Long-term consequences of previous preeclampsia and complicated pregnancy: analysis of echocardiographic aspects

AIM

To evaluated echocardiographic aspects in women with history of preeclampsia or preeclampsia-related complications in their previous pregnancies.

MATERIALS AND METHODS

Consecutive women receiving echocardiography during daily clinical echolab activity were studied using complete echocardiographic examination data and anamnestic data collection of hypertension, diabetes, dyslipidemia, and rheumatic diseases. Studied women should have at least one pregnancy in more than the 10 past years, and were subdivided into two groups according to the history of complicated or physiological pregnancy. Complicated pregnancies were defined by preeclampsia or preeclampsia-related complication, such as preterm delivery or small-for-gestational age newborn. Echocardiographic parameters and prevalence of hypertension, diabetes, dyslipidemia, and rheumatic disease were compared between the two groups of studied women.

RESULTS

From March 2016 to May 2020, 545 women were studied, of whom 218 had a history of complicated pregnancy (mean age 60.81 ± 11.109 years vs. 62.78 ± 9.758 years of not complicated pregnancy; P = 0.03). Compared with physiological pregnancy women, complicated pregnancy ones were shorter (159.97 ± 6.608 vs. 161.42 ± 6.427 cm; P = 0.012) with lower body surface area (1.678 ± 0.1937 vs. 1.715 ± 0.1662 m2; P = 0.02), had higher prevalence of diabetes (6.9 vs. 3.1%; P = 0.04; odds ratio = 2.34; CI 1.0323--5.3148) and rheumatic diseases (33 vs. 22.3%; P = 0.006; odds ratio = 1.72; CI 1.1688--2.5191), and showed a slight, not significant higher prevalence of hypertension. As for echocardiographic parameters, they showed significantly higher values of end-diastolic left ventricular posterior wall (LPWd) (P = 0.034), a trend toward a more concentric geometry, and a worse longitudinal systolic left and right ventricle performance, represented by lower tissue Doppler systolic waves (septal: 7.41 ± 1.255 vs. 7.69 ± 1.376 cm/s; P = 0.018; and tricuspidalic: 12.64 ± 2.377 vs. 13.32 ± 2.548 cm/s; P = 0.003).

CONCLUSION

Patients with previous preeclampsia present an increased risk of hypertension, diabetes, and rheumatic diseases, suggesting that these women could share a specific predisposition to a high-risk profile. Furthermore, they show a higher prevalence of classically considered echocardiographic hypertensive-derived cardiac damage, suggesting structural and functional left ventricular modifications as subclinical aspects of long-term worse cardiovascular prognosis for these women.

Effects of sacubitril valsartan on clinical and echocardiographic parameters of outpatients with heart failure and reduced ejection fraction

•

How sacubitril-valsartan (SV) can affect cardiac remodelling is still unclear.

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SV therapy is associated with reduction of left ventricular mass and thickness.

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In our study women had less reverse cardiac remodelling than men.

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SV therapy also induced a decreased need for loop diuretics.

Aim

Sacubitril valsartan (SV) has revolutionized disease history in patients with heart failure and reduced ejection fraction (HFrEF). Our study assessed SV impact on clinical and echocardiographic parameters in HFrEF outpatients previously treated with optimized therapy.

Methods

Forty-nine HFrEF outpatients were retrospectively included in the study. We collected data from transthoracic echocardiography and clinical assessment at baseline and after 3 ± 1 and 12 ± 1 months of treatment with SV. Results were also stratified by sex to analyse possible sex-based differences in reverse remodelling response to SV.

Results

After 3 months of treatment we observed a significative improvement of both systolic and diastolic function with a reduction of left ventricular mass and relative wall thickness (RWT). At 12 months we observed a further improvement of all previous parameters, plus systolic pulmonary artery pressure (PAP) and left atrial (LA) diameter. In women, most of the echocardiographic parameters improved after SV initiation, but did not reach the statistical significance, except for left ventricular ejection fraction (LVEF), PAP and LA diameter. As for clinical parameters, SV improved New York Heart Association (NYHA) Class, systolic blood pressure and loop diuretic dosage with a mild but significative increase in serum creatinine and potassium.

Conclusion

Our study showed significative reverse remodelling properties of SV with an improvement of LV volumes, mass and systo-diastolic function. NYHA Class, systolic blood pressure and loop diuretic dosage also improved with only mild increase in serum creatinine and potassium. Women showed a lesser extent of reverse remodelling compared with men.

Efficacy of zofenopril in combination with amlodipine in patients with acute myocardial infarction: a pooled individual patient data analysis of four randomized, double-blind, controlled, prospective studies

OBJECTIVE

In the four SMILE (Survival of Myocardial Infarction Long-Term Evaluation) studies, early administration of zofenopril in acute myocardial infarction (AMI) showed beneficial effects as compared to placebo and other angiotensin converting enzyme inhibitors (ACEIs). This study investigated whether the concomitant administration of the dihydropyridine calcium channel-blocker amlodipine may improve zofenopril efficacy to prevent cardiovascular events in post-AMI patients.

METHODS

This was a post-hoc analysis of pooled individual patient data from the four large randomized SMILE studies. The primary endpoint was the 1-year combined occurrence of death or hospitalization for cardiovascular causes.

