The Comparison of The Efficacy and The Confidence of The Vasodilator Therapy With Felodipine And Lisinopril in Chronic, Moderate to Severe Aortic Regurgitation

Abstract

Purpose: Afterload reduction decreases volume overload on the left ventricle in chronic asymptomatic aortic regurgitation (AR). In this prospective, randomized trial, we aimed to compare the effects of a 6-months long treatment with lisinopril versus felodipine on left ventricular function and hemodynamic parameters. Methods: 41 asymptomatic patients with moderate to severe chronic, isolated AR were randomly assigned to treatment with either lisinopril (20 mg) or felodipin (10 mg). Echocardiographic ([ESV], [EDV], [EF], [FSV], [LVSV], [RV], [RF], [FCO], [LVCO], [SW], [CW], [LVWS]) and hemodynamic parameters [SBP], [DBP], [SVR]) at baseline and at 6 months were compared. Results: At 6 months, with lisinopril, SBP 8,9 %, DBP 5,9 %, SVR 16,7 %, RV 8,4 %, RF 11 %, SW 6 %, CW 7.2 % decreased and FSV 11,2 %, LVSV 3 % increased (p

Keywords

• Chronic aortic regurgitationi,felodipine,lisinopril,echocardiography

Kronik, Orta-Ciddi Aort Yetmezliginde Felodipin Ve Lisinopril Vazodilatör Tedavisinin Etkinliginin Ve Güvenilirliginin Karsilastirilmasi

Abstract

Amaç: Aort Yetmezligi varliginda ciddi hacim yüküne karsi çalismak zorunda olan sol ventrikül (LV) kompansatuar mekanizmalar ile pompa fonksiyonunu uzun süre normal düzeylerde tutabilir. Fakat ileri dönemlerde ventrikül fonksiyonlarindaki bozulma beklenen sonuçtur. Ciddi AY’nde vazodilatör tedavinin uygulanma nedeni de LV dilatasyonu ve operasyon gerekliligini mümkün oldugunca geciktirebilmektir. Bu çalisma ciddi, izole, asemptomatik, kronik AY olan olgularda farkli iki ajan ile saglanan vazodilatör tedavinin etkinligini karsilastirmak üzere yapilmistir. Gereç ve Yöntem: Kronik, asemptomatik ve transtorasik ekokardiyografi ile en az 2. AY olan yas ort. 48,4±17 olan 21 erkek ( %51) , 20 kadin (%49) toplam 41 olgu çalismaya alindi.Transtorasik ekokardiyografi ile EDV (Diastol sonu volüm), ESV(Sistol sonu volüm), EF, FSV (Ileriye dogru atim volümü), LVSV (Sol ventrikülün toplam atim volümü), RV (Geriye kaçan volüm), RF (Geriye kaçan volüm fraksiyonu), FCO (Ileriye dogru kardiyak output), LVCO (Sol ventrikül toplam kardiyak outputu), SW (Sistolik is yükü) , CW (Kardiyak yük), LVWS(Sol ventrikül duvar stresi) parametreleri ve noninvaziv olarak SKB (sistolik kan basinci), DKB (diastolik kan basinci), SVR (Sistemik vasküler rezistans)ölçümleri yapilarak hastalar felodipin veya lisinopril tedavi grubuna alindi. Maksimum 10 mg felodipin veya 20 mg lisinopril olacak sekilde toplam 6 ay uygulanan vazodilatör tedavi sonras i ekokardiyografi tekrarlandi. 6 aylik tedavi periyodu boyunca ortaya çikan major klinik olaylar (ölüm, AVR gereksinimi, semptom gelisimi) ve ilaç yan etkileri kaydedildi. Bulgular: Toplam 36 olgu çalismayi tamamladi. Felodipin grubunda 2 olgu ilaç yan etkisi nedeniyle, 2 olgu yeni baslayan atrial fibrilasyon sebebiyle çalisma disi birakildi. Her iki ilaç grubunda da major klinik olay gözlenmedi. Çalismanin sonunda lisinopril grubunda SKB’da %8.9 , DKB’da %5.9 , SVR’da %16.7 azalma, FSV’de %11.2, LVSV’de % 3 artma, RV’de %8.4 , RF’da %11, SW’de %6 ve CW’de %7.2 azalma saptandi (p < 0.05).Felodipin grubunda SKB’da %11.3, DKB’da %9.4 , SVR’da %17.3 azalma, FSV’de %5.6 artma, RF’da %9.7, SW’de %10.8 ve CW’de %8.9 azalma saptandi (p

