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      Comparative Effects of Preoperative Angiotensin-converting Enzyme In-hibitor, Statin and Beta-blocker Treatment on Human Internal Mammary Artery Reactivity in Patients with Coronary Artery Disease: A Pilot Study

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          Abstract

          Purpose:

          We investigated the effect of angiotensin-converting enzyme (ACE)- inhibitor, statin, and beta-blocker usage before coronary bypass surgery (CABG) on vascular reactivity of the internal mammary artery (IMA).

          Methods:

          Patients, who underwent elective CABG were evaluated. Samples of IMA obtained from 22 patients were divided into 4 groups in respect of drugs used by patients before bypass surgery (control group, ACE inhibitor + statin group, ACE inhibitor + statin + beta-blocker group, and ACE inhibitor + beta-blocker group). The discarded, distal end section of IMA was carefully removed, and the vasoreactivity of IMA rings was evaluated in vitro using an organ chamber. Smooth muscle contractile function was tested on artery segments exposed to 10-80 mM KCl and norepinephrine. The endothelial function of IMA rings was assessed with acetylcholine (ACh) and bradykinin, while endothelium-independent vasorelaxation was evaluated by sodium nitroprusside (SNP).

          Results:

          Both ACh and bradykinin caused concentration-dependent relaxation in endothelium-intact IMA rings. However, the maximal effect produced by endothelium-dependent agents in all treatment groups was more prominent when compared with the control group. There was no significant difference in the endothelium-dependent relaxation response of IMA between ACE inhibitor + statin, ACE inhibitor + beta-blocker and ACE inhibitor + statin + beta-blocker groups. The vasodilatory potency of SNP was similar in all groups. Similarly, contractile response to KCl or norepinephrine was not significantly different between groups.

          Conclusion:

          Use of ACE inhibitors and statins before bypass surgery may influence IMA vasoreactivity by improving endothelial control of vascular tone.

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          Most cited references 33

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          Long-term follow-up of patients with mild coronary artery disease and endothelial dysfunction.

          Coronary endothelial dysfunction is characterized by vasoconstrictive response to the endothelium-dependent vasodilator acetylcholine. Although endothelial dysfunction is considered an early phase of coronary atherosclerosis, there is a paucity of information regarding the outcome of these patients. Thus, this study was designed to evaluate the outcome of patients with mild coronary artery disease on the basis of their endothelial function. Follow-up was obtained in 157 patients with mildly diseased coronary arteries who had undergone coronary vascular reactivity evaluation by graded administration of intracoronary acetylcholine, adenosine, and nitroglycerin and intracoronary ultrasound at the time of diagnostic study. Patients were divided on the basis of their response to acetylcholine into 3 groups: group 1 (n=83), patients with normal endothelial function; group 2 (n=32), patients with mild endothelial dysfunction; and group 3 (n=42), patients with severe endothelial dysfunction. Over an average 28-month follow-up (range, 11 to 52 months), none of the patients from group 1 or 2 had cardiac events. However, 6 (14%) with severe endothelial dysfunction had 10 cardiac events (P<0.05 versus groups 1 and 2). Cardiac events included myocardial infarction, percutaneous or surgical coronary revascularization, and/or cardiac death. Severe endothelial dysfunction in the absence of obstructive coronary artery disease is associated with increased cardiac events. This study supports the concept that coronary endothelial dysfunction may play a role in the progression of coronary atherosclerosis.
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            Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study).

             Michelle Fox (2003)
            Treatment with angiotensin-converting-enzyme (ACE) inhibitors reduces the rate of cardiovascular events among patients with left-ventricular dysfunction and those at high risk of such events. We assessed whether the ACE inhibitor perindopril reduced cardiovascular risk in a low-risk population with stable coronary heart disease and no apparent heart failure. We recruited patients from October, 1997, to June, 2000. 13655 patients were registered with previous myocardial infarction (64%), angiographic evidence of coronary artery disease (61%), coronary revascularisation (55%), or a positive stress test only (5%). After a run-in period of 4 weeks, in which all patients received perindopril, 12218 patients were randomly assigned perindopril 8 mg once daily (n=6110), or matching placebo (n=6108). The mean follow-up was 4.2 years, and the primary endpoint was cardiovascular death, myocardial infarction, or cardiac arrest. Analysis was by intention to treat. Mean age of patients was 60 years (SD 9), 85% were male, 92% were taking platelet inhibitors, 62% beta blockers, and 58% lipid-lowering therapy. 603 (10%) placebo and 488 (8%) perindopril patients experienced the primary endpoint, which yields a 20% relative risk reduction (95% CI 9-29, p=0.0003) with perindopril. These benefits were consistent in all predefined subgroups and secondary endpoints. Perindopril was well tolerated. Among patients with stable coronary heart disease without apparent heart failure, perindopril can significantly improve outcome. About 50 patients need to be treated for a period of 4 years to prevent one major cardiovascular event. Treatment with perindopril, on top of other preventive medications, should be considered in all patients with coronary heart disease.
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              Physiology of the endothelium.

              In the past, the endothelium was considered to be inert, described as a 'layer of nucleated cellophane', with only non-reactive barrier properties, such as presentation of a non-thrombogenic surface for blood flow and guarding against pro-inflammatory insults. However, it is now becoming clear that endothelial cells actively and reactively participate in haemostasis and immune and inflammatory reactions. They regulate vascular tone via production of nitric oxide, endothelin and prostaglandins and are involved in the manifestations of atherogenesis, autoimmune diseases and infectious processes. They produce and react to various cytokines and adhesion molecules and it is now clear that they can mount anti- and pro-inflammatory and protective responses depending on environmental conditions and are key immunoreactive cells. Endothelial dysfunction or activation also contributes to a variety of disease states.
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                Author and article information

                Journal
                Open Cardiovasc Med J
                Open Cardiovasc Med J
                TOCMJ
                The Open Cardiovascular Medicine Journal
                Bentham Open
                1874-1924
                23 August 2013
                2013
                : 7
                : 69-75
                Affiliations
                [1 ]Akdeniz University Faculty of Medicine, Department of Pharmacology, 07070, Antalya, Turkey
                [2 ]Akdeniz University Faculty of Medicine, Department of Cardiovascular Surgery, 07070, Antalya, Turkey
                Author notes
                [* ]Address correspondence to this author at the Akdeniz University Faculty of Medicine, Department of Pharmacology, 07070, Antalya, Turkey; Tel: +90 242 2496925; Fax: +90 242 2274482; E-mail: stasatargil@ 123456akdeniz.edu.tr
                Article
                TOCMJ-7-69
                10.2174/1874192401307010069
                3772568
                24044029
                © Dalaklioglu et al.; Licensee Bentham Open.

                This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

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