RESULTS

In total, 3488 patients were considered, 303 (8.7%) treated with concomitant amlodipine. Baseline systolic blood pressure and prevalence of metabolic syndrome were higher in amlodipine treated patients. The 1-year occurrence of major cardiovascular outcomes was significantly reduced in patients receiving concomitant treatment with amlodipine (hazard ratio, HR = 0.66; and 95% confidence interval, CI = 0.44-0.98; p = .039). After accounting for treatment with amlodipine, the risk of cardiovascular events was significantly reduced with zofenopril compared to placebo (HR = 0.78; 95% CI = 0.63-0.97; p = .026]. Among ACEI-treated patients, the zofenopril plus amlodipine combination reduced the risk of cardiovascular events by 38%, compared to the combination of other ACEIs plus amlodipine [HR = 0.76; 95% CI = 0.61-0.94); p = .013). The prognostic benefit of concomitant treatment with zofenopril plus amlodipine was independent from blood pressure lowering.

CONCLUSIONS

Zofenopril had a positive impact on prognosis in post-AMI patients, compared to other ACEIs. Concomitant administration of amlodipine may help to reduce the risk of cardiovascular events at 1 year.

Efficacy of zofenopril in combination with thiazide diuretics in patients with acute myocardial infarction: a pooled individual data analysis of four randomized, double-blind, controlled, prospective studies

Background

In the Survival of Myocardial Infarction Long-Term Evaluation (SMILE) studies, early administration of zofenopril after acute myocardial infarction (AMI) was prognostically beneficial as compared to placebo and other angiotensin-converting enzyme inhibitors (ACEIs), such as lisinopril and ramipril. Here, we investigated whether zofenopril efficacy could be affected by a concomitant use of thiazide diuretics (TDs).

Methods

This was a post hoc analysis of pooled individual patient data from the SMILE studies. Patients treated with other diuretics than TDs were excluded. The primary study endpoint was the 1-year combined occurrence of death or hospitalization for CV causes, with or without TD.

Results

Among 2,995 patients, 263 (8.8%) were treated with a combination including a TD (TD+), whereas 2,732 (91.2%) were not treated with any diuretic (TD−). Proportions of subjects who were treated with TD were equally distributed (p=0.774) within the placebo, zofenopril, and other ACEIs groups. The 1-year risk of major cardiovascular events was similar in TD+ (18.3%) and TD− (16.8%) patients (hazard ratio [HR] 1.04; 95% CI 0.74–1.45; p=0.838). After stratifying per concomitant treatment and TD, the 1-year risk of CV events was significantly lower with zofenopril than with placebo (HR 0.70; 95% CI 0.55–0.88; p=0.002) and other ACEIs (HR 0.58; 95% CI 0.46–0.74; p=0.0001). Treatment with ACEIs and TD as concomitant therapy was associated with a larger blood pressure (BP) reduction (p=0.0001 for systolic BP and p=0.045 for diastolic BP).

Conclusion

In post AMI patients, zofenopril maintained its positive impact on prognosis compared to placebo or other ACEIs, regardless concomitant TD administration. In this setting, TD shows advantages in managing the most difficult hypertensive patients.

Effects of the concomitant administration of xanthine oxidase inhibitors with zofenopril or other ACE-inhibitors in post-myocardial infarction patients: a meta-analysis of individual data of four randomized, double-blind, prospective studies

Background

Oxidative stress is increased in hyperuricemic patients with acute myocardial infarction (AMI). Use of sulfhydryl ACE-inhibitors (ACEIs), such as zofenopril or captopril, plus xanthine oxidase inhibitors (XOIs), may potentially result in enhanced antioxidant effects and improved survival.

Objective

We verified the benefit of such combination in a randomly stratified sample of 525 of the 3630 post-AMI patients of the four randomized prospective SMILE (Survival of Myocardial Infarction Long-term Evaluation) studies.

Methods

One hundred sixty-five (31.4%) patients were treated with XOIs (79 under zofenopril, 86 placebo, lisinopril or ramipril), whereas 360 were not (192 zofenopril, 168 placebo or other ACEIs). In these four groups, we separately estimated the 1-year combined risk of major cardiovascular events (MACE, death or hospitalization for cardiovascular causes).

Results

MACE occurred in 10.1% of patients receiving zofenopril + XOIs, in 18.6% receiving placebo or other ACEIs + XOIs, in 13.5% receiving zofenopril without XOIs and in 22.0% receiving placebo or other ACEIs, but no XOIs (p = 0.034 across groups). Rate of survival free from MACE was significantly larger under treatment with zofenopril + XOIs than with other ACEIs with no XOIs [hazard ratio: 2.29 (1.06–4.91), p = 0.034]. A non-significant trend for superiority of zofenopril + XOIs combination was observed vs. zofenopril alone [1.19 (0.54–2.64), p = 0.669] or vs. placebo or other ACEIs + XOIs [1.82 (0.78–4.26), p = 0.169].

Conclusions

Our retrospective analysis suggests an improved survival free from MACE in post-AMI patients treated with a combination of an urate lowering drug with antioxidant activity and an ACEI, with best effects observed with zofenopril.

Efficacy of Ace Inhibition with Zofenopril, Lisinopril, or Ramipril in Postacute Myocardial Infarction Patients With or Without Metabolic Syndrome: A Pooled Individual Data Analysis of Four Randomized, Double-Blind, Controlled, Prospective Studies

Background: The metabolic syndrome (MS) is a clustering of different cardiovascular (CV) risk factors, which further enhances the risk of death and CV complications in post-acute myocardial infarction (AMI) patients. In the present meta-analysis of individual data of the four randomized, prospective SMILE studies, we evaluated the efficacy of zofenopril vs. lisinopril, ramipril, and placebo on 1-year CV morbidity and mortality, according to the presence (+) or absence (−) of the MS.

