Atrial natriuretic peptide levels in rheumatic mitral regurgitation and response to angiotensin-converting enzyme inhibitors

BACKGROUND

Rheumatic mitral regurgitation (MR) causes heart failure by volume overload and an increase in atrial natriuretic peptide (ANP) levels by atrial stretching. Symptoms of heart failure improve with ANP treatment. Angiotensin-converting enzyme inhibitors (ACEI) and ANP have similar effects, such as vasodilation, natriuresis and diuresis.

OBJECTIVE

To determine ANP levels and response to ACEI treatment in children with rheumatic MR.

PATIENTS AND METHODS

Patients with rheumatic MR were divided into two groups: the digoxin group (10 girls, two boys; age range 10 to 18 years, mean 14 +/- 0.72 years; taking digoxin for at least one year) and the control group (eight girls, four boys; age range eight to 17 years, mean 13.5 +/- 0.81 years). None of the patients in either group had symptoms of heart failure. Serum ANP levels, left ventricular systolic functions, and mitral and aortic stroke volumes of both groups were evaluated on admission. The digoxin group was given ACEI and re-evaluated on the 20th day of treatment.

RESULTS

At baseline, ANP levels were higher in the digoxin group (27.3 +/- 6.5 pg/100 microL) than in the control group (6.9 +/- 0.9 pg/100 microL) (P<0.05). On the 20th day of treatment, there were no significant differences in the ANP levels of the digoxin (13.2 +/- 6.1 pg/100 microL) and control groups. There was a significant decrease in ANP levels in the digoxin group between baseline and the 20th day of therapy. Mitral stroke volumes (510.4 +/- 92.8 mL/m2) and left ventricular diastolic volume (108 +/- 12 mL/m2) in the digoxin group at baseline were higher than those in the control group (315.3 +/- 59.9 mL/m2 and 82 +/- 6.5 mL/m2, respectively) on admission; on the 20th day of treatment, there were no significant differences in these values. At baseline, aortic stroke volume in the digoxin and control groups were 86.9 +/- 59.1 and 82.9 +/- 28.3 mL/m2, respectively (P>0.05). On the 20th day of therapy, the aortic stroke volume of digoxin group had increased to 104.7 +/- 70.1 mL/m2, significantly higher than that of the control group.

CONCLUSION

ANP levels are a good indicator of volume overload. ACEI should be introduced at an early stage of rheumatic MR because, even if patients are taking digoxin, their heart failure may progress silently.

A case of acute rheumatic fever accompanied by transient aortic regurgitation

Though acute rheumatic fever (RF) is now rare in Japan, it continues to be an important disease condition that physicians should be prepared to diagnose and treat. We describe a patient with acute RF accompanied by transient aortic regurgitation (AR). The AR was detected only by echocardiography. There were no other indications, and it disappeared after treatment with prednisolone. The changes in cardiac valves in the early phase of RF have been the subject of only a few case studies. Echocardiography is quite valuable in the workup of patients with acute RF and should be performed even if there are no signs of cardiac involvement.

