Cardioprotection with angiotensin-converting enzyme inhibitors: redefined for the 1990s

Potential role of renin-angiotensin system blockade for preventing myocardial ischemia/reperfusion injury and remodeling after myocardial infarction

Experimental and clinical studies have demonstrated that myocardial ischemia induces activation of various components of the renin-angiotensin system (RAS), including angiotensinogen, renin, angiotensin-converting enzyme (ACE), angiotensins, and angiotensin receptors, in the acute phase of myocardial infarction and the postinfarction remodeling process. Pharmacological inhibition of the RAS by administration of renin inhibitors, ACE inhibitors, and angiotensin receptor blockers has shown beneficial effects on the pathological processes of myocardial infarction in both experimental animal studies and clinical trials. However, the potential mechanisms responsible for the cardioprotection of RAS inhibition remain unclear. In this review, we discuss roles of RAS blocking in the prevention of myocardial ischemia/reperfusion injury and postinfarction remodeling.

Effects of early captopril therapy after myocardial infarction on the incidence of late potentials

BACKGROUND

Late potentials (LP) on signal-averaged electrocardiography (SAECG), recorded 6 to 30 days after an acute myocardial infarction (AMI), identify patients at risk for late arrhythmic events. Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce ventricular remodeling and cardiovascular mortality after AMI.

HYPOTHESIS

The aim of this study was to investigate the effect of early (< 24 h) administration of captopril on the presence of LP on Days 6-30 after AMI.

METHODS

The study included 117 patients with a first AMI; 63 patients (53 men and 10 women, aged 59 +/- 12 years), 35 with an anterior and 28 with an inferior AMI (44 thrombolyzed), received early captopril therapy. The control group consisted of 54 age-matched patients (39 men and 15 women, aged 60 +/- 12 years), 19 with an anterior and 35 with an inferior AMI (31 thrombolyzed, p = NS), who did not receive early therapy with an ACE inhibitor. The mean left ventricular ejection fraction was similar in both groups (48 vs. 46%). Time domain analysis of SAECG was performed using a band-pass filter of 40-250 Hz. Late potentials were considered present if any two of three criteria were met: (1) Filtered QRS duration (QRSD) > 114 ms, (2) root-mean-square voltage of the last 40 ms of the QRS complex (RMS) < 20 microV, and (3) duration of low amplitude (< 40 microV) signal of the terminal portion of the QRS (LAS) > 38 ms.

RESULTS

In the two groups of patients there were no differences in mean values of SAECG parameters. No patient was receiving any antiarrhythmic drugs. In the captopril group LPs were present in 9 of 63 patients (14%) and in the control group in 17 of 54 patients (31%) (p = 0.046). There was no difference in the number of patients with a patent infarct-related artery in the two groups (76 vs. 59%).

CONCLUSION

Captopril treatment early after an AMI reduces the incidence of LPs recorded on Days 6-30 and may thus favorably affect the arrhythmogenic substrate.

Inhibitory effect of telmisartan on the blood pressure response to angiotensin II challenge

Telmisartan is a new angiotensin receptor antagonist possessing potent, selective, and insurmountable inhibitory activity specific to the angiotensin II type 1 (AT 1 ) receptor. The current study was performed to determine the inhibition of the angiotensin II pressor response by telmisartan in 48 healthy volunteers challenged with hypertension-inducing doses of i.v. angiotensin II. Subjects were challenged with this dose of angiotensin II at intervals between 0.25 and 48 h after double-blind single-dose oral administration of telmisartan 20 mg (n = 12), 40 mg (n = 12), or 80 mg (n = 12) or placebo (n = 12) in parallel groups. Diastolic and systolic blood pressure and pulse rate were recorded continuously using a servophotoplethysmograph. Urine samples were collected during the study for urinalysis. Tolerability of telmisartan, in comparison with placebo, was also monitored throughout the study. Telmisartan 20-80 mg dose dependently inhibited the increase in diastolic and systolic blood pressure induced by angiotensin II. Telmisartan 40 mg produced 80.1% maximum inhibition, and with 80 mg 89.6% maximum inhibition of diastolic blood pressure was achieved. Inhibition was apparent after 0.3-1.1 h and was still observed 48 h after administration for all telmisartan doses. The inhibitory effect of telmisartan 20, 40, and 80 mg, 48 h after dosing was significantly greater than that of placebo. A > 25% inhibition of the angiotensin II response on diastolic blood pressure was detected until 26.9, 35.4, and 40.5 h, respectively, after telmisartan 20 mg, 40 mg, and 80 mg. Anti-clockwise hysteresis was observed, indicating a delay and longer persistence of effect than to be expected from the plasma concentration-time course. The slow dissociation of telmisartan from the receptor probably contributed to this hysteresis. The incidence of adverse events was comparable in telmisartan-and placebo-treated subjects and was not dose dependent. In conclusion, telmisartan 40 mg provides rapid-onset, well-tolerated, and near-maximal inhibition of angiotensin II-induced hypertension, with maintenance of the inhibitory effect for 48 h.

Acute Staphylococcal myocarditis masquerading as an acute myocardial infarction

It is well known that viral myocarditis can mimic acute myocardial infarction and the differentiation of both diseases presents a diagnostic challenge. This report discusses the case presentation of an 18-year-old man who developed acute Staphylococcal myocarditis in the setting of acute tonsillitis in whom clinical, enzymatic, and electrocardiographic findings have led to tentative erroneous diagnosis of acute myocardial infarction. The outcome was favorable with cephalotin and captopril therapy. This is the first reported case of bacterial myocarditis masquerading as an acute myocardial infarction.