Methods: 2203 (63.2%) of the 3488 patients were classified as MS+, 1285 (36.8%) as MS−. Five hundred two MS+ and 380 MS− were treated with placebo, 1134 and 608 with zofenopril 30–60 mg/die, 340 and 175 with lisinopril 5–10 mg/die, and 227 and 122 with ramipril 10 mg/die. Treatment was continued for 6 to 48 weeks.

Results: The 1-year risk of a major CV event was similar (P = 0.420) in MS+ (18.1%) and MS− (18.0%) patients [HR and 95% confidence interval: 0.92 (0.76–1.12)]. After accounting for MS+/MS−, the 1-year risk of CV events vs. placebo was significantly lower under zofenopril [0.79 (0.63–0.97); P = 0.028] and lisinopril [0.65 (0.47–0.89); P = 0.007], but larger under ramipril [2.57 (1.94–3.93); P = 0.0001]. Treatment with zofenopril was associated with a statistically significant (P = 0.0001) reduction in CV risk as compared with the other angiotensin-converting enzyme inhibitors [MS+: 0.52 (0.42–0.66); MS−: 0.52 (0.38–0.73)].

Conclusions: In post-AMI patients with MS, zofenopril treatment is associated with a clinically relevant reduction in long-term CV morbidity and mortality, compared with placebo, with an efficacy similar to lisinopril, but better than ramipril.

Cardioprotective role of zofenopril in hypertensive patients with acute myocardial infarction: a pooled individual data analysis of the SMILE studies

PURPOSE

The four SMILE studies demonstrated that early administration of zofenopril following acute myocardial infarction is prognostically beneficial compared to placebo or other angiotensin-converting enzyme (ACE) inhibitors. In the present retrospective pooled analysis of individual SMILE studies, we evaluated the efficacy of zofenopril on cardiovascular (CV) outcomes in 1880 hypertensive and 1662 normotensive patients.

MATERIALS AND METHODS

Four hundred and forty-nine hypertensives and 486 normotensives were treated with placebo, 980 and 786 with zofenopril 30-60 mg daily, 252 and 259 with lisinopril 5-10 mg daily, 199 and 131 with ramipril 10 mg daily, for 6 to 48 weeks.

RESULTS

The 1-year risk of death or hospitalization for CV causes was significantly reduced with zofenopril and lisinopril vs. placebo in both hypertensive (HR: 0.65; 95%CI: 0.48-0.86; p = .003 and .60, .36-.99; p = .049, respectively) and normotensive patients (0.56, 0.42-0.75; p = .0001 and .51, .28-.90; p = .020), whereas this was not the case for ramipril (hypertensives: 1.02, 0.69-1.52; p = .918; normotensives: 0.91, 0.59-1.41; p = .670). Zofenopril significantly reduced the risk of CV outcomes vs. the other two ACE-inhibitors pooled together in hypertensive (0.76; 0.58-0.99; p = .045), but not in normotensive patients (0.77; 0.55-1.10; p = .150).

CONCLUSIONS

In cardiac patients of the SMILE studies with arterial hypertension treatment with the ACE-inhibitor zofenopril was beneficial in reducing the 1-year risk of CV events as compared to placebo and ramipril. An efficacy similar to that of zofenopril was observed with lisinopril.

Cardioprotective role of zofenopril in patients with acute myocardial infarction: a pooled individual data analysis of four randomised, double-blind, controlled, prospective studies

BACKGROUND

Early administration of zofenopril following acute myocardial infarction (AMI) proved to be prognostically beneficial in the four individual randomised, double-blind, parallel-group, prospective SMILE (Survival of Myocardial Infarction Long-term Evaluation) studies. In the present analysis, we evaluated the cumulative efficacy of zofenopril by pooling individual data from the four SMILE studies.

METHODS

3630 patients with AMI were enrolled and treated for 6-48 weeks with zofenopril 30-60 mg/day (n=1808), placebo (n=951), lisinopril 5-10 mg/day (n=520) or ramipril 10 mg/day (n=351). The primary study end point of this pooled analysis was set to 1 year combined occurrence of death or hospitalisation for cardiovascular (CV) causes.

RESULTS

Occurrence of major CV outcomes was significantly reduced with zofenopril versus placebo (-40%; HR=0.60, 95% CI 0.49 to 0.74; p=0.0001) and versus the other ACE inhibitors (-23%; HR=0.77, 0.63 to 0.95; p=0.015). The risk reduction observed under treatment with the other ACE inhibitors was nearly statistically significant (-22%; HR=0.78, 0.60 to 1.02; p=0.072). The benefit of zofenopril versus placebo was already evident after the first 6 weeks of treatment (-28%; HR=0.72, 0.54 to 0.97; p=0.029), while this was not the case for the other ACE inhibitors (-19%; HR=0.81, 0.57 to 1.17; p=0.262). In this early phase of treatment, zofenopril showed a non-significant trend towards a larger reduction in CV events versus the other ACE inhibitors (-11%; HR=0.89, 0.69 to 1.15; p=0.372).

CONCLUSIONS

The pooled data analysis from the SMILE Programme confirms the favourable effects of zofenopril treatment in patients with post-AMI and its long-term benefit in terms of prevention of CV morbidity and mortality.

Randomised comparison of zofenopril and ramipril plus acetylsalicylic acid in postmyocardial infarction patients with left ventricular systolic dysfunction: a post hoc analysis of the SMILE-4 Study in patients according to levels of left ventricular ejection fraction at entry

Objective

Conflicting evidence exists on the benefits of treating patients with coronary artery disease and preserved left ventricular ejection fraction (LVEF) with an ACE inhibitor. This retrospective analysis of the SMILE-4 Study sought to compare the efficacy of zofenopril 60 mg plus acetylsalicylic acid (ASA) versus ramipril 10 mg plus ASA 100 mg in patients with acute myocardial infarction (AMI) and heart failure, according to an impaired or preserved LVEF.