Clinical profile of acute rheumatic fever in Pakistan

We designed a multi-hospital prospective study of children less than 12 years to determine the comparative clinical profile, severity of carditis, and outcome on follow up of patients suffering an initial and recurrent episodes of acute rheumatic fever. The study extended over a period of 3 years, with diagnosis based on the Jones criteria. We included 161 children in the study, 57 having only one episode and 104 with recurrent episodes. Those seen in the first episode were differentiated from those with recurrent episodes on the basis of the history. The severity of carditis was graded by clinical and echocardiographic means. In those suffering their first episode, carditis was significantly less frequent (61.4%) compared to those having recurrent episodes (96.2%). Arthritis was more marked in the first episode (61.4%) compared to recurrent episodes (36.5%). Chorea was also significantly higher in the first episode (15.8%) compared to recurrent episodes (3.8%). Sub-cutaneous nodules were more-or-less the same in those suffering the first (7%) as opposed to recurrent episodes (5.8%), but Erythema marginatum was more marked during the first episode (3.5%), being rare in recurrent episodes at 0.9%. Fever was recorded in approximately the same numbers in first (45.6%) and recurrent episodes (48.1%). Arthralgia, in contrast, was less frequent in first (21.1%) compared to recurrent episodes (32.7%). A history of sore throat was significantly increased amongst those suffering the first episode (54.4%) compared to recurrent episodes (21.2%). When we compared the severity of carditis in the first versus recurrent episodes, at the start of study mild carditis was found in 29.8% versus 10.6%, moderate carditis in 26.3% versus 53.8%, and severe carditis in 5.3% versus 31.8% of cases, respectively. At the end of study, 30.3% of patients suffering their first episode were completely cured of carditis, and all others showed significant improvement compared to those with recurrent episodes, where only 6.8% were cured, little improvement or deterioration being noted in the remainder of the patients. We conclude that the clinical profile of acute rheumatic fever, especially that of carditis, is milder in those suffering their first attack compared to those with recurrent episodes.

Anti-inflammatory treatment for carditis in acute rheumatic fever

BACKGROUND

Rheumatic heart disease remains the most important cause of acquired heart disease in developing countries. Although the prevention of rheumatic fever and the management of recurrences is well established the optimal management of active rheumatic carditis is still unclear.

OBJECTIVES

To assess the effects of anti-inflammatory agents such as aspirin, corticosteroids and immunoglobulin for preventing or reducing further heart valve damage in patients with acute rheumatic fever.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Issue 4, 2000), MEDLINE (1966 to April 2002), EMBASE (1998 to November 2002), LILACS (1998 to November 2002), Index Medicus (1950 to December 2000) and references lists of identified studies.

SELECTION CRITERIA

Randomised controlled trials comparing anti-inflammatory agents (e.g. aspirin, steroids, immunoglobulins) with placebo or controls, or comparing any of the anti-inflammatory agents with one another, in patients with acute rheumatic fever diagnosed according to the Jones, or modified Jones criteria. The presence of cardiac disease one year after treatment was the major outcome criteria selected.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Eight randomised controlled trials involving 996 people were included. Several steroidal agents viz. ACTH, cortisone, hydrocortisone, dexamethasone and prednisone, and intravenous immunoglobulin were compared to aspirin, placebo or no treatment in the various studies. Six of the trials were conducted between 1950 and 1965, whilst the remaining two were done in the last 10 years. Overall there was no significant difference in the risk of cardiac disease at one year between the corticosteroid-treated and aspirin-treated groups (relative risk 0.87, 95% confidence interval 0.66 to 1.15). Similarly use of prednisone (relative risk 1.78, 95% confidence interval 0.98 to 3.34) or intravenous immunoglobulins (relative risk 0.87, 95%confidence interval 0.55 to 1.39) when compared to placebo did not reduce the risk of developing heart valve lesions at one year.

REVIEWER'S CONCLUSIONS

There is no benefit in using corticosteroids or intravenous immunoglobulins to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. New randomised controlled trials in patients with acute rheumatic fever to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisone, and other new anti-inflammatory agents are warranted. Advances in echocardiography will allow for more objective and precise assessment of cardiac outcomes.

