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Abstract
BACKGROUND Little evidence exists to support pharmacotherapeutic strategies for heart failure management in paediatrics. A recent Europe-wide survey suggests that this translates into substantial variability in clinical practice. OBJECTIVE To conduct a formal discussion among an expert group of paediatric cardiology physicians on controversial aspects regarding the pharmacotherapy of children heart failure, facilitate consensus, and highlight areas of agreement and disagreement. METHODS A two-round modified Delphi process was conducted between July and August 2015. Topics addressed were predominantly selected from the results of a previous Europe-wide survey. Fourteen statements were presented for discussion grouped under three categories; Angiotensin-converting-enzyme-inhibitors: Considerations for optimal dosage; Angiotensin-converting-enzyme-inhibitors for the management of CHDs; Neurohumoral antagonists for the management of dilated cardiomyopathy-related heart failure. RESULTS A total of 13 paediatricians dedicated to cardiology from across Europe and the United States of America completed the study; of them, 92% had a working experience in the field of more than 10 years and were working in a specific paediatric cardiology unit. Agreement on the acceptance/rejection of 11 statements was achieved. Results show agreement on the importance of a set of topics relevant to the standardisation of the therapy as well as consensus upon specific therapeutic attitudes. CONCLUSIONS We have found areas of common thinking and motivation, which can provide a means of triggering scientific collaboration. Our results might also contribute to disseminate available paediatric evidence and promote reducing unjustified variability in everyday practice. Until solid evidence is available, other research methods can contribute to advancing the goal of safe and effective paediatric heart failure pharmacotherapy.
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2
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Abstract
OBJECTIVES In this review, we will discuss aortic stenosis, aortic regurgitation, mitral regurgitation, and mitral stenosis. We will review the etiology, anatomy, pathophysiology, presentation, and treatment of aortic and mitral valve disease. Age and lesion specific treatments are outlined based on the severity of valve disease with an aim at long-term preservation of left ventricular function. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS Mitral and aortic valve disease leads to unique hemodynamic burdens that can impact left ventricular function, quality of life, and longevity. The primary challenge in the management of mitral and aortic valve disease is to apply appropriate medical management and identify that point in time at which the surgery is necessary. Although guidelines have been established for the management of aortic and mitral valve disease in adults, the challenges of early presentation, maintenance of growth potential, and apparent increased tolerance of hemodynamic burden in children makes decision making challenging.
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3
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The Use and Misuse of ACE Inhibitors in Patients with Single Ventricle Physiology. Heart Lung Circ 2016; 25:229-36. [DOI: 10.1016/j.hlc.2015.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 09/18/2015] [Accepted: 10/10/2015] [Indexed: 11/19/2022]
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Broch K, Urheim S, Lønnebakken MT, Stueflotten W, Massey R, Fosså K, Hopp E, Aakhus S, Gullestad L. Controlled release metoprolol for aortic regurgitation: a randomised clinical trial. Heart 2015; 102:191-7. [DOI: 10.1136/heartjnl-2015-308416] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/12/2015] [Indexed: 11/04/2022] Open
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Alonso-Gonzalez R, Dimopoulos K. Biomarkers in congenital heart disease: do natriuretic peptides hold the key? Expert Rev Cardiovasc Ther 2014; 11:773-84. [PMID: 23750686 DOI: 10.1586/erc.13.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Congenital heart disease is the most common congenital abnormality. The long-term prognosis of these patients has changed significantly over the last half century, thanks to improvements in cardiovascular diagnosis, surgery and postoperative care. However, residual lesions are not uncommon and many of the interventions performed remain palliative rather than reparative, leading to the development of ventricular dysfunction and heart failure. Natriuretic peptides are well-established markers of disease severity and prognosis in patients with heart failure due to noncongenital (acquired) heart disease. However, the role of biomarkers in congenital heart disease is unclear. This review highlights the impact of neurohormonal activation in patients with congenital heart disease, as well as the usefulness of assessing natriuretic peptide levels in specific clinical situations.