Increased plasma adrenomedullin in acute myocardial infarction

Adrenomedullin has a potent vasodilating effect comparable to that of calcitonin gene-related peptide. To investigate the pathophysiologic role of endogenous adrenomedullin, we determined sequentially the plasma adrenomedullin level in 15 consecutive patients with acute myocardial infarction (AMI). Plasma adrenomedullin was higher immediately after the onset of AMI and decreased gradually; plasma levels during the 3-week period after the AMI were higher than plasma levels in 15 healthy control subjects (p < 0.001), with higher levels in patients with congestive heart failure than in patients without congestive heart failure throughout the period of the study (p < 0.05). Plasma adrenomedullin was positively correlated with pulmonary capillary wedge pressure, pulmonary arterial pressure, right atrial pressure, and heart rate in the early stage of AMI. These findings suggest that the elevation of plasma adrenomedullin is related to the retention of body fluid volume, the enhancement of sympathetic activity, and/or the elevation of pressure in pulmonary vascular beds. Adrenomedullin may act against excessive vasoconstrictors increased in AMI.

Regulation of cell proliferation and growth by angiotensin II

The peptide hormone angiotensin II (AngII) has clearly defined physiologic roles as a regulator of vasomotor tone and fluid homeostasis. In addition AngII has trophic or mitogenic effects on a variety of target tissues, including vascular smooth muscle and adrenal cells. More recent data indicate that AngII exhibits many characteristics of the 'classical' peptide growth factors such as EGF/TGF alpha, PDGF and IGF-1. These include the capacity for local generation ('autocrine or paracrine' action) and the ability to stimulate tyrosine phosphorylation, to activate MAP kinases and to increase expression of nuclear proto-oncogenes. The type 1 AngII receptor, which is responsible for all known physiologic actions of AngII, has been cloned. Activation of this receptor leads to elevated phosphoinositide hydrolysis, mobilization of intracellular Ca2+ and diacylglycerol, and activation of Ca2+/calmodulin and Ca2+/phospholipid-dependent Ser/Thr kinases, as well as Ca2+ regulated tyrosine kinases. The existence of other AngII receptor subtypes has been postulated, but the function(s) of these sites remains unclear. In vascular smooth muscle, AngII can promote cellular hypertrophy and/or hyperplasia, depending in part on the patterns of induction of secondary factors that are known to stimulate (PDGF, IGF-1, basic FGF) or inhibit (TGF-beta) mitosis. Together, these findings have suggested that AngII plays important roles in both the normal development and pathophysiology of vascular, cardiac, renal and central nervous system tissues.

Early and late angiotensin-converting enzyme inhibition in acute myocardial infarction

Studies in animals and humans have shown that angiotensin-converting enzyme (ACE) inhibitors can prevent or at least attenuate ventricular dilation and remodeling following acute myocardial infarction (MI) and can improve subsequent left ventricular dysfunction, a strong predictor of survival. The question as to which patients will benefit most from ACE inhibitor therapy and the optimal timing of administration of such intervention after the onset of symptoms is still matter of debate, even if it is hypothesized that a greater benefit in terms of remodeling prevention may occur after early administration. However, while it is currently accepted that patients with asymptomatic postinfarctual left ventricular dysfunction can benefit from long-term administration of an ACE inhibitor when therapy is started late, the usefulness of an early administration is still to be clarified. In this setting, the question of early versus late ACE inhibitor treatment has to be related to the different evolving pattern of myocardial infarction with regard to the different degrees of postinfarction ventricular dysfunction and neurohormonal activation, whose extent could influence the effect of ACE inhibition. For example, not all patients with acute MI show progressive ventricular dilation. Early dilation is frequent in patients with anterior localization of necrosis, whereas it is usually not relevant in patients with acute inferior MI. Thus, different postinfarction patterns may differently influence the clinical success of therapeutic interventions, which can be instituted at various stages following acute MI.(ABSTRACT TRUNCATED AT 250 WORDS)

"Cardioprotection" by ACE-inhibitors in acute myocardial ischemia and infarction?

Coronary artery occlusion results in the acute activation of the renin-angiotensin system and production of angiotensin II, a potent vasoconstrictor and positive inotropic agent. This has raised the possibility that angiotensin converting enzyme (ACE) inhibitors might be "cardioprotective" (that is, might attenuate myocardial injury, dysfunction and necrosis) in the setting of acute ischemia and infarction. Captopril, enalapril and ramipril have, in fact, been reported to acutely limit myocardial injury and necrosis in models of permanent coronary artery occlusion. The mechanisms responsible for this cardioprotection are complex, but include favorable alterations in myocardial oxygen supply/demand, and, in some instances, inhibition of bradykinin metabolism and/or increased prostaglandin synthesis. Other studies, however, have failed to document a reduction in infarct size with ACE inhibitor treatment. Results obtained in models of coronary occlusion/reperfusion have also been mixed. In models of brief transient ischemia not associated with necrosis, captopril and zofenopril have consistently been found to attenuate postischemic contractile dysfunction of the viable but "stunned" myocardium during the early hours following relief of ischemia. In contrast, there is no consensus on the effects of enalapril on the stunned myocardium: both positive and negative results have been obtained. Similar disparity has been reported in models of more prolonged ischemia/reperfusion resulting in subendocardial necrosis: some studies have reported myocardial salvage, while others have provided disturbing evidence of apparent exacerbation of myocardial necrosis with captopril and enalapril therapy. Thus, after a decade of investigative effort, the question of whether ACE inhibitors are "cardioprotective" in the setting of acute myocardial ischemia and infarction remains unresolved. Nonetheless, clinical protocols are in progress to assess the effects of early ACE inhibitor treatment in patients with acute myocardial infarction.