Keywords

• kronik aort yetmezligi,felodipin,lisinopril,ekokardiyografi

References

1. 1. Ross J Jr: Adaptation of left ventricle to chronic volume overload. Circ Res. 35: 64- 70, 1974.
2. 2. Katz AM. Cardiomyopathy of overload. A major determination of prognosis in congestive heart failure. N Engl. J Med. 332:100-110, 1990.
3. 3. Bonow RO, Rosing DR, McIntosh CL, Jones M, Maron BJ, Lan KK, Lakatos E, Bacharach SL, Green MV, Epstein SE: The natural history of asymptomatic patients with aortic regurgitation and normal left ventricular function. Circulation. 68: 509-517, 1983.
4. 4. Chatterjee K, Parmley WW, Swan HJ, Berman G, Forrester J, MarcusHS: Beneficial effects of vasodilator agents in severe mitral regurgitation due to dysfunction of subvalvular apparatus. Circulation. 48: 684-690, 1973.
5. 5. Goodman DJ, Rossen RM, Holloway EL, Alderman EL, Harrison DC: Effect of nitroprusside on left ventricular dynamics in mitral regurgitation. Circulation. 50: 1025-1032, 1974.
6. 6. Chatterjee K, Parmley WW, Massie B, Greenberg B, Werner J, Klausner S, Norman A: Oral hydralazine therapy for chronic refractory heart failure. Circulation. 54: 879-883, 1976.
7. 7. Kovick RB, Tillisch JH, Berens SC, Bramowitz AD, Shine KI: Vasodilator therapy for chronic left ventricular failure. Circulation. 53: 322-328, 1976.
8. 8. Miller RR, Awan NA, Maxwell KS, Mason DT: Sustained reduction of cardiac impedance and preload in congestive heart failure with antihypertensive vasodilator prazosin. N Engl J Med. 297: 303-307, 1977.

9. 9. Greenberg BH, DeMots H, Murphy E, Rahimtoola S: Beneficial effects of hydralazine on rest and exercise hemodynamics in patients with chronic severe aortic insufficiency. Circulation. 62: 49-55, 1980.
10. 10. Sondergaard L, Aldershvile J, Hildebrandt P, Kelbaek H, Stahlberg F, Thomsen C: Vasodilatation with felodipine in chronic asymptomatic aortic regurgitation. Am Heart J. 139; 667-674, 2000.
11. 11. Lin M, Chiang HT, Lin SL, Chang MS, Chiang BN, Kuo HW, CheItlin MD: Vasodilator therapy in chronic asymptomatic aortic regurgitation enalapril versus hydralazine therapy J Am Coll Cardiol. 24: 1046-1053, 1994.
12. 12. Gentile F, Ornaghi M, Esposti D, Triulzi MO: Hemodynamic effects of nifedipine in patients with asymptomatic aortic regurgitation: Evaluation by Doppler echocardiography. Acta Cardiol. 48: 495- 506, 1993.
13. 13. Heck I, Mattern H, Fricke G, Krück F: Aktivierungzutsande des Reninangiotensin-Systems (RAS) bei Aortenund Mitralvitten vor und nach Klappenersatz. Z Kardiol. 72: 20, 1983.
14. 14. Reske SN, Heck I, Kropp J, Mattern H, Ledda R, Knopp R, Winkler C: Captopril mediated decrease of aortic regurgitation. Br. Heart J. 54: 415-419, 1985.
15. 15. Globits S, Blake L, Bourne M, Fujita N, Duerinckx A, Szolar D, Cheitlin M, Higgins CB: Assesment of hemodynamic effects of angiotensin-converting enzyme inhibitor therapy in chronic aortic regurgitation by using velocity-encoded cine magnetic resonance imaging. Am Heart J. 131: 289-293, 1996.
16. 16. Scognamiglio R, Fasoli G, Ponchia A, Dalla-Volta S: Long-term nifedipine unloading therapy in asymptomatic ptaients with chronic aortic regurgitation. J Am Coll Cardiol. 16: 424-429. 1990.
17. 17. Grinstead WC, Young JB: The myocardial renin-angiotensin system: existence, importance, and clinical implications.Am Heart J. 123: 1039-1045, 1992.
18. 18. Chatterjee K, Parmley WW, Ganz W, Forrester J, Walinsky P, Crexells C, Swan HJ: Hemodynamic and metabolic responses to vasodilator therapy in acute myocardial infarction. Circulation. 48: 1183-1193, 1973.
19. 19. Guiha NH, Cohn JN, Mikulic E, Franciosa JA, Limas CJ: Treatment of refractory heart failure with infusion of nitroprusside. N Engl J Med. 291: 587-592, 1974.
20. 20. 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. 353: 1342-1349, 2005.