Methods

The primary study end point was 1-year combined occurrence of death or hospitalisation for cardiovascular causes. A preserved LVEF was defined by a baseline LVEF >40% and an impaired one by an LVEF ≤40%.

Results

448 patients (63%) had preserved and 262 (37%) had impaired LVEF. The primary end point occurred in 125 patients with preserved (28%) and 106 patients with impaired LVEF (41%, p=0.001). In the first group, the rate of major cardiovascular events was significantly lower under zofenopril than under ramipril (23% vs 33%; OR and 95% CI 0.60, 0.39 to 0.91; p=0.016). This was also the case for patients with impaired LVEF, though between-group difference was not statistically significant (38% zofenopril vs 44% ramipril; OR 0.77, 0.47 to 1.26; p=0.297). LVEF values significantly (p<0.0001) increased during the follow-up in both subsets with no between-treatment differences. However, improvement rates in LVEF (increase ≥5%) were higher in patients with impaired LVEF (72% vs 61%, p=0.006).

Conclusions

In the SMILE-4 Study, the cardiovascular outcome of patients with post-AMI with preserved LVEF was more favourable in the zofenopril than in the ramipril treatment group.

Trial registration number

EudraCT Number: 2004-001150-88 (http://www.clinicaltrialsregister.eu); Italian Ministry of Health Code: GUIDOTT_III_2004_001 (https://oss-sper-clin.agenziafarmaco.it).

Serum uric acid and other short-term predictors of electrocardiographic alterations in the Brisighella Heart Study cohort

INTRODUCTION

Recent studies show that serum uric acid (SUA) is a predictor of atrial fibrillation, while its association with other kinds of arrhythmias is not yet established. We aimed to evaluate the incidence of the most common electrocardiographic alterations in a relatively large sample of general population and their association with SUA.

MATERIALS AND METHODS

We selected a Brisighella Heart Study cohort sample of 1557 subjects, consecutively visited in the 2004 and 2008 surveys, in a setting of primary prevention for cardiovascular disease and without a known diagnosis of arrhythmia or left ventricular hypertrophy, excluding subjects affected by gout or taking any antihyperuricemic agent or drugs able to interfere with the QT interval. A step-wise Cox regression analysis was used to determine the independent prognostic significance of age, gender, physical activity, smoking, body mass index (BMI), fasting plasma glucose, mean arterial pressure (MAP), heart rate, LDL-cholesterol, HDL-cholesterol, triglycerides, SUA and eGFR on ECG alterations during a 4-year follow-up.

RESULTS

No one of the considered variables was associated with the incident diagnosis of sinus tachycardia and sinus bradycardia. SUA predicted incident tachyarrhythmias, Q waves and ECG signs of left ventricular hypertrophy; age, female sex and active smoking predicted incident tachyarrhythmias; male sex, active smoking and LDL-cholesterol predicted incident ECG signs of previous myocardial infarction; BMI and MAP predicted incident ECG-diagnosed left ventricular hypertrophy.

CONCLUSION

In a cohort of general population, SUA seems to be a significant middle-term predictor of electrocardiographically diagnosed myocardial infarction, left ventricular hypertrophy and tachyarrhythmias.

VO2 kinetics in supra-anaerobic threshold constant tests allow the visualization and quantification of the O2 saving after cytochrome c oxidase inhibition by aerobic training or nitrate administration

We tested whether the known cytochrome c oxidase (COX) inhibition by nitric oxide (NO) could be quantified by VO(2) kinetics during constant load supra-Anaerobic Threshold (AT) exercises in healthy trained or untrained subjects following aerobic training or nitrate administration. In cycle ergometer constant load exercises supra-AT, identified in previous incremental tests, VO(2) kinetics describe a double exponential curve, one rapid and one appreciably slower, allowing the area between them to be calculate in O(2) l. After training, with increased NO availability, this area decreases in inverse ratio to treatment efficacy. In fact, in 11 healthy subjects after aerobic training for 6-7 weeks, area was decreased on average by 51 %. In 11 untrained subjects, following the assumption of an NO donor, 20 mg isosorbide 5 mononitrate, area was decreased on average by 53 %. In conclusion, supra-AT VO(2) kinetics in constant load exercises permit the quantification of the inhibitory effect NO-dependent on COX after either physical training or nitrate assumption.

Cost-effectiveness of zofenopril in patients with left ventricular systolic dysfunction after acute myocardial infarction: a post hoc analysis of SMILE-4

BACKGROUND

In SMILE-4 (the Survival of Myocardial Infarction Long-term Evaluation 4 study), zofenopril + acetylsalicylic acid (ASA) was superior to ramipril + ASA in reducing the occurrence of major cardiovascular events in patients with left ventricular dysfunction following acute myocardial infarction. The present post hoc analysis was performed to compare the cost-effectiveness of zofenopril and ramipril.

METHODS

In total, 771 patients with left ventricular dysfunction and acute myocardial infarction were randomized in a double-blind manner to receive zofenopril 60 mg/day (n = 389) or ramipril 10 mg/day (n = 382) + ASA 100 mg/day and were followed up for one year. The primary study endpoint was the one-year combined occurrence of death or hospitalization for cardiovascular causes. The economic analysis was based on evaluation of cost of medications and hospitalizations and was applied to the intention-to-treat population (n = 716). Cost data were drawn from the National Health Service databases of the European countries participating in the study. The incremental cost-effectiveness ratio was used to quantify the cost per event prevented with zofenopril versus ramipril.

