Angiotensin converting enzyme inhibitors and magnesium conservation in patients with congestive cardiac failure

Review Article on Molecular Mechanism of Regulation of Hypertension by Macro-elements (Na, K, Ca and Mg), Micro-elements/Trace Metals (Zn and Cu) and Toxic Elements (Pb and As)

Hypertension (HT) is a medical condition arising due to increase in blood pressure (BP) prevalent worldwide. The balanced dietary intakes of macro-elements and micro-elements including Na, K, Ca, Mg, Zn, and Cu have been described to maintain BP in humans by regulating the osmolarity of blood, cells/tissues, prevention of generation of oxidative and nitrosative stress (OANS), and endothelial damage through their functioning as important components of renin-angiotensin-aldosterone system (RAAS), antioxidant enzyme defense system, and maintenance of blood vascular-endothelial and vascular smooth muscle cell (VSMC) functions. However, inadequate/excess dietary intakes of Na/K, Ca/Mg, and Zn/Cu along with higher Pb and As exposures recognized to induce HT through common mechanisms including the followings: endothelial dysfunctions due to impairment of vasodilatation, increased vasoconstriction and arterial stiffness, blood clotting, inflammation, modification of sympathetic activity and higher catecholamine release, increased peripheral vascular resistance, and cardiac output; increased OANS due to reduced and elevated activities of extracellular superoxide dismutase and NAD(P)H oxidase, less nitric oxide bioavailability, decrease in cGMP and guanylate cyclase activity, increase in intracellular Ca2+ ions in VSMCs, and higher pro-inflammatory cytokines; higher parathyroid and calcitriol hormones; activation/suppression of RAAS resulting imbalance in blood Na+, K+, and water regulated by renin, angiotensin II, and aldosterone through affecting natriuresis/kaliuresis/diuresis; elevation in serum cholesterol and LDL cholesterol, decrease in HDL cholesterol due to defect in lipoprotein metabolism. The present study recommends the need to review simple dietary mineral intervention studies/supplementation trials before keeping their individual dietary excess intakes/exposures in consideration because their interactions lead to elevation and fall of their concentrations in body affecting onset of HT.

Mineral factors controlling essential hypertension--a study in the Chandigarh, India population

Essential hypertension (EH) is a major public health problem world over and in India. Recent data on EH in the population of Chandigarh (Union Territory and capital of Punjab and Haryana States of India) revealed that the prevalence of EH has become double in the last 30 years in the residents of Chandigarh (26.9 to 45.80% in the year 1968 and 2002). Zinc (Zn), copper (Cu), magnesium (Mg), and manganese (Mn) in the serum are considered important in maintaining the human hypertension. The high Zn intake was considered to increase the blood pressure (BP) and to affect the other mineral status in the body. Recent survey on the trace metal status of different vegetables in the State of Punjab around Chandigarh (India) revealed that Zn level is significantly higher (40 mg/kg or more in above ground vegetables and 120 mg/kg or above in underground vegetables) in underground water-irrigated vegetables, but the levels of Cu and Mg are within prescribed limit. The present study was conducted on Chandigarh population to evaluate the levels of Zn, Cu, Mg, and Mn in the blood and urine of normotensive (NT) control and hypertensive (HT) subjects matched with number, age and sex. Atomic absorption spectrophotometer studies reevaluated that the levels of serum Zn, Mg, and Mn were significantly higher (p < 0.001), but the level of Cu was low in the HT subjects (BP = 160/93) compared to NT control (BP = 140/83). Higher levels of urinary Zn, Cu, Mg, and Mn were observed in the HT subject vs NT control (p < 0.001). Positive correlations were evaluated between the levels of serum Zn, Mg, and Mn vs systolic and diastolic pressures (DP and SP), respectively (r = 0.928, 0.863, 0.876, 0.808, 0.404, 0.326, p < 0.01), but negative and positive nonsignificant correlations between the serum Cu with SP and DP were recorded (r = -0.032, r = 0.024). Positive correlations were also evaluated between urinary levels of Zn, Cu, Mg, and Mn vs SP and DP (r = 0.718, 0.657, 0.750, 0.681, 0.630, 0.578, 0.516, 0.461, p < 0.01). Prevalence of essential hypertension may be due to higher Zn level in the food chain that makes the individuals vulnerable to other diseases over the time related to essential hypertension.

Early administration of intravenous magnesium to high-risk patients with acute myocardial infarction in the Magnesium in Coronaries (MAGIC) Trial: a randomised controlled trial

BACKGROUND

The benefits of supplemental administration of intravenous magnesium in patients with ST-elevation myocardial infarction (STEMI) are controversial. Despite promising results from work in animals and the ready availability of this simple, inexpensive treatment, conflicting results have been reported in clinical trials. Our aim was to compare short-term mortality in patients with STEMI who received either intravenous magnesium sulphate or placebo.

