Transdermal nitroglycerin patch therapy improves left ventricular function and prevents remodeling after acute myocardial infarction: results of a multicenter prospective randomized, double-blind, placebo-controlled trial

A review of therapeutic approaches for post-infarction left ventricular remodeling

Left ventricular remodeling is an adaptive process initially developed in response to acute myocardial infarction (AMI), but it ends up with negative adverse outcomes such as infarcted wall thinning, ventricular dilation, and cardiac dysfunction. A prolonged excessive inflammatory reaction to cardiomyocytes death and necrosis plays the crucial role in the pathophysiological mechanisms. The pharmacological treatment includes nitroglycerine, β-blockers, ACEi/ARBs, SGLT2i, mineralocorticoid receptor antagonists, and some miscellaneous aspects. Stem cells therapy, CD34+ cells transplantation and gene therapy constitute the promissing therapeutic approaches for post AMI cardiac remodeling, thereby enhancing angiogenesis, cardiomyocytes differenciation and left ventricular function on top of inhibiting apoptosis, inflammation, and collagen deposition. All these lead to reduce infarct size, scar formation and myocardial fibrosis.

Investigation of the Therapeutic Potential of Organic Nitrates in Mortality Reduction Following Acute Myocardial Infarction in Hyperlipidemia Patients: A Population-Based Cohort Study

BACKGROUND

Dyslipidemia is a known risk factor for cardiac dysfunction, and lipid-lowering therapy with statins reduces symptoms and reduces hospitalization related to left ventricular heart failure. Acute myocardial infarction (AMI) is a cause of morbidity and mortality worldwide. In this study, we aimed to determine the real-world AMI treatment drug combination used in Taiwan by using the NHI database to understand the treatment outcomes of current clinical medications prescribed for hyperlipidemia patients with AMI.

METHODS

Using the NHI Research Database (NHIRD), we conducted a retrospective cohort study that compared different treatments for AMI in hyperlipidemia patients in the period from 2016 to 2018. We compared the survival outcomes between those treated with and without organic nitrates in this cohort.

RESULTS

We determined that most hyperlipidemia patients were aged 61-70 y (29.95-31.46% from 2016 to 2018), and the annual AMI risk in these patients was <1% (0.42-0.68% from 2016 to 2018). The majority of hyperlipidemia patients with AMI were women, and 25.64% were aged 61-70 y. Receiving organic nitrates was associated with lower all-cause mortality rates (HR, 95% CI, p-value = 0.714, 0.674-0.756, p < 0.0001). After multivariate analysis, the overall survival in four groups (beta-blockers, beta-blocker + diuretics, diuretics, and others) receiving an organic nitrate treatment was significantly higher than in the groups that were not treated with organic nitrates (beta-blockers HR = 0.536, beta-blocker + diuretics HR = 0.620, diuretics HR = 0.715, and others HR = 0.690).

CONCLUSIONS

The survival benefit was significantly greater in patients treated with organic nitrates than in those treated without organic nitrates, especially when combined with diuretics. A combination of organic nitrates could be a better treatment option for hyperlipidemia patients with AMI.

Approccio diagnostico e terapeutico al paziente con sindrome coronarica acuta

The current management strategy of acute coronary syndromes aims at symptoms relief as well as at specifically antagonizing each of the different pathogenic components of myocardial ischemia, including the pro-thrombotic state, poor coronary flow and myocardial damage.

Different approaches are available, including revascularization procedures and pharmacological interventions. Various anti-anginal, anti-thrombotic and anti-coagulant drugs can be used according to individual features and needs, as well as secondary prevention measures based on statin use and ACE-inhibition. The appropriate use of available measures is crucial to reduce mortality and improve long-term prognosis in patients with acute coronary syndromes.

