Treatment of asymptomatic myocardial ischemia

BACKGROUND

Asymptomatic myocardial ischemia is commonly observed in patients with coronary artery disease. Numerous studies have shown that patients with asymptomatic ischemia are at higher risk for adverse outcome than those without ischemia. Several recent studies have investigated the therapeutic options available in the management of patients with asymptomatic myocardial ischemia.

METHODS

Recently published randomized controlled trials investigating the treatment of asymptomatic myocardial ischemia were reviewed.

RESULTS

The controlled trials suggest that (1) asymptomatic ischemia can be suppressed to various degrees using pharmacologic therapy or revascularization, (2) beta-blockers are in general superior to calcium channel blockers or nitrates in relieving asymptomatic ischemia, and (3) revascularization is superior to pharmacologic therapy.

CONCLUSIONS

A growing body of evidence suggests that in patients with coronary artery disease, treatment of asymptomatic ischemia may result in improved outcome. However, because of significant limitations in the published studies, additional studies with large sample sizes and broader inclusion criteria are needed.

A randomized trial of acidified nitrite cream in the treatment of tinea pedis

BACKGROUND

Nitric oxide is continually released from normal skin and has antimicrobial effects. An acidified nitrite cream releases supraphysiologic concentrations of nitric oxide and is fungicidal in vitro.

OBJECTIVE

The purpose of this study was to assess the efficacy of an acidified nitrite cream as treatment for tinea pedis.

METHODS

Sixty patients were recruited with both a clinical diagnosis of tinea pedis and hyphae identified on direct microscopy; they were randomly placed into an active group treated with twice-daily application of a mixture of 3% salicylic acid in aqueous cream and 3% nitrite in aqueous cream for 4 weeks and a control group treated with 3% salicylic acid in aqueous cream and aqueous cream alone. Nineteen patients completed the trial in the active group and 16 patients in the control group. Mycologic cure (negative results on microscopy and culture) and clinical improvement were measured at 0, 2, and 4 weeks and after a 2-week interval with no treatment.

RESULTS

At the end of the treatment period, 18 of the 19 patients in the active group were mycologically cured as were 11 of 16 in the control group (p = 0.042). Two weeks after the cessation of treatment, 13 of 19 patients in the active group were mycologically cured and 5 of 16 in the control group (p = 0.028). The initial clinical scores in the active and control groups were 8.1 and 8.19 (two-tailed p = 0.95). At 4 weeks they were 1.66 and 6.0 (two-tailed p = 0.002) and after 2 weeks with no treatment 1.45 and 7.4 (two-tailed p < 0.0002).

CONCLUSION

Acidified nitrite is effective therapy for tinea pedis.

Nitrite inhalants: history, epidemiology, and possible links to AIDS

Nitrite inhalants have been commonly abused substances in the United States. Nitrite inhalants and AIDS was a popular topic in the early 1980s, when the cause of AIDS was not known. With the discovery of HIV, concern about nitrite use in the USA waned. However, nitrite inhalant use is associated with behavioral relapse and HIV transmission among gay men, with decreased lymphocyte counts and natural killer cell activity in a few laboratory studies, and it remains a candidate cofactor in the pathogenesis of AIDS-related Kaposi's sarcoma. Discouraging nitrite use continues to be a worthwhile public health goal.

Synergism between superoxide dismutase and sodium nitrite in cardioprotection following ischemia and reperfusion

The effects of acidified sodium nitrite (NaNO2), a releaser of nitric oxide (NO), combined with human superoxide dismutase (hSOD), were investigated in a 6-hour model of myocardial ischemia (MI) with reperfusion in open-chest, anesthetized cats. Acidified NaNO2 (12.5 mmol/kg/hr) was infused intravenously in cats starting 0.5 hour after occlusion of the left anterior descending (LAD) coronary artery, which was reperfused 1.5 hour following occlusion. Significantly lower plasma creatine phosphokinase activities were observed at all times beyond 3 hours for MI cats given NaNO2 + hSOD when compared with the other MI groups. The areas-at-risk expressed as percentages of the total left ventricular weights were not significantly different among any of the MI groups. However, the necrotic area expressed as a percentage of the myocardial area-at-risk was significantly lower in the MI + NaNO2 + hSOD-treated cats compared with all other MI groups. The NaNO2-treated group also produced a significant decrease in the necrotic area relative to the area-at-risk. Cardiac myeloperoxidase (MPO) activities indicated no significant difference in number of neutrophils attracted to the ischemic zone in the NaNO2 + hSOD-treated MI cats when compared with the other MI groups. Acidified NaNO2 + hSOD together exert significant protection on the myocardium subjected to ischemia and reperfusion injury. NaNO2 may act synergistically with hSOD to prolong the action of NO by scavenging free radicals that inactivate NO.