RESULTS

Zofenopril significantly (P = 0.028) reduced the risk of the primary study endpoint by 30% as compared with ramipril (95% confidence interval, 4%-49%). The number needed to treat to prevent a major cardiovascular event with zofenopril was 13 less than with ramipril. The cost of drug therapies was higher with zofenopril (328.78 Euros per patient per year, n = 365) than with ramipril (165.12 Euros per patient per year, n = 351). The cost related to the occurrence of major cardiovascular events requiring hospitalization averaged 4983.64 Euros for zofenopril and 4850.01 Euros for ramipril. The incremental cost-effectiveness ratio for zofenopril versus ramipril was 2125.45 Euros per event prevented (worst and best case scenario in the sensitivity analysis was 3590.09 and 3243.96 Euros, respectively).

CONCLUSION

Zofenopril is a viable and cost-effective treatment for managing patients with left ventricular dysfunction after acute myocardial infarction.

Long-term clinical experience with zofenopril

Angiotensin-converting enzyme inhibitors are extensively used to improve clinical outcome of patients with several cardiovascular diseases. Zofenopril proved to be very effective in patients with coronary artery disease and myocardial infarction, thanks to its unique effective mechanism of action for improving blood pressure control, left ventricular function and myocardial ischemia burden, as well as angiotensin-converting enzyme inhibition. The SMILE project involved more than 3500 patients with coronary artery disease and demonstrated that zofenopril treatment may reduce mortality and morbidity in patients with myocardial infarction, also when combined with acetyl salicylic acid and to a greater extent than lisinopril and ramipril. In addition, the results of the SMILE-ISCHEMIA study have demonstrated an interesting anti-ischemic effect of zofenopril, and these properties largely contribute to the overall clinical benefit of the drug. The effects of zofenopril on blood pressure control and cardiovascular protection clearly support its primary role for prevention and treatment of cardiovascular diseases.

Predictors of the short-term effect of isoleucine-proline-proline/valine-proline-proline lactotripeptides from casein on office and ambulatory blood pressure in subjects with pharmacologically untreated high-normal blood pressure or first-degree hypertension

Our aim was to evaluate the predictors of Isoleucine-Proline-Proline/Valine-Proline-Proline (IPP-VPP) lactotripeptides (LTPs) antihypertensive effect in the context of a short-term large double-blind randomized clinical trial involving 164 pharmacologically untreated subjects in primary prevention for cardiovascular disease. When compared with the baseline, office systolic blood pressure (SBP) (-3.42 mm Hg, P < .001) and diastolic blood pressure (DBP) (-2.35 mm Hg, P < .001) significantly decreased, in the LTP-treated patients only. No significant change in predictors during the study of ambulatory blood pressure measurement (ABPM) parameters was observed. A short-term supplementation with LTPs significantly improves the office SBP and DBP, especially in male subjects. The main predictor of LTP antihypertensive effect was the baseline BP.

Hemodynamic and neurohumoral profile in patients with different types of hypertension in pregnancy

Hypertension in pregnancy is a frequent disorder that includes a spectrum of conditions. We aimed at comparatively evaluating the hemodynamic, echocardiographic and biohumoral profile of a sample of pregnant Caucasian women with different form of pregnancy-related hypertension. We enrolled 39 non-hypertensive pregnant women (NP), 26 with Chronic HBP in pregnancy (CH), 24 with gestational hypertension (G-PIH), and 33 with pre-eclampsia. We recorded and compared blood pressure (BP), echocardiographic parameters, resting plasma renin activity (PRA) and plasma aldosterone (PA), Plasma levels of atrial (ANP) and brain natriuretic peptide (BNP). PE patients had a significantly higher BP than either G-PIH or NP patients. PE patients had also significantly lower cardiac output than NP, G-PIH and CH. In comparison to NP patients, the total peripheral vascular resistance was 61% higher in PE women and 38% higher in CH patients. All echographic parameters were significantly more altered in PE patients when compared with NP, in respect to any other form of hypertension. Either ANP (+35%) and BNP (+40%) were significantly higher in PE patients than in controls. The PRA was reduced in PE and CH patients when compared either with NP (-38 and -35%, respectively) or G-PIH (-47 and -43%, respectively). On the basis of our data, we can conclude that PE is the gestation associated hypertension with the largest anatomical, functional and biohumoral involvement, and so it has to be involved in a more intensive monitoring and evaluation.

Effects of early angiotensin-converting enzyme inhibition in patients with non-ST-elevation acute anterior myocardial infarction

BACKGROUND

No data are available on the clinical efficacy of the early administration (<24 hours from onset of chest pain) of angiotensin-converting enzyme inhibitors in non-thrombolysed patients with non-ST-elevation myocardial infarction (NSTEMI). We have addressed this issue in a subgroup of NSTEMI patients enrolled in the SMILE trial.

METHODS

Of the overall population of 1556 patients, 526 (33.8%) had an anterior wall NSTEMI, defined as an ST elevation <1 mm or an ST depression in at least two contiguous precordial leads with or without new abnormal Q waves. No patient of the SMILE Study received thrombolytic therapy or was reperfused. Patients were randomized, double-blind, to zofenopril (n = 253) or placebo (n = 273) for 6 weeks. The primary end point was the effect of treatment on the 6-week combined occurrence of death and severe congestive heart failure (CHF). Secondary end points included the evaluation of the 6-week rate of severe CHF as well as the 1-year mortality rate.