METHODS

We did a randomised, double-blind trial in 6213 patients with acute STEMI who were assigned a 2 g intravenous bolus of magnesium sulphate administered over 15 min, followed by a 17 g infusion of magnesium sulphate over 24 h (n=3113), or matching placebo (n=3100). Our primary endpoint was 30-day all-cause mortality. At randomisation, patients were stratified by their eligibility for reperfusion therapy. The first stratum included patients who were aged 65 years or older and eligible for reperfusion therapy, and the second stratum included patients of any age who were not eligible for reperfusion therapy. Analysis was by intention-to-treat.

FINDINGS

At 30 days, 475 (15.3%) patients in the magnesium group and 472 (15.2%) in the placebo group had died (odds ratio 1.0, 95% CI 0.9-1.2, p=0.96). No benefit or harm of magnesium was observed in eight prespecified subgroup analyses of patients and in 15 additional exploratory subgroup analyses. After adjustment for factors shown to effect mortality risk in a multivariate regression model, no benefit of magnesium was observed (1.0, 0.8-1.1, p=0.53).

INTERPRETATION

Early administration of magnesium in high-risk patients with STEMI has no effect on 30-day mortality. In view of the totality of the available evidence, in current coronary care practice there is no indication for the routine administration of intravenous magnesium in patients with STEMI.

Angiotensin converting enzyme inhibitor therapy in severe postcardiotomy dysfunction: a prospective randomized study

BACKGROUND

Occurrence of severe postcardiotomy dysfunction requiring prolonged postoperative support with intra-aortic balloon counterpulsation (IABP) and inotropes, complicating surgery for coronary artery disease and valvular heart disease carries important hospital morbidity and mortality. This study evaluated the impact of angiotensin converting enzyme inhibitor (captopril) therapy in these patients in the early postoperative period.

METHODS

During a 5-year period, 298 patients with prolonged diminished cardiac output required support (> 48 to 72 hours) with IABP plus two or three inotropes. This cohort was randomized to two groups, group A (195 patients) who were continued on IABP and inotropes alone and group B (103 patients) who were given an angiotensin converting enzyme (ACE) inhibitor, captopril 48 to 72 hours postoperatively and continued on IABP and inotropes.

RESULTS

Tissue perfusion and hemodynamic parameters improved (p < 0.0001) in group B with early termination of IABP (duration of support mean 86 hours in group B vs 169 hours in group A) and inotropes. Peak improvement in tissue perfusion and hemodynamic parameters correlated with decreased serum angiotensin converting enzyme levels. Hospital mortality occurred in 31% of patients in group A and 14.5% in group B. Morbidity complications developed in 37% of patients in group A and 20% in group B. The average length of hospital stay in group A was 27 days and 17 days in group B. Cardiac, pulmonary, infective, gastrointestinal, renal, and neurological complications were common in both groups.

CONCLUSION

Administration of ACE inhibitors in the early postoperative period to patients with severe postcardiotomy dysfunction caused improvement in tissue perfusion with decreases in mortality, morbidity, and length of hospital stay. These drugs, by effectively limiting physiological effects induced by renin angiotensin-aldosterone axis and other mechanisms, caused recovery of stunned myocardium. More randomized trials are needed before recommending these drugs for routine use in similar patients.

Effects of elements on blood pressure

This article present a comprehensive review of all known elements involved in blood pressure control. Data source was by computerized literature searches. A total of 28 elements have been documented as being involved in blood pressure control. The individual elements react directly and indirectly in a variety of metabolic and structural activities known to participate in blood pressure regulation. Reports from both experimental animal and human subjects are presented. The role of certain elements in blood pressure control is controversial. Conversely, important established functions of dosage, absorption, storage, and excretion of individual elements are known and are described in relation to blood pressure control. Some elements are pressor, whereas others are depressor in action, and this article demonstrates the important role elements play in the control of blood pressure.

Magnesium supplementation in patients with congestive heart failure

OBJECTIVE

To evaluate several potential clinical indicators of magnesium status (diet, blood, urine, 24-hour load retention) in patients with congestive heart failure before, during, and after oral magnesium supplementation.

METHODS

Twelve patients with New York Heart Association class II-III heart failure and 12 age and sex matched healthy control subjects were supplemented with 10.4 mmol oral magnesium lactate for 3 months. For the determination of magnesium status, samples of whole blood, serum, plasma, red blood cells, and urine (24-hour) were collected. Four-day dietary intake records were reviewed. A 4-hour IV magnesium load retention study was performed before and 3 months after magnesium supplementation. A non-supplemented control group was similarly studied.

RESULTS

At baseline, magnesium intakes for all groups were below the RDA. No significant differences were seen in serum, plasma, ultrafiltrates of serum or plasma or red cell magnesium concentrations among groups over time. At baseline 5/27 subjects (19%) compared to 11/27 subjects (41%) after supplementation demonstrated normal magnesium retentions (< 25%). Magnesium excretions among groups were significantly different during supplementation. Percent magnesium retentions among groups were not different.