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Affiliation(s)
- Rafael Alonso-Gonzalez
- Adult Congenital Heart Disease Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Sydney Street, London, UK
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6
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7
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Randomised trial of ramipril in repaired tetralogy of Fallot and pulmonary regurgitation. Int J Cardiol 2012; 154:299-305. [DOI: 10.1016/j.ijcard.2010.09.057] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Accepted: 09/25/2010] [Indexed: 11/17/2022]
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8
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Elder DH, Wei L, Szwejkowski BR, Libianto R, Nadir A, Pauriah M, Rekhraj S, Lim TK, George J, Doney A, Pringle SD, Choy AM, Struthers AD, Lang CC. The Impact of Renin-Angiotensin-Aldosterone System Blockade on Heart Failure Outcomes and Mortality in Patients Identified to Have Aortic Regurgitation. J Am Coll Cardiol 2011; 58:2084-91. [DOI: 10.1016/j.jacc.2011.07.043] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 06/30/2011] [Accepted: 07/26/2011] [Indexed: 02/03/2023]
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9
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Is medical management of paediatric heart failure evidence based? COR ET VASA 2011. [DOI: 10.33678/cor.2011.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Gisler F, Knirsch W, Harpes P, Bauersfeld U. Effectiveness of angiotensin-converting enzyme inhibitors in pediatric patients with mid to severe aortic valve regurgitation. Pediatr Cardiol 2008; 29:906-9. [PMID: 18401634 DOI: 10.1007/s00246-008-9228-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Revised: 01/21/2008] [Accepted: 03/22/2008] [Indexed: 11/30/2022]
Abstract
The long-term benefit of angiotensin-converting enzyme inhibitors in pediatric patients with aortic valve regurgitation is under consideration. Eighteen patients with mid to severe aortic valve regurgitation were retrospectively evaluated. Echocardiographic parameters (left ventricular end-diastolic diameter, shortening fraction, left ventricular posterior wall thickness, and grade of aortic valve regurgitation) were analyzed before and during therapy with angiotensin-converting enzyme inhibitors. Data are given as standard deviation scores (Z-scores) derived from body surface-adjusted normal values. Median (interquartile range) age at start of therapy was 8.4 (5.4 to 10.0) years, and total follow-up 2.3 (0.9 to 5.4) years. Left ventricular end-diastolic diameter increased from 3.6 (2.3 to 4.5) to 3.7 (2.4 to 4.8), and left ventricular posterior wall diameter decreased from 1.9 (1.1 to 3.0) to 1.1 (0.5 to 2.3). Grade of aortic valve regurgitation increased from 3.5 (2.3 to 4.0) to 4.0 (2.0 to 4.0), and shortening fraction decreased from 39% (34% to 43%) to 37% (34% to 42%). No significant effect of angiotensin-converting enzyme inhibitors on left ventricular dimensions or function was found in our population of patients with mid to severe aortic valve regurgitation. Angiotensin-converting enzyme inhibitors may not alter left ventricular overload in pediatric patients with aortic valve regurgitation.
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Affiliation(s)
- Fabian Gisler
- Division of Paediatric Cardiology, University Children's Hospital, Steinwiesstr. 75, 8032, Zurich, Switzerland
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11
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Dimopoulos K, Diller GP, Piepoli MF, Gatzoulis MA. Exercise Intolerance in Adults with Congenital Heart Disease. Cardiol Clin 2006; 24:641-60, vii. [PMID: 17098517 DOI: 10.1016/j.ccl.2006.08.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This article describes the ways to assess exercise capacity in adults with congenital heart disease (ACHD) and the impact of exercise intolerance in the population. It also discusses the likely pathogenesis of exercise intolerance in ACHD, the similarities between ACHD and acquired heart failure, and potential therapeutic options.
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Affiliation(s)
- Konstantinos Dimopoulos
- Adult Congenital Heart Programme, Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK.