RESULTS

After 6 weeks of treatment, zofenopril significantly reduced both the incidence of the primary end point (risk reduction 65%, 95% CI 20-80, 2P = .003) and the 6-week incidence of severe CHF (84%, 95% CI 33-97, 2P = .006) in NSTEMI patients. One-year mortality was also significantly reduced by zofenopril treatment (43%, 95% CI 14-57, 2P = .036).

CONCLUSIONS

Results of this post hoc analysis of the SMILE Study strongly suggest the benefit of the early administration of zofenopril even in patients with an anterior wall NSTEMI.

A review of the angiotensin-converting enzyme inhibitor, zofenopril, in the treatment of cardiovascular diseases

Based on preclinical and clinical findings, zofenopril appears to be an angiotensin-converting enzyme (ACE) inhibitor with high potency, significant tissue selectivity and a long duration of action. Its ancillary properties, such as antioxidant activity and cardiovascular (CV) protection, make this drug potentially suitable for the treatment, and possibly prevention, of several CV diseases. There is a large body of evidence that support a complex interaction between ACE inhibitors and CV disease. A review of the preclinical profile of zofenopril clearly suggest that such interaction can be even more complex and could involve some drug-specific properties directly involved in the definition of the overall clinical profile of zofenopril as emerged from randomised clinical trials. In particular, zofenopril combines the feature of an effective ACE inhibitor, with plasma and tissue activity, along with that of an antioxidant compound, and both these characteristics can contribute to its capacity of controlling hypertension and improving the prognosis of patients with coronary artery disease. The results of The Survival of Myocardial Infarction Long term Evaluation (SMILE) trials have demonstrated that the early administration of zofenopril to patients with acute myocardial infarction is associated with a significant reduction in the 6-week occurrence of major CV events (death and congestive heart failure) in high-risk patients with anterior non-thrombolysed myocardial infarction, and this effect is enhanced in some higher-risk subgroups of patients, such as those with a history of diabetes or arterial hypertension.

Serum cholesterol levels, blood pressure response to stress and incidence of stable hypertension in young subjects with high normal blood pressure

RATIONALE

Elevated serum cholesterol levels are common in patients with high blood pressure (BP) and could contribute to the progression of the hypertensive disease.

OBJECTIVE

To determine whether serum cholesterol levels affect the BP response to mental stress (MA) and the development of stable hypertension in young subjects with high normal BP.

METHODS

Seventy young (age < 45 years) high normal BP subjects with elevated (> 200 mg/dl, n = 49; HC) or normal (< or = 199 mg/dl, n = 21; NC) serum cholesterol levels, and 20 normotensive normocholesterolaemic (serum cholesterol < 199 mg/dl; C) subjects undergoing standardized mental challenge (mental arithmetic) were followed up for 15 years according to a prospective, longitudinal, cohort study design conducted in an ambulatory setting. The main outcome measure was the evaluation of the 15-year incidence of stable hypertension (diastolic BP > 95 mmHg).

RESULTS

After adjustment for age, resting BP, family history of high BP and body mass index at the study entry, high normal BP subjects with HC showed an enhanced BP reactivity to stress and a higher 15-year incidence of stable hypertension compared to high normal BP and NC subjects [relative risk (RR) = 2.1; 95% confidence interval (CI) = 1.7-5.5, P < 0.001] and controls (RR = 3.1; 95% CI = 1.4-5.3, P < 0.001). In a multivariate analysis of data the presence of high cholesterol levels was an independent predictor for the development of hypertension.

CONCLUSION

These data suggest that subjects with high normal BP and elevated serum cholesterol might have an exaggerated cardiovascular response to stress and have an increased risk for stable hypertension that can be detected at young age.

Effects of the early ACE inhibition in diabetic nonthrombolyzed patients with anterior acute myocardial infarction

OBJECTIVE

The aim of the present study was to evaluate the clinical efficacy of the ACE inhibitor zofenopril in a cohort of diabetic patients with nonthrombolyzed anterior acute myocardial infarction who were enrolled in the Survival of Myocardial Infarction Long-Term Evaluation (SMILE) trial.

RESEARCH DESIGN AND METHODS

Among the overall population of 1,512 patients, 303 (20.0%) had diabetes. The primary end point of this study was the effect of treatment on the 6-week combined occurrence of death and severe congestive heart failure (CHF). Secondary end points included the evaluation of the 6-week rate of major cardiovascular events as well as the 1-year survival rate.

RESULTS

After 6 weeks of double-blind treatment, zofenopril significantly reduced both the incidence of the primary end point (8.6 vs. 18.3%; P = 0.019) and the 6-week incidence of severe CHF (0 vs. 7.3%; P = 0.001) in diabetic patients, and the effect was greater than that observed in nondiabetic patients. Conversely, 1-year mortality was significantly reduced among nondiabetic patients (9.1 vs. 13.8%; P = 0.010), whereas in the diabetic population, the decrease did not reach statistical significance (13.7 vs. 16.5%; P = 0.52).

CONCLUSIONS

The present data suggest that the clinical outcome of patients with diabetes and myocardial infarction can be significantly improved by early treatment with zofenopril. The lesser effect on 1-year mortality seems to suggest that long-term treatment is probably needed to maintain the benefits of the early ACE inhibition in patients with diabetes.