Treatment of rheumatic carditis

Rheumatic fever and rheumatic heart disease continue unabated in most of the developing nations, affecting young individuals. Focal outbreaks of smaller magnitude have also been reported since mid 1980s from industrialized western nations, where this disease had almost disappeared. Introduction of penicillin in mid 1940s had markedly changed the natural history of rheumatic fever, although the incidence of rheumatic fever declined in developed nations before that, due to better living conditions. Treatment of rheumatic fever chiefly involves use of antibiotics (penicillin) to eradicate streptococci, and anti-inflammatory drugs like salicylates or corticosteroids. Patients with severe carditis, congestive heart failure and/or pericarditis are best treated with corticosteroids as these are more potent anti-inflammatory agents than salicylates. Salicylates may be sufficient for cases with mild or no carditis. The treatment must be continued for 12 weeks. Several studies have shown that valvular regurgitation, and not myocarditis, is the cause of congestive heart failure in active rheumatic carditis. Therefore surgery with mitral valve replacement or repair is indicated in cases with intractable hemodynamics due to mitral regurgitation. Development of chronic valvular lesion after an episode of rheumatic fever is dependent upon presence or absence of carditis in the previous attack and compliance with secondary prophylaxis. Recurrences due to inadequate penicillin prophylaxis are responsible for hemodynamically significant chronic valvular lesions requiring surgery.

Comparison of an intravenous pulse of methylprednisolone versus oral corticosteroid in severe acute rheumatic carditis: a randomized clinical trial

OBJECTIVES

To compare the short-term prognosis of patients with severe acute rheumatic carditis when treated with an intravenous pulse of methylprednisolone in comparison with conventional treatment using oral prednisone.

METHODS

We designed a randomized clinical trial in the setting of a university general hospital in Brazil. We randomly allocated 18 patients with the diagnosis of severe acute rheumatic carditis and congestive heart failure to receive an intravenous pulse as opposed to oral prednisolone. Methylprednisolone was administered in a dose of 1 g intravenously for 3 consecutive days in the first and second weeks, for two days in the third, and one day in the fourth week. Prednisone was administered in a dose of 1.5 mg/kg/day over the period of 4 weeks.

RESULTS

The mean age of the patients was 11.1 +/- 3.7 years, with a median of 12 years. Patients on oral treatment showed a more pronounced decrease in the heart rate, sedimentation rate, and in the titres of C-reactive protein than those receiving intravenous therapy. At the end of treatment, a mild decrease in the left ventricular end-systolic dimension was found in those having oral treatment, compared to an increase in the group having intravenous treatment (p = 0.036). The ejection fraction showed a median increase of 5% in those undergoing oral treatment, and a median decrease of 6% in the group with intravenous therapy (p = 0.009). There were 5 therapeutic failures in those receiving intravenous therapy (56%), including 1 death. Therapeutic failures were not observed in those treated orally (p = 0.03).

CONCLUSION

Intravenous treatment of methylprednisolone, as a single anti-inflammatory agent, was inferior to conventional treatment with oral prednisone in the control of severe rheumatic carditis.

A community-based rheumatic fever/rheumatic heart disease cohort: twelve-year experience

BACKGROUND

A pilot rheumatic fever and rheumatic heart disease control porject was started in 1988 in blocks of district Ambala (Haryana) to test the feasibility of early detection, treatment and secondary prophylaxis for rheumatic fever/rheumatic heart disease cases. School teachers, students and health workers were trained to identify and refer suspected cases of rheumatic fever/rheumatic heart disease to the community health center where physicians examined the suspected cases and monthly secondary prophylaxis was provided to the confirmed cases.

METHODS AND RESULTS

A survey of registered cases was done in 1999 to determine the compliance rate of secondary prophylaxis and to describe clinical and epidemiologic features of the registered cohort of rheumatic fever/rheumatic heart disease patients. A total of 257 patients had been registered till the end of 1999 with 1263 person-years of follow-up. Out of these registered patients, 132 were receiving secondary prophylaxis, 52 had died, 17 had migrated, 8 were lost to follow-up, 18 had stopped prophylaxis and 30 completed the prophylaxis course. The mean age at registration was 18 years. Half of the cases were in the 6-15 years age group at registration. Over half of the patients were registered with a history of rheumatic fever. Fever was the most common symptom (75.9%). Carditis was more common among cases with recurrent attacks of rheumatic fever than after a first attack. The mortality in rheumatic fever/rheumatic heart cases was 32.5/1000 person-years. The mean age at death was 24.4 years. Compliance with secondary prophylaxis was 92% during the past 12 years.

