Medical Academy pf postgraduate education of Kyiv city Cardiac ischemia is induced with insufficient blood supply in separate myocardium sections due to changes in vessel walls and in epithelium resulted in damage of vessel lumens (patch, spasm). Cardiac ischemia is characterized by the misbalance between potentials of oxygen supply to the myocardium and the myocardium needs in oxygen for maintaining a proper level of oxidizing in cell mitochondria. Such a misbalance entails a number of metabolic, structural and functional rearrangements reflecting ischemic lesion of myocardium. Cardiac ischemia is often complicated with chronic heart failure. From a pathophysiological point of view heart failure is heart’s incapacity to supply nutritious matter to body tissues in accordance with their metabolic needs in quietness and/or with moderate physical loading (definition of WHO, 1995). Heart failure is based on heart pumping function failure: myocardium is disabled to more or less eject blood into vascular channel at systole and/or to be adequately filled at diastole. With this physical loading tolerance (fatigue), dyspnea, fluids retention in the body (these result in the formation of peripheral edemas and of pulmonary edemas) and consistent disease progressing are clinically observed. Disease progressing is directly associated with consistent deterioration of myocardium structure and functioning resulting in a significant reduction of patient’s life period. Modern medicamentous treatment of patients with chronic heart failure includes the use of inhibitor of angiotensin-transforming ferment, diuretics, -adrenoblockers and of digitalis-based preparations (1). A wide implementation of inhibitor of angiotensin-transforming ferment had influenced on the principles of pathogenic treatment of patients with chronic heart failure. Classic randomized trials CONSENSUS (CONSENSUS Trial Study Group, 1987), V-HeFT II (V-HeFT II Study Group, 1991), and SOLVD-Treatment (SOLVD Investigators, 1991) had proved the efficacy of inhibitor of angiotensin-transforming ferment. New unique possibilities have appeared to modify disease progress, reduce needs in hospitalization, improve the quality of patients’ treatment and prolong their life, reduce probability of sudden cardiac death and of death from progressing chromic heart failure (2). Results of numerous controllable trials evidence advantages of inhibitor of angiotensin-transforming ferment as a powerful organ-protecting drug. These preparations prevent the development of hypertrophy and remodeling of smooth muscles of vessels, provide reverse development of hypertrophy of heart sections and protect renal glomeruluses (3). A quick improvement of hemodynamics, reduction of sympathetic activation and of expressiveness of clinical symptoms with chronic heart failure occurs due to immediate neurohumoral changes: systemic blockade of angiotensin II formation and inhibition of bradikinin decomposition. Despite the proved efficacy of inhibitor of angiotensin-transforming ferment in treatment and reduction of mortality of patients with chronic heart failure its use remains insufficient. Many patients are treated with no use of inhibitor of angiotensin-transforming ferment or with its use in inadequate doses. Under recommendations of the Ukrainian Scientific Society of Cardiologists for treatment of patients with heart failure (2001) inhibitors of angiotensin-transforming ferment must be imperatively used (excluding cases of contraindication and intolerance) by all patients with left ventricle systole dysfunction (EF  40%) irrespective of functional class (1). The first dose must be minimal. Further on in case of an adequate tolerance (no hypotension and other side effects) the dose may be gradually increased (“titrated”) trying to achieve a maximal wanted dose recommended for clinical trials (4). Lisinopril is a water-soluble non-sulfhydryl inhibitor of angiotensin-transforming ferment requiring after absorption from the intestine no biotransformation for starting its effect. In compliance with pharmacokynetic classification of inhibitors of angiotensin-transforming ferment it belongs to representatives of the third generation (5). Maximal concentration of this preparation in blood plasma is achieved relatively slow – in 6 hours after internal administration of 10 to 20 mg of lisinopril (6). Its half-life is approximately up to 12 hrs (7). Taking meals gives no effect on preparation bioavailability, which is up to 50%. As distinct from other inhibitors of angiotensin-transforming ferment lisinopril is not metabolized in the liver, therefore this preparation is not contraindicated for patients with a moderate hepatic dysfunction. The preparation is excreted unchanged through kidneys. It suppresses the activity of both local and systemic renin-angiotensin systems for 24 hrs. The preparation gives cardio-protecting (reduction of left ventricle hypertrophy), vascular protecting (improvement of endothelium function, of aorta tensility and reduction of large vessels rigidity), neuro-protecting (improvement of nerve fiber conduction, of temperature and vibration sensitivity), with underlying diabetes mellitus a proved nephro-protecting (reduction of albuminuria, deceleration of nephropathy progress) effects (8, 9). The results of trial ATLAS (Assessment of Treatment with Lisinopril and Survival, 1998) demonstrate that with heart failure lisinopril in high doses (32.5 or 35 mg/day) as compared with its use in small doses (2.5 or 5 mg/day) essentially reduces the risk of total mortality and the frequency of all cases of hospitalization of patients by 13% and with heart failure by 24% (10, 11). The recommended supporting dose of lisinopril is achieved in patients with heart failure in several steps (12): starting dose – 2.5 mg once a day, further on 5 mg once a day, 10 mg once a day and 20 mg once a day (purpose-oriented dose). For combined treatment lisinopril may be used practically with any group of preparations, however its use with diuretics and/or calcium antagonists looks preferable. From literature data coughing is most frequent side effect (4%) with lisinopril use, vertigo (2.3%) and headache (2.1) occur more rare. It must be noted that in accordance with results of some studies coughing with the use of lisinopril occurs more rare than with the use of other inhibitors of angiotensin-transforming ferment. The purpose of this study was the assessment of clinical efficacy of lipril (lisinopril made by SIC “Borshchahivskiy Chemical-Pharmaceutical Plant” CJSC, Kyiv, Ukraine) and of its effect on endocardiac hemodynamics in patients with cardiac ischemia complicated with chronic heart failure. Subjects and Methods of the Study 73 patients with cardiac ischemia complicated with chronic heart failure of functional classes II – IV [under the classification of New York Association of Cardiologists (NYHA, 1973)] were examined. All patients passed standard general clinical examination including physician’s examination, total blood count and urinalysis, biochemical blood tests (total proteins, bilirubin, uric acid, cholesterol, triglycerides, АLАТ, АSАТ activities), ECG and EchoCG. Patients were divided into two groups comparable in age in functional classes. Patients of group I (37 people) were treated with lipril, its dose being titrated every 2 weeks (from 2.5 mg/day to 20 mg/day) for 8 weeks. Patients of group II (control) were treated with cardiac glycosides (digoxin), diuretics (furosemide) and peripheral vasodilators. Indicators of hemodynamics and myocardium contractile function in patients were examined before and after treatment course (in 8 weeks). Results and Discussion On the background of applied therapy positive clinical dynamics in both groups under study were observed. In patients of group I the use of lipril resulted in a significant reduction of clinical symptoms of chronic heart failure (expressiveness of dyspnea, of peripheral edemas, heart pain), better tolerance of physical loading and essential reduction of both systole and diastole arterial tension in patients with underlying arterial hypertension as compared to patients of group II. A positive dynamics of ECG indicators (reduction of symptoms of left ventricle overloading, a positive dynamics of peak T) were observed. The study of lipril effect on indicators of endocardiac hemodynamics has demonstrated a reliable rise of EF from 62.4  2.1% to 67.9  2.7% (in 8 weeks (p < 0.05). No reliable changes of left ventricle size were found. From literature data (13, 14) reliable dynamics of indicators of size, systole and diastole volumes of left ventricle occur after 3 months of treatment with lisinopril. The treatment with Lipril had not essentially affected indicators of total blood count, urinalysis and of biochemical blood testing. Preparation tolerance was good. Only 2 patients (of total 37) complained during treatment on dry cough, which was probably associated with bradikinin-accumulating effect of lisinopril, however its occurrence did not require preparation use discontinuation. In a single patient skin eruption occurred, due to which fact preparation use was discontinued.