CONCLUSIONS

Supplementation with 10.4 mmol oral magnesium daily for 3 months did not significantly alter blood levels or magnesium retention; however, patients demonstrated lower retention of magnesium after supplementation. Differences in magnesium retention was not related to basal magnesium intake, blood levels or excretion. Unfortunately, even an intensive effort at characterizing magnesium status did not identify a clinical indicator of utility for differentiating patients with congestive heart failure before, during, and after 3 months of magnesium supplementation.

Ramipril decreases chlorthalidone-induced loss of magnesium and potassium in hypertensive patients

A double-blind clinical trial was conducted to compare the efficacy of and electrolyte changes caused by ramipril-chlorthalidone combination treatment (5 mg + 25 mg) and chlorthalidone monotherapy (25 mg daily) in patients with hypertension. After a 4-week placebo period, 32 patients (mean age, 51 +/- 9 years) with essential hypertension (average blood pressure of 181.4/104.5 +/- 13.0/6.9 mmHg) were randomly assigned to receive combination therapy (group A, n = 17) or monotherapy (group B, n = 15). After 12 weeks of active treatment, systolic and diastolic blood pressure decreased by 16.1% and 13%, respectively, for patients taking combined therapy, and by 12.7% and 9.8%, respectively, for patients taking monotherapy. The difference was significant for between-group comparisons. There were no changes in serum sodium concentration, but a significant similar increase in 24-hour urinary sodium excretion was seen in both groups. Serum calcium levels increased slightly and 24-hour urinary calcium excretion decreased significantly in both groups, probably due to chlorthalidone administration. Serum potassium levels increased slightly in group A (from 4.16 +/- 0.39 mmol/L to 4.30 +/- 0.42 mmol/L) and decreased slightly in group B (from 4.18 +/- 0.32 mmol/L to 3.99 +/- 0.49 mmol/L). Urinary potassium excretion did not change significantly in group A, but increased by approximately 15% in group B. There was a decrease in 24-hour urinary magnesium excretion (from 4.01 +/- 1.24 mmol/24 hours to 3.50 +/- 0.93 mmol/24 hours) in group A and an increase (from 3.49 +/- 0.98 mmol/24 hours to 4.35 +/- 1.12 mmol/24 hours) in group B. At the end of the trial these changes were significant in between-group comparisons. Consistent with the previously shown amelioration by ramipril of thiazide-induced metabolic side-effects, ramipril appears to improve magnesium balance during cotreatment with chlorthalidone.

Clinical relevance and management of the major electrolyte abnormalities in congestive heart failure: hyponatremia, hypokalemia, and hypomagnesemia

Electrolyte disturbances are a common complication of CHF. CHF provides a perfect milieu for the development of these disturbances; renal dysfunction, elevation of neurohormonal substances, activation of the renin-angiotensin-aldosterone axis, and diuretic therapy represent the major contributory factors. Hyponatremia is closely aligned with an unfavorable clinical course. Hypokalemia is associated with increased ventricular dysrhythmias. Hypomagnesemia noted in advanced CHF can be accompanied by arrhythmias and refractory hypokalemia. CHF also offers the ideal milieu (diseased, ischemic, and arrhythmogenic myocardium; elevated catecholamines; and arrhythmogenic drugs) for the threatening clinical consequences (clinical deterioration, dysrhythmias, or death) of these disturbances. These consequences underscore the importance of the recognition, appreciation, and management of these electrolyte abnormalities.

Electrolyte balance in heart failure and the role for magnesium ions

It is well established that clinically significant changes in a number of electrolytes occur in patients with congestive heart failure (CHF). Magnesium ions are an essential requirement for many enzyme systems, and evidence is rapidly emerging that magnesium deficiency is a major risk factor for survival of CHF patients. In animal experiments, magnesium has been shown to be involved in several steps of the atherosclerotic process and, although in humans the situation is somewhat more complex, magnesium ions play an extremely important role in CHF and various cardiac arrhythmias. A number of drugs commonly used to treat CHF can significantly affect not only cellular magnesium ion homeostasis, but potassium as well. These include mercurial, thiazide, and loop diuretics. It has also been reported that hypomagnesemia is common in digitalis intoxication. In contrast, a number of agents have been shown to have either a magnesium-conserving effect (potassium-sparing diuretics) or not to affect magnesium ion balance (angiotensin-converting enzyme inhibitors). The clinical consequences of magnesium deficiency include the development of various cardiac arrhythmias, all of which respond well to magnesium treatment. Thus, it is more than apparent that magnesium ion homeostasis is of major importance in CHF. Future studies should address the complex role of magnesium ions in electrolyte imbalance, particularly in relation to heart failure.