The Function of Rho-Associated Kinases ROCK1 and ROCK2 in the Pathogenesis of Cardiovascular Disease

Rho-associated kinases ROCK1 and ROCK2 are serine/threonine kinases that are downstream targets of the small GTPases RhoA, RhoB, and RhoC. ROCKs are involved in diverse cellular activities including actin cytoskeleton organization, cell adhesion and motility, proliferation and apoptosis, remodeling of the extracellular matrix and smooth muscle cell contraction. The role of ROCK1 and ROCK2 has long been considered to be similar; however, it is now clear that they do not always have the same functions. Moreover, depending on their subcellular localization, activation, and other environmental factors, ROCK signaling can have different effects on cellular function. With respect to the heart, findings in isoform-specific knockout mice argue for a role of ROCK1 and ROCK2 in the pathogenesis of cardiac fibrosis and cardiac hypertrophy, respectively. Increased ROCK activity could play a pivotal role in processes leading to cardiovascular diseases such as hypertension, pulmonary hypertension, angina pectoris, vasospastic angina, heart failure, and stroke, and thus ROCK activity is a potential new biomarker for heart disease. Pharmacological ROCK inhibition reduces the enhanced ROCK activity in patients, accompanied with a measurable improvement in medical condition. In this review, we focus on recent findings regarding ROCK signaling in the pathogenesis of cardiovascular disease, with a special focus on differences between ROCK1 and ROCK2 function.

Exogenous nitric oxide inhibits Rho-associated kinase activity in patients with angina pectoris: a randomized controlled trial

The RhoA/Rho-associated kinase (ROCK) pathway has a key physiological role in the pathogenesis of atherosclerosis. Increased ROCK activity is associated with cardiovascular diseases. Endogenous nitric oxide (NO) has an anti-atherosclerotic effect, whereas the exogenous NO-mediated cardiovascular effect still remains controversial. The purpose of this study was to evaluate the effect of exogenous NO on ROCK activity in patients with angina pectoris. This is a prospective, open-label, randomized, controlled study. A total of 30 patients with angina pectoris were randomly assigned to receive 40 mg day(-1) of isosorbide mononitrate (n=15, 12 men and 3 women, mean age of 63±12 years, isosorbide mononitrate group) or conventional treatment (n=15, 13 men and 2 women, mean age of 64±13 years, control group) for 12 weeks. ROCK activity in peripheral leukocytes was measured by western blot analysis. ROCK activities at 4 and 12 weeks after treatment were decreased in the isosorbide mononitrate group (0.82±0.33 at 0 week, 0.62±0.20 at 4 weeks, 0.61±0.19 at 12 weeks, n=15 in each group, P<0.05, respectively) but not altered in the control group. ROCK1 and ROCK2 expression levels were similar in all treatment periods in the two groups. These findings suggest that the administration of exogenous NO can inhibit ROCK activity, indicating that the usage of exogenous NO could have a protective effect in patients with angina pectoris.

Potential of delayed gadolinium enhancement magnetic resonance imaging for quantification of reverse remodeling of the peri-infarct zone in patients with ischemic cardiomyopathy treated with chronic vasodilator therapy: initial experience

PURPOSE

The peri-infarct zone represents the morphologic substrate for reentry ventricular tachycardia after myocardial infarction, and its extent is a strong predictor of major cardiac events. Although delayed gadolinium enhancement magnetic resonance imaging (DGE-MRI) was shown to allow for detailed characterization of myocardial infarction by quantifying infarct core zone and peri-infarct zone volume, potentials of DGE-MRI for measuring changes in peri-infarct zone volume are unknown. Therefore, we aimed to assess changes in volume of the peri-infarct zone among patients with ischemic cardiomyopathy treated with chronic vasodilator therapy.

MATERIALS AND METHODS

Core and peri-infarct zone volumes as assessed with DGE-MRI were measured in 5 patients at baseline and after 6 months treatment with sustained-release dipyridamole.

RESULTS

Core zone volume remained stable during follow-up [median (range), 19 mL (9 to 42) vs. 16 mL (11 to 46); P=0.785]. The ratio between the peri-infarct zone and the core zone volume decreased significantly at 6 months compared with baseline [median (range), 0.22 (0.19 to 0.42) vs. 0.18 (0.09 to 0.32); P=0.043], and a trend toward reduction in peri-infarct zone volume was found [median (range), 5 mL (2 to 8) vs. 3 mL (2 to 6); P=0.059]. The peri-infarct zone volume decreased in all but 1 patient over the follow-up.

CONCLUSIONS

This initial experience suggests that reverse remodeling of the peri-infarct zone with reduction in peri-infarct zone volume may take place in patients with ischemic cardiomyopathy. Quantification of this process may be feasible with DGE-MRI, but further studies are needed to confirm this hypothesis and to further clarify the role of DGE-MRI for the assessment of changes in peri-infarct zone volume in patients with ischemic cardiomyopathy.