CONCLUSIONS

A rheumatic fever/rheumatic heart disease control program can be sustained within the primary health care system and the case registry can be utilized not only for monitoring the program but also to gain insight into the epidemiology of the disease.

[Subclinical carditis during an initial attack of acute rheumatic fever: contribution of colored Doppler echocardiography and therapeutic advantages]

OBJECTIVES

To determine and to evaluate valvular involvement, in particular subclinical, as confirmed by colored Doppler echocardiography (CDE) during an initial attack of acute rheumatic fever (ARF). Means of diagnosis and therapeutic implications.

MATERIALS AND METHODS

Over a 7-year period, from January 1994 to December 2000, 49 patients (27 females and 22 males), with a mean age of 9.2 years (range 5-14 years), who presented with a first attack of ARF, were diagnosed on the basis of clinical data (history, physical findings, specific laboratory data, EKG, and CDE) to determine the major and minor criteria of acute rheumatic fever. All patients were reinvestigated and controlled clinically and by echocardiography two weeks to three months after the first investigation.

RESULTS

Reported clinical major criteria were: Arthritis, 46 cases (94%); carditis, 27 cases (55%); erythema marginatum, 3 cases (6%); subcutaneous nodules, 3 cases (6%) and chorea, 3 cases (6%). CDE abnormalities were identified in 37 cases with cardiac involvement (75% of patients), 10 of them had subclinical evidence of valvular involvement: 6 cases with mild to moderate mitral regurgitation (MR), 2 cases with moderate aortic regurgitation (AR), and 2 cases had both mild to moderate MR and moderate AR. All patients with subclinical disease and evidence of inflammatory process (7 cases) were treated by salicylates. Repeated echocardiography for control showed disappearance of valvular insufficiency in 8 patients with subclinical valvulopathy, and aggravation was observed in 2 other patients.

CONCLUSION

CDE is recommended in patients with suspicion of ARF, even in normal cardiac auscultation in order to detect an acute cardiac involvement leading to an early diagnosis. The confirmation of subclinical valvular disease should be considered as major criteria for ARF. Isolated and subclinical mitral and/or aortic regurgitations, with evidence of inflammatory process, should receive corticosteroids and be followed-up regularly, clinically and non-invasively by CDE.

Treatment of rheumatic carditis with intravenous gammaglobulin: is there a beneficial effect?

Rheumatic carditis is a major manifestation of acute rheumatic fever. Conventional therapy includes the use of salicylates and steroids. To date, however, such therapy has not been proven to have a clear benefit in reducing valvar heart disease. We report the use of high-dose intravenous immunoglobulin in two chidlren with acute rheumatic carditis in whom we have been able to document the beneficial effect.

[Clinical study of Astragalus injection plus ligustrazine in protecting myocardial ischemia reperfusion injury]

OBJECTIVE

To investigate the mechanism of Astragalus injection plus ligustrazine in preventing the occurrence of myocardial ischemia reperfusion injury (MIRI) during open heart surgery of cardiopulmonary bypass, and the treating principle of MIRI in TCM.

METHODS

Twenty-four patients suffering from either valvular heart diseases or congenital ventricular septal defect were randomly divided into three treated groups (Astragalus, ligustrazine, Astragalus plus ligustrazine) and the control group, 6 in each group. Blood samples were taken via subclavian central vein at the time before anesthesia (T1), 10 minutes of occlusion of aorta (T2), 10 minutes (T3) and 30 minutes (T4) after the release, and the end of operation (about 180 minutes after release, T5) respectively; EKG was observed, and the levels of asparate aminotransferase (AST), lactate dehydrogenase (LDH), creatine kinase (CK), MB isoenzyme of CK (CK-MB), malondialdehyde (MDA) and the activity of superoxide dismutase (SOD), nitric oxide (NO), nitric oxide synthetase (NOS) were determined.