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12
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Abstract
This article reviews reports of ACE inhibitor use in pediatric heart failure and summarizes the present implications for clinical practice. Captopril, enalapril, and cilazapril are orally active ACE inhibitors, and widely used in pediatric cardiology, although more than ten other ACE inhibitors have been applied clinically in adults. Effects of ACE inhibitors on the renin-angiotensin-aldosterone system in pediatric patients are similar to those in adults. ACE inhibitors lower aortic pressure and systemic vascular resistance, do not affect pulmonary vascular resistance significantly, and lower left atrial and right atrial pressures in pediatric patients with heart failure. In infants with a large ventricular septal defect and pulmonary hypertension, ACE inhibitors decrease left-to-right shunt in those infants with elevated systemic vascular resistance. ACE inhibitors induce a small increase in left ventricular ejection fraction, left ventricular fractional shortening, and systemic blood flow in children with left ventricular dysfunction, mitral regurgitation, and aortic regurgitation. These beneficial effects usually persist long term without the development of tolerance. Therapeutic trials of ACE inhibitors have been reported in children with heart failure and divergent hemodynamics, including myocardial dysfunction, left-to-right shunt, such as large ventricular septal defect and pulmonary hypertension, aortic or mitral regurgitation, and Fontan circulation. Hypotension and renal failure usually occur within 5 days after starting ACE inhibition or increasing the dose and, in most cases, recovery is seen after reduction or cessation of the drug. With all ACE inhibitors, smaller doses are administered initially to prevent excessive hypotension, and doses are increased gradually to the target dose. Captopril is administered orally, usually every 8 hours. Daily doses range from 0.3 to 1.5 mg/kg in children. Enalapril is administered orally, once or twice a day, and daily doses range from 0.1 to 0.5 mg/kg. Enalaprilat is administered intravenously, one to three times a day, in doses ranging from 0.01 to 0.05 mg/kg/dose. For the treatment of chronic heart failure in children, ACE inhibitors are essential along with other medications including diuretics, digoxin, and beta-blockers (beta-adrenoceptor antagonists).
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Affiliation(s)
- Kazuo Momma
- Department of Pediatric Cardiology, Heart Institute, Tokyo Women's Medical University, Tokyo, Japan.
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13
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Evangelista A, Tornos P, Sambola A, Permanyer-Miralda G, Soler-Soler J. Long-term vasodilator therapy in patients with severe aortic regurgitation. N Engl J Med 2005; 353:1342-9. [PMID: 16192479 DOI: 10.1056/nejmoa050666] [Citation(s) in RCA: 164] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Vasodilator therapy can reduce the left ventricular volume and mass and improve left ventricular performance in patients with aortic regurgitation. Accordingly, it has been suggested that such therapy may reduce or delay the need for aortic-valve replacement. METHODS We randomly assigned 95 patients with asymptomatic severe aortic regurgitation and normal left ventricular function to receive open-label nifedipine (20 mg every 12 hours), open-label enalapril (20 mg per day), or no treatment (control group) to identify the possible beneficial effects of vasodilator therapy on left ventricular function and the need for aortic-valve replacement. RESULTS After a mean of seven years of follow-up, the rate of aortic-valve replacement was similar among the groups: 39 percent in the control group, 50 percent in the enalapril group, and 41 percent in the nifedipine group (P=0.62). In addition, there were no significant differences among the groups in aortic regurgitant volume, left ventricular size, left ventricular mass, mean wall stress, or ejection fraction. One year after valve replacement, the left ventricular end-diastolic diameter and end-systolic diameter had decreased to a similar degree among the patients who underwent surgery in each of the three groups, and all the patients had a normal ejection fraction. CONCLUSIONS Long-term vasodilator therapy with nifedipine or enalapril did not reduce or delay the need for aortic-valve replacement in patients with asymptomatic severe aortic regurgitation and normal left ventricular systolic function. Furthermore, such therapy did not reduce the aortic regurgitant volume, decrease the size of the left ventricle, or improve left ventricular function.