Importance of residual myocardial ischemia after intervention in the genesis of cardiovascular events among patients with chronic coronary artery disease

Recent randomized clinical trials support the strategy of ischemia-guided management for patients with stable ischemic heart disease. The application of serial testing to examine the efficacy of therapeutic intervention for ischemia suppression and to document the extent and severity of ischemia provides an important means to guide clinical decision making. This review provides a synopsis of available evidence on serial testing and meaningful thresholds for application of paired rest/stress myocardial perfusion single photon emission computed tomography imaging.

Nitric oxide pathway in hypertrophied heart: new therapeutic uses of nitric oxide donors

Left ventricular hypertrophy (LVH) is regarded as a complication common to a number of cardiovascular diseases, including hypertension, myocardial infarction and ischaemia associated with coronary artery disease. Initially LVH is a compensatory mechanism, but in the long term cardiac hypertrophy predisposes individuals to heart failure, myocardial infarction and sudden death. Alteration of the nitric oxide (NO) pathway is believed to play an important role in the haemodynamically overloaded heart and pathological cardiac remodelling. Although re-establishment of the physiological NO pathway could be considered an important therapeutic target, the use of conventional nitrates is limited in the clinical setting by the development of tissue resistance and tolerance and by the shortage of large-scale clinical trials unequivocally confirming the beneficial impact of NO donors on cardiovascular morbidity and mortality. The aim of this review is to present current therapeutic options for dealing with changes in the L-arginine-NO pathway. The most promising therapeutic approach is represented by a new neutral sugar organic nitrate, LA-419, the thiol group of which seems to protect NO from degradation, thereby increasing its bioavailability. In a model of aortic stenosis-induced pressure overload, LA-419 has been found to restore the complete NO signalling cascade and reduce left ventricular remodelling, but without restoring the original pressure gradient, indicating a possible direct antiproliferative effect. Future studies are needed to confirm this therapeutic benefit in other animal models of hypertension and in the clinical setting.

Exploiting cGMP-based therapies for the prevention of left ventricular hypertrophy: NO* and beyond

Left ventricular hypertrophy (LVH), an increased left ventricular (LV) mass, is common to many cardiovascular disorders, initially developing as an adaptive response to maintain myocardial function. In the longer term, this LV remodelling becomes maladaptive, with progressive decline in LV contractility and diastolic function. Indeed LVH is recognised as an important blood-pressure independent predictor of cardiovascular morbidity and mortality. The clinical efficacy of current treatments for LVH is reduced, however, by their tendency to slow disease progression rather than induce its reversal, and thus the development of new therapies for LVH is paramount. The signalling molecule cyclic guanosine-3',5'-monophosphate (cGMP), well-recognised for its role in regulating vascular tone, is now being increasingly identified as an important anti-hypertrophic mediator. This review is focused on the various means by which cGMP can be stimulated in the heart, such as via the natriuretic peptides, to exert anti-hypertrophic actions. In particular we address the limitations of traditional nitric oxide (NO*) donors in the face of the potential therapeutic advantages offered by novel alternatives; NO* siblings, ligands of the cGMP-generating enzymes, soluble (sGC) and particulate guanylyl cyclases (pGC), and phosphodiesterase inhibitors. Further impact of cGMP within the cardiovascular system is also discussed with a view to representing cGMP-based therapies as innovative pharmacotherapy, alone or concurrent with standard care, for the management of LVH.

Continuous long-term dosing with oral slow-release isosorbide dinitrate does not reduce incidence of cardiac events in patients with healed myocardial infarction

BACKGROUND

In the short term, isosorbide dinitrate (ISDN) is considered to be therapeutically effective. The long-term effects of treatment with slow-release ISDN are less clear.

HYPOTHESIS

The study was undertaken to investigate the effects of continuous, long-term dosing with oral slow-release ISDN on the incidence of cardiac events in patients with healed myocardial infarction (MI). The study was carried out in accordance with the intention-to-treat principle.