RESULTS

The treated groups could reduce the levels of AST, LDH, CK, CK-MB, MDA, SOD compared with the control group, particularly Astragalus plus ligustrazine, there had significant difference (P < 0.05, P < 0.01). In NO activity improvement, Astragalus plus ligustrazine won the best effect, Astragalus group the next.

CONCLUSIONS

The mechanism of MIRI is Qi deficiency and blood stasis in TCM, its treating principles should be promoting Qi and removing the blood stasis. According to the authors' study, Astragalus plus ligustrazine could effectively protect against MIRI, which is better than using the 2 medicines separately.

[Effects of aprotinin on TNF-alpha levels after cardiopulmonary bypass]

OBJECTIVE

This study evaluates the anti-inflammatory activity of full-dose and pump-prime-only(low-dose) aprotinin by means of comparing tumor necrosis factor alpha(TNF-alpha) levels of both groups after CPB.

METHODS

Twenty-nine adults with rheumatic heart disease were randomized into three groups: (1) full-dose aprotinin-treated group(Group A, n = 10); (2) pump-prime-only aprotinin-treated group(Group B, n = 10), and (3) control group(Group C, n = 9). Plasma concentrations of TNF-alpha were measured by enzyme-linked immunosorbent assay technique at baseline(before operation), and at 2, 24 hours after CPB termination.

RESULTS

A significant(P < 0.05) increase of TNF-alpha occurred in all three groups at 2 and 24 hours after CPB termination when compared with the same group at baseline. In Group A, TNF-alpha level was significantly lower than that in group C(P < 0.05) at 24 hours after CPB, but not in group B(P > 0.05).

CONCLUSIONS

Both CPB and operative stimulus induce the increase of cytokine TNF-alpha after CPB. Full-dose aprotinin has the anti-inflammatory effect by means of reducing TNF-alpha level after CPB. Low-dose aprotinin dose not reduce TNF-alpha level. So it no significant anti-inflammatory effect.

Perforated gastric ulcer complicating corticosteroid therapy in acute rheumatic fever

We report an 11-year-old boy with acute rheumatic fever who presented with gastric perforation while treated with corticosteroids (CS). He had been treated initially with acetylsalicylic acid for 11 days, CS replaced the treatment with acetylsalicylic acid due to deterioration of carditis. The possible pathogenesis is discussed.

Profile of secondary prophylaxis among children with rheumatic heart disease in Alexandria, Egypt

A cross-sectional study was conducted in specialist children's hospitals in Alexandria, which aimed to evaluate the current regimen of secondary prophylaxis for children suffering from rheumatic heart disease. Two-thirds of the patients had complied with their prophylactic regimen. Prophylactic failure occurred in one-third of the patients, raising doubts about the efficacy of the brands of penicillin prescribed. Recurrence of rheumatic fever was recorded in 37.3% of the patients, with semiruban or rural residence and non-compliance with secondary prophylaxis the significant risk factors. These unsatisfactory findings suggest the need for a more effective strategy of primary and secondary prophylaxis for controlling rheumatic fever in our community.

Urticarial eruption associated with rheumatic fever in a child

The classic description of erythema marginatum is of a few asymptomatic erythematous patches or plaques with a characteristic central clearing which may coalesce and develop a polycyclic configuration. We report a boy with a urticarial eruption without the classic lesions of erythema marginatum in whom the diagnosis of rheumatic fever was subsequently made. Histology of the urticarial lesions revealed a mixed, superficial, perivascular infiltrate with prominent eosinophils. Rheumatic fever should be considered in children with fever and urticaria-like eruptions even in the absence of the classically described erythema marginatum.