Findings

1. In patients with cardiac ischemia complicated with chronic hear failure of functional classes II –IV a positive clinical effect on the background of therapy with Lipril in dose from 2.5 to 20 mg/day and a significant reduction of chronic hear failure (versus patients of group II) were recorded.

2. The therapy withLipril facilitated the improvement of endocardiac hemodynamics (reliable increase of left ventricle EF after 8-week therapy).

3. As a whole all patients well tolerated therapy with Lipril.

Literature

1. Voronkov L.G. Chronic heart failure. –Kyiv, 2002. –136 p.
2. Voronkov L.G., Kovalenko V.N., Riabchenko D.V. Chronic heart failure: mechanisms, diagnostic and treatment standards. Kyiv, Morion. –1999. –128 p.
3. Svischenko E.P., Kovalenko V.N. Hypertension. Secondary hypertension. Kyiv, Libid. –2002. –504 p.
4. Task Force for the diagnosis and treatment of chronic heart failure, European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure // Eur. Heart J. –2001. –Vol. 21. –P. 1527 – 1560.
5. Opie L. Angiotensin converting enzyme inhibitors: The advance continues. Authors Publishing House. New York. –1999. –275 p.
6. Lancaster S.G., Todd P.A. Lisinopril. A preliminary review of its pharmacodynamics and pharmacokynetic properties, and therapeutical use in hypertension and congestive heart failure // Drugs. –1988. Vol. 35. –P. 646 – 669.
7. Thind G.S. Angiotensin converting enzyme inhibitors: comparative structure, pharmacokynetics and pharmacodynamics // Cardiovasc. Drugs Therapy. –1990. –Vol. 4. –P. 199 – 206.
8. Neilsen F.S., Rossing P., Gall M.A. et al. Lisinopril improves endothelial dysfunction in hypertensive NIDDM subjects with diabetic nephropathy // Scand. J. Clin. Lab. Invest. –1997. –Vol. 57. –P. 427 – 434.
9. Remuzzi G., Ruggenenti P., Benigni A. Understanding the nature of renal disease progression // Kidney Int. –1997. –Vol. 51. –P. 2 – 15.
10. Packer M., Poole-Wilson P., Armstrong P. et al. Comparative effects of low-dose versus high dose lisinopril on survatal and major events in chronic heart failure: the Assessment of Treatment with Lisinopril and Survival study (ATLAS) // Eur. Heart J. –1998. –Vol. 19. –P. 142.
11. ATLAS of heart failure trials. A brief review of ACE inhibitor studies in heart failure // ZENECA Pharmaceuticals. Alderley House. –1998. –P.
12. 12. Manufacturer’s recommendations. Guidelines for the treatment of heart failure // Eur. Heart J. –1997. Vol. 18. –P. 736 – 753.
13. Eichstaedt H.W., Metens D/Ch., Danne O. et al. Effects of Lisinopril on LVH-regression in patients treated for essential hypertension // Perfusion. –1994. –Vol. 7. –P. 426 – 428.
14. Terpestra W.F., May I.F., Smit A.I. et al. Long-term evaluation of long-term effects of amlodipine and lisinopril on left ventricular mass and diastolic function in elderly, previously untreated hypertensive patients (the ELDERA trial) // Eur. Heart J. –199. –19 (Suppl.). –P. 596.