ACE Inhibitors

Zofenopril is a lipophilic, sulfhydryl group-containing angiotensin-converting enzyme (ACE)-inhibitor, characterized by wide tissue distribution, long duration of action, and pleiotropic effects on endothelial dysfunction. Its clinical efficacy and safety have been described in the four randomized controlled trials of the SMILE program, which globally enrolled more than 3600 patients in post-acute myocardial infarction (AMI) setting. The SMILE-4 study specifically selected patients with left ventricular dysfunction at admission, and compared the effects of zofenopril or ramipril in combination with acetylsalicylic acid (ASA). Zofenopril demonstrated its superiority over ramipril in reducing the combined occurrence of death or hospitalization for cardiovascular causes both in the overall population included in the original study and in subgroups of patients at highest risk, namely hypertensive and diabetic subjects. The effects of the early treatment with zofenopril were sustained over time, and, after 5 years of follow-up, zofenopril increased the survival likelihood and reduced the hospitalization rate. Compared to ramipril, zofenopril was cost-effective with a number to treat of 13 and an incremental cost-effectiveness ratio (ICER) of 2125.45 euros for any additional event prevented. Furthermore, in real-world settings, zofenopril decreased the risk of death in patients with heart failure, particularly in men, and in subjects older than 76 years or with ejection fraction lower than 54%. These results support the early use of zofenopril immediately after AMI, even in the presence of comorbidities, and its maintenance over time to reduce the risk of heart failure.

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 random-ized 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 ¼ 0.66; and 95% confidence interval, CI ¼ 0.44–0.98; p ¼ .039). After accounting for treatment with amlodipine, the risk of cardiovascular events was significantly reduced with zofenopril compared to placebo (HR ¼ 0.78; 95% CI ¼ 0.63–0.97; p ¼ .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 ¼ 0.76; 95% CI ¼ 0.61–0.94); p ¼ .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.

Cardiovascular events in hypertensives are associated with elevated average blood pressure (BP) and higher short-term BP variability (V), but little is known on treatment effects on BPV and on how to assess changes in short-term BPV. Aim of our study was to address the methodology of short-term BPV assessment and its reduction by Lercanidipine (L) or Enalapril (E) and their combination, through analysis of 24-hour ambulatory BP recordings from two studies including subjects of different age. Study-1: 64 middle-age hypertensives (52.9 ± 9.5 yrs) received L and E s.i.d. at 10 mg (L10, E10) or 20 mg doses (L20, E20) for 8 weeks. Study-2: 66 elderly hypertensives (65.5 ± 4.7 yrs) received placebo, L10, E20 and L10 + E20 s.i.d. for 4 weeks. In middle-age subjects, both L and E decreased mean BP and, at the highest dose, also short-term BPV. In elderly subjects, L10 alone or in combination with E20 reduced BPV. Treatment-induced reductions in BP levels and BPV were uncorrelated. Different methods for short-term BPV assessment did not always provide superimposable results in the elderly. Our study supports a better reduction of BPV by L in the elderly and by E + L combination at any age, suggesting BPV reduction to be independent from reduction in average BP.

AIMS: In our small case series we would like to highlight some severe clinical consequences of the empirical use of NSAIDs and the necessity of educating parents and caregivers. CASE REPORTS: Throughout a period of two years, four children (two boys and two girls, median age 26±0.9 months) have been hospitalized in our unit for upper digestive hemorrhage after receiving single doses of NSAIDs. Two patients received aspirin (500mg) and the other two received ibuprofen (50-100mg). In three cases, aspirin and ibuprofen were given for fever control, while the 4th child accidentally ingested two half-tablets of aspirin, which were used as a preservative agent in home-made stewed fruits. Within the first 24-48 hours after receiving NSAIDs, all patients were brought to our unit, with hematemesis (two cases), melena (one case) and both hematemesis and melena (one case). History for gastrointestinal problems, chronic drugs usage or overdosage of NSAIDs was negative. Hemoglobin values ranged from 5.5 to 10.5mg/dl and the coagulation tests were normal. Within 24-48 hours of admission, an upper digestive endoscopy was performed in two children; for the other two cases we could not obtain an informed consent from the parents. In both patients who underwent endoscopy we found double gastric ulcers in the antral region. No evidence of Helicobacter pylori infection was obtained. In one case, lack of early endoscopy due to parental refusal was followed by progressive worsening vomiting and acute dehydration; a barium meal revealed a decompensated pyloric stenosis that imposed an antrectomy. Two children were treated with intravenous PPI and one with H2-blockers. The patients were discharged after 7-10 days with a recommendation for oral PPI/H2-blockers. The endoscopic revaluation after two months showed a complete healing of the gastric lesions in three children. CONCLUSIONS: Improving parental education about the risks of self medication and severe side effects of NSAIDs and using acetaminophen as a first choice medication for fever control in young patients seems to be a reasonable attitude of general practitioners and pediatricians.