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Affiliation(s)
- Artur Evangelista
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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14
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Plante E, Gaudreau M, Lachance D, Drolet MC, Roussel E, Gauthier C, Lapointe E, Arsenault M, Couet J. Angiotensin-converting enzyme inhibitor captopril prevents volume overload cardiomyopathy in experimental chronic aortic valve regurgitation. Can J Physiol Pharmacol 2005; 82:191-9. [PMID: 15052285 DOI: 10.1139/y04-005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The efficacy of angiotensin-converting enzyme inhibitors (ACEIs) in the treatment of chronic aortic regurgitation (AR) is not well established and remains controversial. The mechanisms by which ACEIs may protect against left-ventricular (LV) volume overload are not well understood, and clinical trials performed until now have yielded conflicting results. This study was therefore performed to assess the effectiveness of two different doses of the ACEI captopril in a rat model of chronic AR. We compared the effects of a 6-month low-dose (LD) (25 mg/kg) or higher dose (HD) (75 mg/kg) treatment with captopril on LV function and hypertrophy in Wistar rats with severe AR. Untreated animals developed LV eccentric hypertrophy and systolic dysfunction. LD treatment did not prevent hypertrophy and provided modest protection against systolic dysfunction. HD treatment preserved LV systolic function and dimensions and tended to slow hypertrophy. The cardiac index remained high and similar among all AR groups, treated or not. Tissue renin-angiotensin system (RAS) analysis revealed that ACE activity was increased in the LVs of AR animals and that only HD treatment significantly decreased angiotensin II receptor mRNA levels. Fibronectin expression was increased in the LV or AR animals, but HD treatment almost completely reversed this increase. The ACE inhibitor captopril was effective at high doses in this model of severe AR. These effects might be related to the modulation of tissue RAS and the control of fibrosis.
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MESH Headings
- Angiotensin-Converting Enzyme Inhibitors/pharmacology
- Angiotensin-Converting Enzyme Inhibitors/therapeutic use
- Animals
- Aortic Valve Insufficiency/complications
- Aortic Valve Insufficiency/drug therapy
- Captopril/pharmacology
- Captopril/therapeutic use
- Cardiac Output/drug effects
- Cardiac Output/physiology
- Cardiomyopathy, Dilated/complications
- Cardiomyopathy, Dilated/drug therapy
- Cardiomyopathy, Dilated/prevention & control
- Chronic Disease
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Fibronectins/drug effects
- Fibronectins/genetics
- Fibronectins/metabolism
- Gene Expression
- Hypertrophy, Left Ventricular/drug therapy
- Hypertrophy, Left Ventricular/genetics
- Male
- RNA, Messenger/chemistry
- RNA, Messenger/metabolism
- Rats
- Rats, Wistar
- Receptors, Angiotensin/genetics
- Receptors, Angiotensin/metabolism
- Renin-Angiotensin System/drug effects
- Stroke Volume/drug effects
- Stroke Volume/physiology
- Time Factors
- Ventricular Function, Left/drug effects
- Ventricular Function, Left/physiology
- Ventricular Remodeling/drug effects
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Affiliation(s)
- Eric Plante
- Centre de Recherche Hôpital Laval, Institut de cardiologie de Québec, Université Laval, Quebec City, Canada
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15
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Abstract
Major advances in the diagnostic, evaluation, and particularly surgical treatment of aortic regurgitation (AR) have redefined the role of medical treatment. In acute AR, aortic valve replacement (AVR) is the only life-saving treatment. Medical treatment may improve the hemodynamic state temporarily before surgery. Rationale of medical treatment in chronic AR is based on the natural history and pathophysiology of the disease. The primary goal is to optimize the time of the AVR. If there is any symptom and/or left ventricular (LV) dysfunction, early AVR is required. Vasodilators should only be considered as a short-term treatment before surgery if there is evidence of severe heart failure or as a long-term treatment if AVR is contraindicated because of cardiac or noncardiac factors. In asymptomatic patients with severe chronic AR and normal LV function (even if the left ventricle is moderately dilated), vasodilators may prolong the compensated phase of chronic AR, although proof of their efficacy in delaying AVR is limited. Nifedipine is the best evidence-based treatment in this indication. ACE inhibitors are particularly useful for hypertensive patients with AR. beta-Adrenoceptor antagonists (beta-blockers) may be indicated to slow the rate of aortic dilatation and delay the need for surgery in patients with AR associated with aortic root disease. Furthermore, they may improve cardiac performance by reducing cardiac volume and LV mass in patients with impaired LV function after AVR for AR.