Beneficial effects of two forms of NO administration in feline splanchnic artery occlusion shock

We studied the effects of nitric oxide (NO) solution and acidified sodium nitrite (NaNO2), which produces NO, in splanchnic artery occlusion (SAO) shock in cats. NO is thought to be endothelium-derived relaxing factor (EDRF), a labile substance having several potentially valuable biological effects. Anesthetized cats subjected to total occlusion of the celiac, superior mesenteric, and inferior mesenteric arteries for 120 min, followed by reperfusion, usually died approximately 60 min after reperfusion. NO infusion significantly improved survival time in SAO-shock cats compared with those receiving vehicle (P less than 0.005). Administration of NO also attenuated the increase in plasma activities of the lysosomal hydrolase cathepsin D (P less than 0.05), total amino-nitrogen (P less than 0.001), and of the cardiotoxic peptide, myocardial depressant factor (MDF) (P less than 0.001). SAO-shock cats treated with NaNO2 at pH 2.0 also exhibited lower plasma cathepsin D (P less than 0.001), amino-nitrogen (P less than 0.05), and MDF activities (P less than 0.01), and survival time was also significantly improved (P less than 0.02). The same dose of NaNO2 infused at pH 7.4 failed to exert any significant protective effect. These results indicate that NO exerts beneficial effects in SAO shock in cats and suggest that exogenously administered NO may be a potentially useful therapeutic agent in splanchnic ischemic shock, probably via a cytoprotective rather than a vasodilator effect.

[Prolonged use of intravenous nitro derivatives in acute myocardial infarction (AMI)]

A retrospective survey is made on 166 cases of acute myocardial infarction, treated with intravenous nitro-derivatives for eight days of continuous therapy. This therapeutic modality appears to gain four goals: a reduction in mortality of patients, a faster return of ST tract on isoelectric guideline, fewer ventricular pump failures. In the authors' point of view, a delay in the downward return of ST tract towards the isoelectric guideline is an important but ominous prognostic sign in this group of patients. Therefore, this modality of treatment is suggested for all patients with AMI, wherever the myocardial coronary lesion is localized.

Antidotal use of methemoglobin forming cyanide antagonists in concurrent carbon monoxide/cyanide intoxication

An estimated 35% of all fire victims in the United States have toxicologically significant blood levels of CO and CN. However, the treatment of concurrent CO/CN intoxication has been paid scant attention. The suggestion has been made that these victims should be treated for CN poisoning. The current therapeutic management of CN poisoning in this country includes the utilization of two methemoglobin formers: amyl nitrite and sodium nitrite. This study was undertaken to determine if the administration of methemoglobin formers is advisable, as the victim is already suffering from O2 deprivation due to the presence of carboxyhemoglobin. Groups of 28 male ICR mice (22-24 g) were injected i.p. with 5.0 mg/kg of KCN and then were exposed immediately to 0.35% CO for 8.5 min in a dynamic inhalation chamber. Half of the animals were marked randomly for antidotal intervention, the other 14 animals acted as controls. Treatment of survivors with amyl nitrite (12 mg/l of chamber air) for 1 min increased mortality 43%, whereas treatment for 2 min resulted in a 59% increase in mortality. A 25% increase in mortality was noted among those animals treated with sodium nitrite (80 mg/kg i.p.), as compared to the nontreated control survivors. Treatment with dimethylaminophenol (49 mg/kg i.p.) did not statistically affect mortality.

Therapeutic problems in cyanide poisoning

In three patients with severe acute cyanide poisoning, a cyanosis was observed instead of the bright pink skin coloration often mentioned as a sign in textbooks. Treatment of cardiopulmonary insufficiency is as essential as antidotal therapy and the use of sodium nitrite and 4-DMAP is not without risk as, in practice, the methemoglobin-level induced is difficult to control.

