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Kobayashi, K., Abe, S., Nakajima, M., Shimada, N., Tani, M., Chiba, K., and Yamamoto, T. 1999 ; Drug Metab Dispos 27, 1429-1433. The following definitions are from Murphy 1998 ; . 1. Angiotentsin Converting Enzyme ACE ; Inhibitors are antihypertensive drugs which are primarily used to aid in the dilation of arteries and veins, thereby reducing blood pressure, The following is a list of drugs in this class: Accupril Altace Avapro Capoten Captopril Cozaar Diovan Diovan HCT Hyzaar Lotensin Mavik Monoprii Prinivil Univasc Vasotec Zestril. Beta blockers, has recently been added to the armament. The specific medication or, more commonly, a combination of these medications, is determined by the type and severity of the heart failure. ACE Inhibitors and Other Vasodilators Vasodilators improve both the quality and duration of life for heart failure patients. They open the arteries and veins, thereby reducing the heart's workload and allowing more blood to reach the tissues. Vasodilators are particularly useful in treating heart failure associated with high blood pressure and dilated cardiomyopathy. Several classes of vasodilators are available, the most effective being the ACE inhibitors. Angiotensin-Converting Enzyme ACE ; Inhibitors. Currently the most important vasodilators are angiotensin-converting enzyme ACE ; inhibitors; these drugs block the formation of angiotensin II, a powerful enzyme that raises blood pressure, constricts blood vessels, and leads to salt retention. Although experts believe that at least 50% to 75% of patients with congestive heart failure should be treated with ACE inhibitors, a current study indicates that primary care doctors are only prescribing them for 22% and specialists for 46% of patients. Women and nonwhites are even less likely to get ACE inhibitors than white males. Even worse, about 15% of patients are being prescribed expensive calcium channel blockers, which may even have adverse effects for patients with heart failure. ACE inhibitors are of particular benefit for patients with left ventricular systolic dysfunction; those patients should take drugs indefinitely unless specific conditions make the drugs inappropriate. Some cardiologists are concerned that ACE inhibitors are still not being prescribed by their family physicians for many patients who might benefit from them. Commonly used ACE inhibitors are captopril Capoten ; , quinipril Accupril ; , enalapril Vasotec ; , and lisinopril Prinivil, Zestril ; . Captopril, which has the most predictable onset and shortest duration, is most often used for initial therapy when patients must be cautiously monitored for low blood pressure. Enalapril has been found to improve survival over combinations of other types of vasodilators hydralazine and nitrates ; , and some studies have indicated that it might actually reduce heart damage by inhibiting the remodeling process that can cause heart attacks after heart failure. Yet another study found that high doses of lisinopril were more effective than low doses and do not cause significantly more adverse effects. Experts say these findings should apply to all ACE inhibitors. A persistent cough is a common and irritating side effect. The primary adverse effect of ACE inhibitors is low blood pressure, which can be severe in some patients, particularly when therapy is first initiated. Because of this, ACE inhibitors have not been used for patients who have pulmonary edema fluid in the lungs ; , a condition commonly accompanied by low blood pressure. One study found, however, that the drugs may benefit even these patients, assuming that blood pressure is not excessively low to begin with. Kidney failure is a rare complication that can occur during initial therapy. Taking ACE inhibitors may also lead to excessive potassium levels, and so they are not generally given with potassium-sparing diuretics or potassium supplements. Diuretics, in general, are often very important for many heart failure patients, however, even those taking ACE inhibitors. ; Hydralazine and Nitrates. The oral direct-acting vasodilators hydralazine Apresoline ; and isosorbide dinitrate Iso-Bed Isorbid ; improve symptoms and may prolong life when used in combination. Intravenous nitroglycerin Nitro-Bid IV, Nitrostat IV, Tridil ; and intravenous nitroprusside Nitropress ; are useful in short-term therapy of acute heart failure and acute pulmonary edema. Intravenous nitroglycerine tends to lose effectiveness quickly, but one study showed that patients who were also given oral hydralazine continued to tolerate this drug. Combinations of hydralazine with nitrates are more effective than either drug used alone and are recommended when patients cannot tolerate ACE inhibitors. Because of this effect, zestril can cause a decrease in the symptoms of congestive heart failure including shortness of breath, fatigue, and swelling ; , as well as improved exercise tolerance. COMMENT: These authors conducted a review and meta-analysis of randomized, controlled trials of the effectiveness of leukotriene receptor antagonists LRAs ; in patients with allergic rhinitis. Of 196 citations, 11 studies were selected; 8 permitted evaluation of LRAs alone and the remainder in combination with other treatments. LRAs were modestly better than placebo, as effective as antihistamines, but less effective than nasal steroids in improving symptoms and quality of life in allergic rhinitis. E. J. B. Wilson AM, O'Byrne PM, Parameswaran K: Leukotriene receptor antagonists for allergic rhinitis: a systemic review and meta-analysis. J Med. 2004; 116: 338-344. COMMENT: Claims of mold-induced health effects are often controversial. However, there is no controversy about the ability of Alternaria species to induce allergy and asthma. This case study presents an opportunity for the authors to review the pathobiology of Alternaria, which has been associated with mortality from asthma. R. J. M. Bush RK, Prochnau JJ: Alternaria-induced asthma. J Allergy Clin Immunol. 2004; 113: 227-234.
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