Fixed combinations of delapril plus indapamide vs fosinopril plus hydrochlorothiazide in mild to moderate essential hypertension

This 12-week randomized, parallel-group, multicenter study compared fixed combinations of delapril (D) 30 mg plus indapamide (I) 2.5 mg and fosinopril (F) 20 mg plus hydrochlorothiazide (H) 12.5 mg in 171 adult patients with mild to moderate essential hypertension. After a 2-week placebo run-in, sitting and standing systolic (SBP) and diastolic blood pressure (DBP) was measured by conventional sphygmomanometry. The primary efficacy endpoint was the percentage of normalized (sitting DBP < or =90 mm Hg) and responder (sitting DBP reduction of 10 mm Hg or DBP < or =90 mm Hg) patients. Treatment effects were analyzed in the intention-to-treat (ITT; n = 171) and the per-protocol (PP; n = 167) populations. The percentage of normalized and responder patients did not differ significantly between the D + I (87.4% and 92%) and the F + H (81% and 86.9%) ITT groups. Similar results were seen in the PP population. In ITT and PP patients, sitting and standing SBP and DBP values were comparable at baseline in the two groups and were significantly (P<.01) and similarly reduced at weeks 4, 8, and 12. Neither treatment induced reflex tachycardia, and both regimens were well tolerated. Four patients in the F + H group dropped out because of adverse events. In this study, the efficacy and safety of D + I were comparable to those of F + H in patients with mild to moderate essential hypertension.

Beta-blockade in hypertension and congestive heart failure

Hypertension is common and increases the risk of death from coronary artery disease and cerebral vascular disease. The reason for treating hypertension is to prevent the long-term complications of this disorder. Many studies of antihypertensive therapy have produced only modest reductions in coronary events; in particular, with the use of beta-blockers. Clinical trials and meta-analyses have shown a lesser effect of these drugs on primary prevention of coronary events, cardiovascular and total mortality with respect to other antihypertensive approaches based on the use of low-dose diuretic therapy, especially in the elderly, even if the reduction of stroke and heart failure (HF) were similar. New beta-blockers with vasodilating properties due to the capacity to enhance the release of endothelial nitric oxide, then lessening a contributory mechanism to the pathogenesis of atherosclerosis as endothelial damage and dysfunction, seem to possess considerable potential in the treatment of hypertension, particularly in terms of improvement of cardiovascular outcome of patients. In HF, there is now considerable interest in the therapeutic use of beta-blockade. Some recent clinical trials have demonstrated conclusive evidence of the beneficial effects of beta-blocker therapy on survival in chronic HF. As a result of these data, beta-blocker therapy has become part of standard therapy for patients with chronic HF, in addition to angiotensin-converting enzyme-inhibitors and diuretics. The treatment is, in general, well tolerated. There are, however, some unanswered questions. One is whether some beta-blockers may be better than others. The major mortality benefit is probably a class-effect of beta1-adrenoceptor blockade, but the differences between beta-blockers might be clinically relevant. For example, it is under debate whether ancillary properties of some beta-blockers, such as the capability of exerting antioxidant effects or enhancing the nitric oxide production, may contribute to the clinical effects of these drugs. Future clinical trials will report over the next few years and help to answer the question about differences in mortality effects among types of beta-blocking agents, thus correctly defining the precise role of these drugs in the wide spectrum of cardiovascular disease.

Anti-ischemic effects of angiotensin-converting enzyme inhibitors: a future therapeutic perspective

The renin-angiotensin system and angiotensin-converting enzyme (ACE) are increasingly being implicated in the pathogenesis of coronary artery disease and its sequelae and the potential of ACE inhibitors to protect the heart is a topic that has emerged recently as a matter for scientific discussion. Experimental and clinical studies have shown the beneficial effects of ACE inhibitors on the metabolism, function and structure of healthy and damaged hearts and these data support the concept of both primary and secondary cardioprotection with this class of drugs. Animal studies have demonstrated the potential beneficial effects of ACE inhibition at a variety of sites, including improvement of endothelial function, inhibition of platelet aggregation, prevention of atherosclerotic lesions and inhibition of myointimal proliferation, extending the concept to a more general definition of cardiovascular protection with ACE inhibitors involving both the heart and the vessels. ACE inhibitors prevent stimulation of smooth muscle cell angiotensin-II (A-II) receptors, thereby blocking both contractile and proliferative actions of A-II. In addition, ACE inhibition of kininase inhibits the breakdown of bradykinin, a direct stimulant of nitric oxide release from the intact endothelial cell. Thus, at the cellular level ACE inhibition shifts the balance of ongoing mechanisms in favour of those promoting vasodilatory, anti-aggregatory, antithrombotic and antiproliferative effects. Although these data have not all been validated in human studies, the reduction of ischemic events in studies of ACE inhibition in left ventricular dysfunction (LVD) and, more recently, also in patients without LVD, cannot be explained solely by improved hemodynamics, and it is possible that actions on the endothelium, the atherosclerotic process and platelets are at least in part responsible. So, the available data underlie the potential benefits of ACE inhibition in the field of ischemic heart disease and atherosclerosis; the results of ongoing studies in humans looking more directly at the influence of ACE inhibitors in this setting are awaited with interest.