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Affiliation(s)
- Aliocha Scheuble
- Cardiology Department, Bichat University Hospital, Paris, France.
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Vonder Muhll I, Liu P, Webb G. Applying standard therapies to new targets: the use of ACE inhibitors and B-blockers for heart failure in adults with congenital heart disease. Int J Cardiol 2004; 97 Suppl 1:25-33. [PMID: 15590076 DOI: 10.1016/j.ijcard.2004.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Increasingly, patients and clinicians are being confronted with congestive heart failure (CHF) as a late complication of congenital heart disease. However, medical management of heart failure in this patient group represents a challenge because of complex hemodynamics and a lack of evidence from large randomized controlled trials to guide therapy. This article will review the evidence of the use angiotensin converting enzyme inhibitors (ACEIs) and beta-blockers (BBs) in left heart failure, discuss the mechanisms of heart failure as they pertain to congenital heart disease and review the limited literature of the use of neurohormonal antagonists in congenital heart disease. Some recommendations for use of angiotensin converting enzyme inhibitors and beta-blockers in heart failure due various congenital heart lesions are offered. Well-designed clinical trials are urgently needed to extend the impressive reductions in morbidity and mortality achieved with neurohormonal blockade in left ventricular (LV) heart failure to adults with congenital heart disease.
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Affiliation(s)
- Isabelle Vonder Muhll
- Joint Fellow in Adult Congenital Heart Disease, Royal Brompton Hospital/Toronto General Hospital, Canada.
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Balfour I. Management of chronic congestive heart failure in children. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2004; 6:407-416. [PMID: 15324616 DOI: 10.1007/s11936-004-0024-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The medical management of congestive heart failure involves manipulating myocardial contractility and loading conditions to achieve optimal performance. Medication may be used to counteract potentially deleterious neurohumoral changes that are associated with congestive heart failure. When appropriate, the correction of the underlying cardiac defect by surgery or catheter intervention is usually the most effective treatment for congestive heart failure in children.
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Affiliation(s)
- Ian Balfour
- Department of Pediatrics, Saint Louis University School of Medicine, 1465 S. Grand Boulevard, St. Louis, MO 63104, USA.
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Hazama K, Nakazawa M, Momma K. Effective dose and cardiovascular effects of cilazapril in children with heart failure. Am J Cardiol 2001; 88:801-5. [PMID: 11589855 DOI: 10.1016/s0002-9149(01)01858-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- K Hazama
- Department of Pediatric Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan.
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Silber JH, Cnaan A, Clark BJ, Paridon SM, Chin AJ, Rychik J, Hogarty AN, Cohen MI, Barber G, Rutkowsky M, Kimball TR, Delaat C, Steinherz LJ, Zhao H, Tartaglione MR. Design and baseline characteristics for the ACE Inhibitor After Anthracycline (AAA) study of cardiac dysfunction in long-term pediatric cancer survivors. Am Heart J 2001; 142:577-85. [PMID: 11579345 DOI: 10.1067/mhj.2001.118115] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE The ACE Inhibitor After Anthracycline (AAA) study is a randomized, double-blind, controlled clinical trial comparing enalapril with placebo to determine whether treatment can slow the progression of cardiac decline in patients who screen positive for anthracycline cardiotoxicity. METHODS The primary outcome measure is the rate of decline, over time, in maximal cardiac index (in liters per minute per meters squared) at peak exercise; the secondary outcome measure is the rate of increase in left ventricular end systolic wall stress (in grams per centimeters squared). Patients >2 years off therapy and <4 years from diagnosis, aged 8 years and older, were eligible if they had received anthracyclines and had at least one cardiac abnormality identified at any time after anthracycline exposure. RESULTS A total of 135 patients were randomized to enalapril or placebo. Baseline characteristics were similar across treatment groups. CONCLUSIONS The AAA study will provide important information concerning the efficacy of using angiotensin-converting enzyme inhibitors to offset the effects of late anthracycline cardiotoxicity.