METHODS

In all, 1.102 in- and outpatients, of either gender, with healed MI were randomly divided into groups treated with ISDN (n = 470) and not treated with ISDN (n = 632). Patients in the ISDN group received a continuous regimen of 20 mg of oral, long-acting ISDN three times a day, after meals. The mean observation period was 15.0 +/- 18.5 months. The primary endpoints were nonfatal and fatal recurrent MI, death from congestive heart failure, and sudden death.

RESULTS

There were no significant differences in the baseline characteristics of the patients in the ISDN and no-treatment groups; nevertheless, significantly more patients in the ISDN group experienced cardiac events. In the ISDN group, 35 patients (7.4%) experienced cardiac events during the observation period, versus only 28 patients (4.4%) in the no-treatment group (p < 0.05; odds ratio 1.74; 95% confidence interval 1.04-2.90).

CONCLUSION

Continuous long-term dosing with oral, slow-release ISDN does not reduce and probably increases the incidence of cardiac events among patients with healed MI.

An Initial Strategy of Intensive Medical Therapy Is Comparable to That of Coronary Revascularization for Suppression of Scintigraphic Ischemia in High-Risk But Stable Survivors of Acute Myocardial Infarction

OBJECTIVES

The purpose of this study was to determine the relative benefit of intensive medical therapy compared with coronary revascularization for suppressing scintigraphic ischemia.

BACKGROUND

Although medical therapies can reduce myocardial ischemia and improve patient survival after acute myocardial infarction, the relative benefit of medical therapy versus coronary revascularization for reducing ischemia is unknown.

METHODS

A prospective randomized trial in 205 stable survivors of acute myocardial infarction was made to define the relative efficacy of an intensive medical therapy strategy versus coronary revascularization for suppressing scintigraphic ischemia as assessed by serial gated adenosine Tc-99m sestamibi myocardial perfusion tomography. All patients at baseline had large total (> or =20%) and ischemic (> or =10%) adenosine-induced left ventricular perfusion defects and an ejection fraction > or =35%. Imaging was performed during 1 to 10 days of hospital admission and repeated in an identical fashion after optimization of therapy. Patients randomized to either strategy had similar baseline demographic and scintigraphic characteristics.

RESULTS

Both intensive medical therapy and coronary revascularization induced significant but comparable reductions in total (-16.2 +/- 10% vs. -17.8 +/- 12%; p = NS) and ischemic (-15 +/- 9% vs. -16.2 +/- 9%; p = NS) perfusion defect sizes. Likewise, a similar percentage of patients randomized to medical therapy versus coronary revascularization had suppression of adenosine-induced ischemia (80% vs. 81%; p = NS).

CONCLUSIONS

Sequential adenosine sestamibi myocardial perfusion tomography can effectively monitor changes in scintigraphic ischemia after anti-ischemic medical or coronary revascularization therapy. A strategy of intensive medical therapy is comparable to coronary revascularization for suppressing ischemia in stable patients after acute infarction who have preserved LV function.

Inhaled nitric oxide decreases infarction size and improves left ventricular function in a murine model of myocardial ischemia-reperfusion injury

To learn whether nitric oxide (NO) inhalation can decrease myocardial ischemia-reperfusion (I/R) injury, we studied a murine model of myocardial infarction (MI). Anesthetized mice underwent left anterior descending coronary artery ligation for 30, 60, or 120 min followed by reperfusion. Mice breathed NO beginning 20 min before reperfusion and continuing thereafter for 24 h. MI size and area at risk were measured, and left ventricular (LV) function was evaluated using echocardiography and invasive hemodynamic measurements. Inhalation of 40 or 80 ppm, but not 20 ppm, NO decreased the ratio of MI size to area at risk. NO inhalation improved LV systolic function, as assessed by echocardiography 24 h after reperfusion, and systolic and diastolic function, as evaluated by hemodynamic measurements 72 h after reperfusion. Myocardial neutrophil infiltration was reduced in mice breathing NO, and neutrophil depletion prevented inhaled NO from reducing myocardial I/R injury. NO inhalation increased arterial nitrite levels but did not change myocardial cGMP levels. Breathing 40 or 80 ppm NO markedly and significantly decreased MI size and improved LV function after ischemia and reperfusion in mice. NO inhalation may represent a novel method to salvage myocardium at risk of I/R injury.