Use of statins and blood pressure control in treated hypertensive patients with hypercholesterolemia

High serum cholesterol has been frequently reported in patients with arterial hypertension in whom it might influence the blood pressure control. The aim of this study was to compare the extent of blood pressure changes in 41 patients with hypertension and hypercholesterolemia, taking antihypertensive drugs and treated for 3 months with statins (HC-S; pravastatin or simvastatin) and compared with matched controls with high (HC-D; 44) or normal serum cholesterol (NC-D; 45) undergoing antihypertensive treatment combined with dietary treatment alone. After 3 months of follow-up, a greater reduction of systolic (SBP) and diastolic (DBP) blood pressure values was observed in HC-S patients (ASBP/DBP, -11.3 +/-3/-10.6 +/- 2%) when compared with both HC-D (deltaSBP/DBP, -6.6 +/- 2/-6.1 +/- 2%; p < 0.05) and NC-D (deltaSBP/DBP, -6.9 +/- 2/-6.8 +/- 1.5%; p < 0.05). In statin-treated patients, a slight linear relation has been found between the percentage changes in DBP and those in plasma total cholesterol (R = 0.37, p = 0.043), whereas no relation was found with SBP changes (R =0.11; p = 0.35). In conclusion, the results of this study demonstrate that the use of statins in combination with antihypertensive drugs can improve blood pressure control in patients with uncontrolled hypertension and high serum cholesterol levels. The additional blood pressure reduction observed in patients treated with statins is clinically relevant and only partially related to the lipid-lowering effect.

Effects of the administration of an angiotensin-converting enzyme inhibitor during the acute phase of myocardial infarction in patients with arterial hypertension. SMILE Study Investigators. Survival of Myocardial Infarction Long-term Evaluation

A positive history of arterial hypertension (HBP) is present in as many as 30% of patients with acute myocardial infarction (AMI) and their clinical outcome could be greatly improved by drugs enhancing blood pressure control and preserving ventricular function. The aim of the present study was to evaluate the importance of a history of HBP on the clinical efficacy of early treatment with the angiotensin-converting enzyme (ACE) inhibitor zofenopril in patients with anterior AMI. We summarize the results of a post-hoc analysis of data from the Survival of Myocardial Infarction Long-term Evaluation (SMILE) study, which randomly evaluated the efficacy of zofenopril given within 24 h of symptom onset to patients with anterior AMI not undergoing thrombolysis. Of 1441 patients who entered the study, 565 (39.2%) had a history of HBP. The mean follow-up time was 12 months and the main outcome measures were 6-week combined occurrence of death and severe congestive heart failure (CHF) and 1-year mortality. After 6-week of treatment with zofenopril the relative risk of death or severe CHF was 0.60 (95% confidence interval [CI]: 0.45-0.81; 2P < .05) in the hypertensive group and 0.89 (0.74-1.08; 2P = .62) for normotensive patients, whereas the 1-year risk of death was 0.61 (95% CI: 0.23,0.89; 2P < .05) and 0.77 (95% CI: 0.52-1.17; 2P = .22), respectively. The 6-week prevalence of mild-to-moderate CHF was also significantly reduced by zofenopril in the hypertensive population (14.1% v 9.4%; 2P < .05). The present data suggest that treatment with zofenopril started within 24 h of the onset of anterior AMI could be highly beneficial in patients with a history of HBP.

[Clinical approach to the hypertensive patient. New guidelines]

Prospective observational studies clearly show that the risks of stroke, coronary artery disease, and premature death are directly related to blood pressure levels. Yet as the results of prospective randomized intervention studies have indicated, these risks are reduced by effective blood pressure control. Over a 5-year period, an average reduction of 5-6 mmHg in diastolic blood pressure and of 10-12 mmHg in systolic blood pressure is associated with a 38% decrease in risk of stroke and a 16% decrease in risk of coronary heart disease. Although awareness of hypertension has increased markedly, and the number of patients treated for this condition has approximately doubled over the last 20 years, premature morbidity and mortality remain higher than in the normotensive population. This situation may arise from the inadequate level of blood pressure control achieved in many patients. Thus, although delineating theoretical rules to treat hypertension seems relatively easy, in real life it is not always possible to adhere to them. This difficulty highlights the need for appropriate guidelines in clinical practice. A number of national groups as well as the World Health Organization and the International Society of Hypertension have recently published recommendations for the diagnosis and treatment of hypertension. Physicians must strive to improve the management of hypertension and remember that a thorough clinical evaluation, treatment of associated cardiovascular risk factors, prevention of target organ damage, and good patient compliance are key elements affecting the success of therapy.

[Integration of therapeutic options and the candidates for treatment: the ABC of the post-infarction period]

Acute myocardial infarction, major cause of death in Western society, has been the focus of many clinical investigations over the past decade. As the result of randomized trials involving hundreds of thousands of infarct patients worldwide, the life-saving potential of several pharmacologic interventions has been validated, and the usefulness of other commonly used treatments has been disproven or brought into question. Much of the innovative therapy has been targeted toward limiting myocardial damage by eradicating the occlusive thrombus or otherwise restoring flow through the infarct-related artery, reducing oxygen demands in the injured ventricle, and altering vascular dynamics to limit the process of ventricular remodeling. Data have accumulated showing substantially lower mortality of acute myocardial infarction with simple pharmacological interventions such as intravenous thrombolytic therapy, aspirin, beta-blockers and ACE-inhibitors. In particular, ACE-inhibitors have recently proven to be effective in infarcted patients, especially in high-risk subjects with acute anterior infarction not treated with thrombolytic agents or patients with left ventricular dysfunction. ACE-inhibitors may limit the process of ventricular remodeling after a large infarction, lessening the risk of sudden death and heart failure. Intravenous heparin has a role in maintaining patency of infarct-related vessel after rt-PA, and it seems that this combination offers some benefits with respect to streptokinase plus subcutaneous heparin. Recent studies have also demonstrated the importance of lipid-lowering agents for secondary prevention after myocardial infarction. Several previously recommended therapies (routine intravenous lidocaine, calcium channel blockers, magnesium, nitrates) have not been proven to be life-saving.