increase cardiac output, initially, as a sequel of positive inotropy and chronotropy, with a subsequent decrease of cardiac output. In contrast, cardiac output fell by 28% and 30% (p less than 0.02) after administration of 250 micrograms/kg molsidomine or isosorbide dinitrate, respectively. These results suggest that molsidomine has no direct effects on myocardial hemodynamics and function in the resting, awake dog. The drug exerts its beneficial effects on heart performance by a long-lasting diminution of cardiac preload caused preferentially by dilatation of postcapillary venous vessels.

Administration, Oral↗
PubMed1983

Importance of venodilation during long-term vasodilator therapy of chronic left ventricular failure.

Vasodilators with different sites of action are used for long-term therapy of congestive heart failure, and selection of agents based on acute hemodynamic effects has been recommended. We compared the acute hemodynamic effects (by Swan-Ganz catheterization) and long-term responses (maximal oxygen uptake during exercise) associated with isosorbide dinitrate, a predominant venodilator, captopril, an arterial and venous dilator, and minoxidil, an arterial dilator, in 22 patients with congestive heart failure. In eight patients isosorbide dinitrate reduced pulmonary wedge pressure by 29% +/- 8% acutely (p less than .001) without significantly changing cardiac index or systemic vascular resistance. In eight patients captopril acutely reduced pulmonary wedge pressure by 42% +/- 22% (p less than .001) and systemic vascular resistance by 27% +/- 12% (p less than .01), while raising cardiac index by 19% +/- 18% (p less than .02). In six patients minoxidil raised cardiac index acutely by 38% +/- 30% (p less than .05) and reduced systemic vascular resistance by 35% +/- 12% (p less than .05) without changing pulmonary wedge pressure. After 2-5 months vasodilator administration maximal exercise oxygen uptake was increased by 7 +/- 3 ml/min/kg on isosorbide dinitrate (p less than .01), by 3 +/- 2 ml/min/kg on captopril (p less than .01), and by only 1 +/- 2 ml/min/kg on minoxidil (ns). Thus exercise capacity improved only during administration of drugs with venodilating action, failing to change during treatment with the arterial dilator despite a reduction in systemic vascular resistance. Predominantly arterial dilators alone may not be suitable for long-term vasodilator therapy for heart failure, and the regimens used should include venodilating agents.

Aged↗
PubMed1996

Effects of gradual volume loading on left ventricular diastolic function in dogs: implications for the optimisation of cardiac output.

BACKGROUND: Volume loading is commonly used to adjust preload and optimise cardiac output. It is difficult to monitor preload at the bedside because filling affects ventricular diastolic function and consequently end diastolic pressure, which is the variable used to monitor preload. OBJECTIVE: To assess the effects of gradual volume loading on the different components of left ventricular diastolic function---filling velocities, relaxation, and chamber compliance---to identify how excessive loading produces diastolic dysfunction. METHODS AND RESULTS: Eight mongrel dogs, anaesthetised and mechanically ventilated with both the chest and the pericardium closed, were studied during basal conditions (B), during gradual volume loading with physiological saline---5 ml/kg (VL5), 10 ml/kg (VL10), and 15 ml/kg (VL15)---and during infusion of isosorbide dinitrate (10 g/kg/min) started after the VL15 load was achieved. Dogs were monitored haemodynamically and by transthoracic Doppler echocardiography to assess peak modal velocities of the E and A waves, E/A ratios, and the deceleration time of the E wave. M mode recordings of aligned mitral and aortic valve motion were also obtained to calculate the isovolumic relaxation time. Effects of volume loading on ventricular diastolic function seemed to occur in two phases. Small and moderate volume loads (VL5 and VL10) promoted early ventricular filling, increasing E wave velocities, improving the mean (SD) E/A ratio from 1.95 (0.3) (B) to 2.0 (0.27) (VL5) and 2.6 (0.3) (VL10) (P < 0.00005), prolonging the E wave deceleration time, and only slightly increasing ventricular diastolic pressures. These changes suggest an improvement in ventricular compliance. Extreme volume loads (VL15) produced an abrupt reduction in early ventricular filling, which was transfered to late in diastole, by decreasing E wave velocity, by increasing A wave velocity, and by decreasing E/A ratio from 2.6 (0.3) (VL10) to 0.8 (0.05) (VL15) (P < 0.00005). The E wave deceleration time was shortened and left ventricular diastolic pressures were much increased, all suggesting a deterioration in chamber compliance. All these restrictive changes were promptly reversed by the perfusion of isosorbide dinitrate. The isovolumic relaxation time steadily increased with volume loading. CONCLUSIONS: Small and moderate volume loads improved ventricular diastolic function by promoting early ventricular filling and increasing ventricular compliance. Extreme volume loads promptly induced a diastolic restrictive pattern, transferring filling to the second part of diastole (increasing dependence on atrial contraction) and reducing ventricular compliance. These changes in ventricular diastolic function were independent of simultaneously measured haemodynamic systolic performance and were promptly reversed by isosorbide dinitrate, which after extreme loading promoted early filling, myocardial relaxation, and improved chamber compliance.

Animals↗
PubMedDate not supplied

[Correction of hemodynamic disorders in phthisiologic surgical patients with chronic pulmonary heart disease in preoperative period].

The hypokinetic blood circulation was detected in 49% (from a total of 180) patients with different forms of pulmonary tuberculosis. Obvious initial signs of disorders in the function of the cardio-vascular system were diagnosed in one half of patients with the normal kinetic blood circulation. 48 patients underwent a preoperative treatment to correct the hemodynamic disorders. Isosorbide dinitrate (5 mg/day), verapamilhydrochlorid (240 mg/day), maleate enalapril (5 mg/day) and isosorbide dinirate (80 mg/day) were administered simultaneously. The preoperative preparation of patients lasted from 4 to 7 days. The cardiac beat, and the mechanical index of the functioning of the left ventricle essentially improved, while the total peripheral resistance significantly decreased due to all treatment schemes. Isosorbide dinitrate and verapamilhydrochlorid produced the most effect on the parameters of the central hemodynamics. The administration of all above preoperative preparation schemes in patients with pulmonary tuberculosis reduces the operation-anesthesiology risk.