Early proarrhythmia during intravenous amiodarone treatment

We present a case of early (within the first 24 hours) development of malignant torsades de pointes (TdP) associated with intravenous amiodarone therapy. After correction of predisposing factors (heart failure, hypokalemia, digoxin) amiodarone again resulted in torsades. This observation suggests that in patients who have experienced amiodarone-induced proarrhythmia, amiodarone administration under different, more stable clinical conditions may still be hazardous.

Partial atrioventricular septal defect causing confusion with rheumatic heart disease in children in Harare--case reports

Four cases of partial atrioventricular septal defect (AVSD) [corrected] which had been confused with rheumatic heart disease are presented. The need for a full clinical and echocardiographic assessment to reduce this confusion and avoid potentially harmful therapy is highlighted in the report.

Rheumatic carditis treated with high doses of pulsetherapy methylprednisolone. Results in 70 children over 12 years

PURPOSE

To report the result of patients treated with IV methylprednisolone divided into three groups and compare their follow-up during the last 12 years.

METHODS

Seventy children with active rheumatic carditis (76 episodes) in heart failure Class III and IV (NYHA) were studied. The diagnosis was based on modified Jones' criteria. After ruling out infections and strongyloidiasis, treatment with IV methylprednisolone bolus was started three times a week until the laboratory tests became negative. Patients were divided into 3 groups, according to the time of hospital admittance: Groups 1, 2 and 3, comprising of 40, 18 and 12 children, respectively.

RESULTS

Eighteen children in Group 1 (45%) were in their 1st attack: 2 series of pulsetherapy were used in 10 (25%), 3 in 9 (23%) and 4 in 21 (52%). In Group 2, 14 cases (77%) were in their 1st attack: 2 series were used in 7 (39%), 4 in 9 (50%) and 5 in 2 (11%). The echocardiogram showed a flail mitral valve in 12 (66%) of these patients (1 death occurred after mitral valvoplasty). In Group 3, 6 patients needed 5 or more series of pulsetherapy and a flail mitral valve was present in 5 (41%). One child underwent mitral valve replacement while still in the active phase, after 8 series of pulsetherapy, and another died. The number of patients who needed 5 or more series was significantly higher in Group 3.

CONCLUSION

There were variations in the presentation and evolution of the cases during these 12 year. The established pulsetherapy protocol continues to be useful to treat severe cases.

[Clinical observation on treatment of postcardiotomic complications with Chinese herbal medicine based on syndrome differentiation with angiocardiopathy]

OBJECTIVE

To study the effect of Chinese herbal medicine (CHM) based on Syndrome Differentiation on postcardiotomic complications in patients with angiocardiopathy.

METHODS

Aimed at the frequently encountered postcardiotomic complications including fever, cough and expectoration, belching, abdominal distension, palpitation, short breath, etc. CHM treatment was applied in combination with routine western drugs treatment (cardiac tonic, diuretics, vascular dilatator and anticoagulant).

RESULTS

Twenty out of 22 patients with protracted fever and irresponsive to multi-antibiotics therapy were cured, the other one with hydrothorax received other therapy and the another one with drug fever was natural cured after stopping medication. Among 23 patients complicated mainly with respiratory symptoms, 17 were cured and 6 improved, among 15 with digestive symptoms, 12 cured and 3 improved, and among 7 with cardiovascular symptoms, 3 cured, 2 improved and 2 ineffective.

CONCLUSION

CHM has good effect on postcardiotomic complications, it could improve the functional recovery of heart and lung.

[Improvement in fibrinolytic function following anticoagulant treatment in chronic rheumatic atrial fibrillation]

INTRODUCTION AND OBJECTIVES

Patients with rheumatic atrial fibrillation are considered at high risk of systemic embolism and require oral anticoagulation. Fibrinolytic function has been little studied. We evaluated fibrinolytic activation markers before starting anticoagulation, at 1 and 6 months following the introduction of oral anticoagulation therapy. We analyzed the relationship with left atrial diameter and mitral area.