Pharmacologic effects on cardiac remodeling

Clinical research during the past several decades has shown the importance of cardiac remodeling as a basic mechanism in the progression of heart failure. Changes in cardiac remodeling have high concordance with long-term clinical outcomes. Cardiac remodeling should be regarded as a primary target for treatment and also can serve as a reliable surrogate for clinical outcomes. Neurohormonal blockade with combination treatments that inhibit the renin-angiotensin-aldosterone and sympathetic systems has proven effective in improving cardiac remodeling and clinical outcomes. Such treatment should be standard therapy for patients with left ventricular dysfunction after myocardial infarction and patients with chronic heart failure.

Pressure overload-induced LV hypertrophy and dysfunction in mice are exacerbated by congenital NOS3 deficiency

To investigate the role of endothelial nitric oxide synthase (NOS3) in left ventricular (LV) remodeling induced by chronic pressure overload, the impact of transverse aortic constriction (TAC) on LV structure and function was compared in wild-type (WT) and NOS3-deficient (NOS3(-/-)) mice. Before TAC, LV wall thickness, mass, and fractional shortening were similar in the two mouse strains. Twenty-eight days after TAC, both WT and NOS3(-/-) mice had increased LV wall thickness and mass as well as decreased fractional shortening. Although the pressure gradient across the TAC was similar in both strains of mice 28 days after TAC, LV mass and posterior wall thickness were greater in NOS3(-/-) than in WT mice, whereas fractional shortening and the maximum rate of developed LV pressure were less. Diastolic function, as measured by the time constant of isovolumic relaxation and the maximum rate of LV pressure decay, was impaired to a greater extent in NOS3(-/-) than in WT mice. The degree of myocyte hypertrophy and LV fibrosis was greater in NOS3(-/-) than in WT mice at 28 days after TAC. Mortality was greater in NOS3(-/-) than in WT mice 28 days after TAC. Long-term administration of hydralazine normalized the blood pressure and prevented the LV dilation in NOS3(-/-) mice but did not prevent the LV hypertrophy, dysfunction, and fibrosis associated with NOS3 deficiency after TAC. These results suggest that the absence of NOS3 augments LV dysfunction and remodeling in a murine model of chronic pressure overload.

Beneficial effects of angiotensin-converting enzyme inhibitor and nitrate association on left ventricular remodeling in patients with large acute myocardial infarction: the Delapril Remodeling after Acute Myocardial Infarction (DRAMI) trial

BACKGROUND

In the large-scale trial, Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-3 (GISSI-3), patients receiving the combination of lisinopril and glyceryl trinitrate benefited most from experimental therapy. Therefore, a multicenter, randomized, double-blind study, Delapril Remodeling After Acute Myocardial Infarction (DRAMI), was designed to assess (1) the possible additive beneficial effect on left ventricular remodeling of nitrates when combined with an angiotensin-converting enzyme inhibitor (ACEI), and (2) the tolerability of a new ACEI, delapril, in respect to lisinopril in patients with large myocardial infarction (MI).

METHODS

A total of 177 patients were randomized to receive delapril plus isosorbide-5-mononitrate (IS5MN) placebo, delapril plus IS5MN, lisinopril plus IS5MN placebo, or lisinopril plus IS5MN starting within the first 36 hours after the onset of symptoms and continuing for 3 months.

RESULTS

More than 80% of the patients showed extensive ST-segment changes and 36.7% had signs or symptoms of heart failure during the first 36 hours. Over 3 months, IS5MN reduced, by 76%, the increase in LVEDV (17.4 +/- 5.0 mL placebo vs 4.2 +/- 4.4 mL IS5MN, P =.0439), reversed the increase in LVESV (7.5 +/- 3.9 mL placebo vs -5.5 +/- 2.9 mL IS5MN, P =.0052), and increased the recovery of LVEF (1.9% +/- 1.3% placebo vs 6.7% +/- 1.2% IS5MN, P =.0119). Overall, 3-month mortality was 10.2%; the most frequent clinical events were new episodes of severe heart failure (18.1%), persistent hypotension (10.7%), and post-MI angina (18.1%), with no differences between treatment groups.

CONCLUSIONS

Administration for 3 months of IS5MN combined with an ACEI, both started within 36 hours from the onset of symptoms, was safe and effective in reducing LV dilation and dysfunction after MI. The 2 ACEIs, delapril and lisinopril, appeared to be equally well tolerated.