Nitrite/thiosulfate treated acute cyanide poisoning: estimated kinetics after antidote

A 34 year old, 73 kg man ingested a 1 gram potassium cyanide pellet in a suicide attempt. Within one hour, coma, apnea, metabolic acidosis, and seizures developed. Sodium nitrite and sodium thiosulfate were administered. Dramatic improvement in the clinical condition occurred by the completion of antidote infusion. Methemoglobin level was 2% immediately after nitrite administration. Serial whole blood cyanide levels were obtained, documenting a highest measured level of 15.68 mcg/mL. Estimations of toxicokinetic parameters including terminal half-life (t 1/2) (19 hours), clearance (163 mL/minute), and volume of distribution (Vd) (0.41 L/kg) were calculated. The nitrite/thiosulfate combination was clinically efficacious in this case and resulted in complete recovery.

[Current therapeutic concepts in the treatment of myocardial ischemia. Current and future drugs]

If myocardial ischemia always results from an imbalance between the needs and supplies in oxygen of the myocardium cells, the physiopathology of this process seems today infinitely more complex than the mere diminution or interruption of the output in a coronary artery. The extension of atheromatous lesions, the platelets aggregation, thrombosis, the coronary spasm, the release of products from the arachidonic cascade, the reactivity of the vascular endothelium, the profibrinolytic activity of the tissues are many of the intricate factors inducing myocardial ischemia. Cellular alterations, of which some are triggered by the release of oxygenated free radicals, lead then to an irreversible necrosis. The medications used until now in the treatment of angina are oxygen scavengers and research goes on in this direction with vaso-dilators beta-blockers, prolonged action nitro-compounds (nicorandil) or nitro-compounds with an action reinforced by N-acetyl-cysteine, bradycardiac derivates of alinidine and the new calcium antagonists dihydropyridine. However, the new physiopathological concepts of ischemia have opened new directions for the research: products which modify the arachidonic cascade by increase of synthesis or release of PGI2 (nafazatrom, defibrotide), by inhibition of TXA2 synthesis or blocking of TXA2 receptors, and similar products of PGI2 (iloprost); thrombolytic agents more specific of thrombin (PTA) or fibrinolysis activators (defibrotide), and anticoagulants with extended action; chelating agents of oxygenated free radicals (peroxide dismutase, catalase, peroxidase) or xanthine oxidase inhibitors; platelets anti-aggregates like ticlopidine which blocks the platelets receptors to fibrinogen, or inhibitors of the synthesis of pro-aggregating agents.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of nitrite treatment and stroma-free methemoglobin solution as antidotes for cyanide poisoning in a rat model

The standard nitrite/thiosulfate regimen for cyanide poisoning was tested in our rat model. By modifying the treatment regimen and the nitrite solution an effective antidote against an LD90 of cyanide could be produced. However, this treatment was effective against two times the LD90 only when administered ten minutes prior to cyanide injection. These results are in marked contrast to our results with stroma-free methemoglobin solutions (SFMS) which showed SFMS to be a highly effective antidote against four times the LD90 when administered 30 seconds after an intravenous injection of cyanide. SFMS proved to be an effective antidote for two times the LD90 when administered up to sixty seconds after the cessation of respiration.

Volatile nitrites. Use and adverse effects related to the current epidemic of the acquired immune deficiency syndrome

Early reports of the acquired immune deficiency syndrome (AIDS) in homosexual men suggested that the cause might be related to homosexual life-style practices, including use of recreational drugs. Inhalation of volatile nitrites is a possible contributing factor in AIDS because their pharmacologic properties lead to toxicity. Metabolism of N-nitroso compounds produces mutagens, teratogens, and potent carcinogens in 39 different animal species, and volatile nitrites have deleterious effects on human lymphocytes in vitro and in vivo. In relation to the current AIDS epidemic, the timing of production and sales of volatile nitrites for recreational use is the only new life-style factor that might answer the question "why AIDS now?" Prevalence of nitrite use among male homosexuals is very high, and almost every reported case of Kaposi's sarcoma during the past three years includes a history of prior nitrite use. The age of the group of patients in whom Kaposi's sarcoma and AIDS are developing is consistent with a cohort initially exposed seven to 10 years ago. Cessation of nitrite use could reduce the epidemic.