Angio-oedema and urticaria can be symptoms of both allergic (IgE-mediated) and non-allergic drug hypersensitivity reactions. Non-allergic drug reactions, that may have a similar clinical presentation as allergic drug reactions, are not caused by an IgE-mediated immune mechanism. Because of unfamiliarity with non-allergic drug reactions and the unclear time course between drug use and reactions, the relationship with the responsible drug is often not recognized, leading to unnecessary patient risks. In the present article three patients with angio-oedema and urticaria as side effects of frequently used drugs (ACE-inhibitors, NSAIDs and betalactams) are presented and discussed. Patient A was a 69-year-old man with ACE-inhibitor induced angio-oedema. Patient B was a 40-year-old woman with urticaria and angio-oedema after ingestion of a NSAID caused by a non-allergic drug reaction. Patient C was a 54-year-old woman who developed an anaphylactic shock because of a type I allergy to betalactams.

Background: In the midst of COVID-19, healthcare specialists and researchers worldwide have been actively investigating treatments for this new disease. As of July 3rd, 2020, there have been a total of 11,048,509 confirmed cases in more than 188 countries and regions with more and more cases being identified every day. Though there have been a couple of medications given EUA status by the FDA such as chloroquine and hydroxychloroquine, remdesivir, and Fresenius Propoven, some of these treatments have been found to carry substantial health risks. Chloroquine and hydroxychloroquine, for example, were found to cause abnormal heart rhythms and facilitated higher rates of death among patients in clinical trials. For this reason, a more natural option such as vitamin D has the potential to be safer and more effective in the prevention of SARS-CoV-2 symptoms.

Objective: In this study, we investigate the benefits of vitamin D supplementation as shown in previous clinical trials involving respiratory illnesses and discussed which foods are most rich in vitamin D. Ultimately, we aim to provide an understanding of the mechanisms by which vitamin D is acquired and the most effective amounts that people should regularly consume in order to strengthen their immune system.
Methods: All of the case studies cited in this review were found through Google Scholar or NCBI by search queries such as “Vitamin D supplementation to treat respiratory illness.” From over 48,000 results, we further searched for clinical trial studies on human subjects which had already been completed. Additional information regarding vaccinations and medications was sourced from the FDA and information about the nutritional value of foods was obtained from the USDA.

Results: Vitamin D has been shown to have many beneficial effects on patients suffering from both respiratory and non-respiratory illnesses. These benefits include, but are not limited to, lowered susceptibility to infection and lower bacterial counts, reduced symptoms of illness, increased serum 25(OH)D, and corrected vitamin D deficiency.

Conclusions: Given the striking symptomatic, molecular, and pathological similarities between infection from SARS-CoV-2 and other respiratory illnesses such as influenza, the positive results from vitamin D supplementation suggest that vitamin D may be a viable prevention option for SARS-CoV-2 symptoms. Through the consumption of vitamin D-rich foods like UV-exposed mushrooms, salmon, and trout, low serum 25(OH)D levels could be corrected, and the reduction of symptoms could be naturally facilitated. Through the induction of cathelicidin and defensin, the regulation of cytokines, and the increased production of anti-microbial peptides, vitamin D has the potential to act as a natural prevention option without adverse side-effects like those caused by chloroquine and other proposed drugs.

Keywords: Vitamin D; Deficiency; Respiratory Illness; COVID-19; Influenza; Cathelicidin; Defensin; SARS-CoV-2; ACE2; ANG II.

Fluorosis, caused by a chronic exposure to fluoride is a worldwide health problem known to affect various organ systems. The present study was aimed at investigating the effect(s) of extracts of seasonal fruits (Indian goose berry, star fruit, guava and wood apple) on angiotensin-converting enzyme (ACE) activity in the lung extracts exposed to different concentrations of fluoride. The lung extracts showed an increasing ACE activity with increasing concentrations of fluoride (2.5-10ppm) with highest ACE activity at 10ppm of fluoride. A reduction in the ACE activity was observed when the fluoride exposed (10ppm) lung extracts were incubated with fruit extracts; wood apple extract exerted a maximum ACE inhibitory activity (28.9%) followed by star fruit, guava and goose berry (20.1 %,19% and 15.5% respectively). A phytochemical analysis and the antioxidant potential of the fruits indicated that the fruits have a high antioxidant potential that correlated well with phytochemical content (phenols, flavonoids, saponins and ascorbic acid) of the fruits. It is suggested that the consumption of these seasonal fruits could be useful in regulating the ACE activity in fluoride endemic areas.

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.