METHODS

Tissue plasminogen activator (tPA), its inhibitor (PAI-1), plasmin-antiplasmin complexes (PAP) and D-dimer were measured in 13 patients with rheumatic atrial fibrillation. Basal levels were compared with those found in plasma of 20 healthy subjects matched by sex and age. Transthoracic echocardiography was made.

RESULTS

A significant increase for PAI-1 and D-dimer levels were detected in patients with atrial fibrillation group (p < 0.05), with no differences in tPA and PAP concentrations. Significant correlation between left atrial diameter and basal t-PA levels was found. Levels of t-PA, PAI-1 and D-dimer decreased significantly under anticoagulation therapy, whereas PAP levels were significantly increased.

CONCLUSIONS

Patients with rheumatic atrial fibrillation show a relative hypofibrinolytic state due to elevated PAI-1 levels with no increase in PAP concentration. At six months of anticoagulation therapy, an improvement of fibrinolytic function markers was observed. This is consistent with the prophylactic effect of oral anticoagulants therapy against thromboembolic risk.

[Chorea subsequent to acute rheumatic fever in a 9-year-old girl]

A nine-year-old girl had acute choreatic symptoms in her face and limbs, after a throat infection 6 weeks previously. On auscultation of the heart a systolic murmur was found and echocardiography showed mitral valve incompetence. There was a positive anti-deoxyribonuclease B titre in the serum, providing evidence of a previously contracted streptococcal infection. Both chorea and acquired carditis are major criteria for the diagnosis of acute rheumatic fever. The course was characterized--as it usually is--by spontaneous, gradual resolution of the symptoms. Protracted penicillin prophylaxis is indicated to prevent recurrence of acute rheumatic fever and cardiac valvular damage.

[Role of beta-blockers in the treatment of mitral stenosis, apropos of 4 cases]

The use of beta blockers during treatment of mitral stenosis is discussed on four cases involving females patients who are symptomatic. All had sinusal tachycardia, one was pregnant, one with cardiothyreosis, two with anemia. In all cases, it's the use of beta-blockers with diuretic, veinous vasodilator and digitalic drugs that allowed the successful treatment of the pulmonary oedema. These observations, added with the literature study, showed that beta-blockers treatment is wise when the subject is carefully studied. The best result is obtained on pure mitral stenosis without left ventricular systolic dysfunction, with sinusal tachycardia and high cardiac output state.

Acute haemodynamic effects of nicorandil in patients with chronic severe regurgitant valvular lesions

The haemodynamic effects of nicorandil, a new balanced vasodilator exhibiting nitrate-like as well as potassium-channel opening activity in patients with chronic severe valvular lesions have not been reported. We studied the acute effect of nicorandil on haemodynamics in 12 stable patients (6 males, 6 females; mean age 23.5 +/- 4.6 years) with chronic severe valvular regurgitation (8 mitral, 4 aortic). All patients were studied in resting, supine and fasting states. All cardioactive drugs were withdrawn five days prior to the study. Intra-arterial line was placed and thermodilution catheter was positioned in the pulmonary artery. Haemodynamic parameters recorded at baseline and at 30, 60, 90 and 120 minutes following a single oral dose of 20 mg nicorandil revealed no significant change in the heart rate while systemic pressures showed a small decline (p < 0.05). There was significant reduction in systolic, diastolic and mean pulmonary artery pressures (p < 0.001). The mean cardiac index increased from 3.16 L/min/m2 at baseline to 3.77 L/min/m2 at 60 minutes. Both the pulmonary and systemic vascular resistance indices reduced significantly, the peak fall being 18 percent and 29 percent, respectively. Maximal changes were observed at 60 to 90 minutes following administration of nicorandil. No adverse effect of nicorandil occurred during the study. We conclude that nicorandil has a favourable acute haemodynamic effect in patients with chronic severe valve regurgitation. Its long-term use in valvular lesions should be explored further.