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Affiliation(s)
- J H Silber
- Division of Pediatric Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Angiotensin-converting enzyme inhibitor therapy for ventricular dysfunction in infants, children and adolescents: a review. PROGRESS IN PEDIATRIC CARDIOLOGY 2000; 12:91-111. [PMID: 11114549 DOI: 10.1016/s1058-9813(00)00061-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Angiotensin-converting enzyme (ACE) inhibitors have become an important part of the pharmacologic armamentarium in the battle against treatment of ventricular dysfunction. There have been a number of large controlled, randomized trials in adults with both asymptomatic and symptomatic ventricular dysfunction, which confirm the safety and efficacy of this category of drugs for the treatment of this potentially lethal condition. ACE inhibitors may be used to treat infants, children and adolescents with asymptomatic and symptomatic ventricular dysfunction as well. The data supporting their use in children is less complete than that concerning the treatment of adults. We review here the various causes of ventricular dysfunction and congestive heart failure (CHF) in infants, children, and adolescents; the data available regarding treatment of these conditions with ACE inhibitors, and the safety and efficacy of these drugs for the various conditions. The pharmacokinetics and proposed mechanisms of action of ACE inhibitors in children are reviewed, as are speculated long-term results of ACE inhibitor use in cohorts of growing children. Recommendations are made for future studies.
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Mori Y, Nakazawa M, Tomimatsu H, Momma K. Long-term effect of angiotensin-converting enzyme inhibitor in volume overloaded heart during growth: a controlled pilot study. J Am Coll Cardiol 2000; 36:270-5. [PMID: 10898445 DOI: 10.1016/s0735-1097(00)00673-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study examined whether long-term therapy with an angiotensin-converting enzyme (ACE) inhibitor reduces excessive increases in left ventricular (LV) mass as well as volume in growing children with aortic regurgitation or mitral regurgitation. BACKGROUND The ACE inhibitor reduces volume overload and LV hypertrophy in adults with aortic or mitral regurgitation. METHODS This study included 24 patients whose ages ranged from 0.3 to 16 years at entry to the study. On echocardiography, we measured LV size, systolic function and mass. After obtaining baseline data, patients were allocated into two groups. Twelve patients were given an ACE inhibitor (ACE inhibitor group), and 12 patients were not (control group). Echo parameters were again assessed after an average 3.4 years of follow-up. RESULTS Left ventricular parameters at baseline in the two groups were similar. The Z value of LV end-diastolic dimensions decreased from +0.82 +/- 0.55 to +0.57 +/- 0.58 in the ACE inhibitor group, whereas it increased from +0.73 +/- 0.85 to +1.14 +/- 1.04 in the control group (mean change -0.25 +/- 0.33 for the ACE inhibitor group vs. +0.42 +/- 0.48 for the control group, p = 0.0007). The mass normalized to growth also reduced from 221 +/- 93% to 149 +/- 44% of normal in the ACE inhibitor group and increased from 167 +/- 46% to 204 +/-59% of normal in the control group (mean change -72 +/- 89% of normal for the ACE inhibitor group vs. +37 +/- 35% of normal for the control group, p = 0.0007). CONCLUSIONS Long-term treatment with ACE inhibitors is effective in reducing not only LV volume overload but also LV hypertrophy in the hearts of growing children with LV volume overload.
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Affiliation(s)
- Y Mori
- Department of Pediatric Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University.
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