Drug Therapy, Combination↗
PubMed1982

Vasodilators in heart failure secondary to coronary artery disease.

Although vasodilators produce acute beneficial hemodynamic effects in patients with chronic congestive heart failure, their effects on the long-term management of such patients are unclear. In 56 patients followed up for an average of 13 months, there was a 37% mortality at 1 year. Because of the potential adverse effects of vasodilators in patients with coronary artery disease, we evaluated the effects of prazosin, hydralazine, and isosorbide dinitrate on hemodynamics, coronary sinus flow, and myocardial oxygen consumption (MVO2). Isosorbide dinitrate reduced ventricular filling pressure with no change in heart rate or mean arterial pressure; coronary sinus flow and MVO2 fell significantly. With prazosin there was a reduction in ventricular filling pressures and rate-pressure product but no change in coronary sinus flow or MVO2. With hydralazine there were parallel changes in the rate-pressure product and MVO2. Results emphasize the differing effects of vasodilators on oxygen supply and demand, which may influence the long-term course of patients with coronary artery disease.

Cardiac Output↗
PubMed1991

The day-long antianginal effectiveness of nitroglycerin patches. A double-blind study using dose-titration.

This study was designed to determine the day-long antianginal effectiveness of nitroglycerin patches in the nitrate-exposed patient, as well as the doses required. Eight men with chronic stable angina, a positive treadmill test, and demonstrated responsiveness to long-term oral isosorbide dinitrate were studied after they had been taking effective doses of isosorbide dinitrate three times a day for at least two weeks. Treadmill exercise bouts were performed every 1 to 2 hours over 1 day, after the 8 am application of active nitroglycerin patches in a previously titrated dose, and on another day after application of placebo patches. Mean necessary effective patch dose was 125 sq cm (60 to 220 sq cm). Mean exercise duration to angina rose from 271 to 480 s (p less than 0.001) 1 hour after active patches, while resting systolic blood pressure fell from 122 mm Hg to 100 mm Hg (p less than 0.001). (After placebo patches: +19 s and -2 mm Hg, respectively.) Active patches were superior to placebo throughout the day, but in declining degree (by 94 s at 7 pm, p less than 0.05). Thus, nitroglycerin patches can provide a significant day-long antianginal effect in the patient with long-term exposure to nitrate. However, the need for large doses and individual titration may make this therapy impractical.

Administration, Cutaneous↗
PubMed1993

The influence of atrial fibrillation on prognosis in mild to moderate heart failure. The V-HeFT Studies. The V-HeFT VA Cooperative Studies Group.

BACKGROUND: Atrial fibrillation occurs commonly in heart failure; however, its importance in terms of prognosis is controversial. METHODS AND RESULTS: We assessed the relation of atrial fibrillation on first Holter monitor to morbidity and mortality in mild to moderate heart failure in 632 patients in the Veterans Affairs Vasodilator-Heart Failure Trial (V-HeFT) I and 795 patients in V-HeFT II: Ninety-nine patients in atrial fibrillation and 533 patients in sinus rhythm were followed for a mean of 2.5 years (range, 6 months to 5.7 years) in V-HeFT I; 107 patients in atrial fibrillation and 688 patients in sinus rhythm in V-HeFT II were followed for a mean of 2.5 years (range, 6 months to 5.0 years). V-HeFT I compared treatment with prazosin, hydralazine-isosorbide dinitrate, and placebo, whereas V-HeFT II compared hydralazine-isosorbide dinitrate with enalapril. Follow-up evaluations included serial Holter monitors, serial metabolic exercise testing, hospitalization data, and clinical examinations. In V-HeFT I, cumulative mortality at 2 years was 0.34 for patients with atrial fibrillation and 0.30 for patients in sinus rhythm (p = 0.25). Overall cumulative mortality was 0.54 for atrial fibrillation patients and 0.64 for sinus rhythm patients (p = 0.86). In V-HeFT II, cumulative mortality at 2 years was 0.20 for patients with atrial fibrillation and 0.21 for patients with sinus rhythm (p = 0.68), and overall cumulative mortality was 0.46 for atrial fibrillation patients and 0.52 for those in sinus rhythm (p < 0.46). Sudden death was not increased with atrial fibrillation in V-HeFT I patients (p = 0.64) or in V-HeFT II (p = 0.68). By multivariate analysis, the relative mortality risk for atrial fibrillation was 0.95 in V-HeFT I and 0.76 in V-HeFT II: Metabolic exercise testing, showed no significant difference in mean change in peak oxygen consumption between patients with atrial fibrillation and those with sinus rhythm in V-HeFT I and a slight decrease late in V-HeFT II: Hospitalization rate for heart failure was not increased in either study. The embolic event rate was not increased for atrial fibrillation patients: 3% versus 4.9% of patients in sinus rhythm (p = 0.41) in V-HeFT I and 4.0% versus 6.0% in V-HeFT II patients (p = 0.44). A secondary analysis compared mortality of patients in atrial fibrillation with that of patients in sinus rhythm on all Holters: Mortality was not increased overall (p = 0.72 in V-HeFT I and p = 0.35 in V-HeFT II). CONCLUSIONS: Atrial fibrillation does not increase major morbidity or mortality in mild to moderate heart failure.

Atrial Fibrillation↗