Cardiac endothelial-myocardial signaling: its role in cardiac growth, contractile performance, and rhythmicity

Experimental work during the past 15 years has demonstrated that endothelial cells in the heart play an obligatory role in regulating and maintaining cardiac function, in particular, at the endocardium and in the myocardial capillaries where endothelial cells directly interact with adjacent cardiomyocytes. The emerging field of targeted gene manipulation has led to the contention that cardiac endothelial-cardiomyocytal interaction is a prerequisite for normal cardiac development and growth. Some of the molecular mechanisms and cellular signals governing this interaction, such as neuregulin, vascular endothelial growth factor, and angiopoietin, continue to maintain phenotype and survival of cardiomyocytes in the adult heart. Cardiac endothelial cells, like vascular endothelial cells, also express and release a variety of auto- and paracrine agents, such as nitric oxide, endothelin, prostaglandin I(2), and angiotensin II, which directly influence cardiac metabolism, growth, contractile performance, and rhythmicity of the adult heart. The synthesis, secretion, and, most importantly, the activities of these endothelium-derived substances in the heart are closely linked, interrelated, and interactive. It may therefore be simplistic to try and define their properties independently from one another. Moreover, in relation specifically to the endocardial endothelium, an active transendothelial physicochemical gradient for various ions, or blood-heart barrier, has been demonstrated. Linkage of this blood-heart barrier to the various other endothelium-mediated signaling pathways or to the putative vascular endothelium-derived hyperpolarizing factors remains to be determined. At the early stages of cardiac failure, all major cardiovascular risk factors may cause cardiac endothelial activation as an adaptive response often followed by cardiac endothelial dysfunction. Because of the interdependency of all endothelial signaling pathways, activation or disturbance of any will necessarily affect the others leading to a disturbance of their normal balance, leading to further progression of cardiac failure.

Effect of intraaortic balloon pumping on left ventricular function in patients with persistent ST segment elevation after revascularization for acute myocardial infarction

The purpose of the present study was to assess the impact of intraaortic balloon pumping (IABP) in patients with persistent ST elevation who underwent revascularization within 6 h of their first acute anterior myocardial infarction (AMI). Persistent ST elevation after revascularization was defined as being > or =50% of the initial value on return to the coronary care unit. Twenty-four patients were treated without IABP (control group) and 27 patients were treated with IABP (IABP group). There was no significant difference between the 2 groups in pretreatment left ventricular ejection fraction (LVEF), end-diastolic volume index or end-systolic volume index. After 137+/-46 days, the change in the LVEF was significantly higher in the IABP group than in the control group (5+/-13% vs 13+/-15%, p=0.04). However, the left ventricular end-diastolic volume index was similar between the 2 groups during follow-up (pretreatment: 77+/-19 ml/m(2) vs 74+/-13 ml/m(2), p=0.54; follow-up: 86+/-22 ml/m(2) vs 83+/-18 ml/m(2), p=0.60). These data suggest that IABP enhances the improvement in LVEF independent of remodeling in AMI patients with persistent ST elevation after revascularization.

[Pathophysiology and therapeutic aspects of left ventricular "remodeling" in the post-infarct phase]

Left ventricular remodeling is the process by which ventricular size, shape, and function are regulated by mechanical, neurohormonal, and genetic factors. Remodeling may be physiological and adaptive during normal growth or pathological due to myocardial infarction, cardiomyopathy, hypertension, or valvular heart disease. Postinfarction remodeling has been divided into an early phase within 72 hours and a late phase beyond 72 hours. The early phase involves expansion of the infarct zone, which may result in early ventricular rupture or aneurysm formation. Late remodeling involves the left ventricle globally and is associated with time-dependent dilatation, the distortion of ventricular shape, and mural hypertrophy. Hypertrophy and collagen degradation are adaptive responses during postinfarction remodeling. Myocardial repair is triggered by cytokines released from injured myocytes. Ventricular remodeling is influenced most by infarct artery patency. Once infarct evolution has occurred, pharmacological intervention, like ACE inhibition and beta-adrenoreceptor blocking agents, may minimize infarct expansion and ventricular dilatation and improve the long-term prognosis.

Alpha calculus in clinical trials: considerations and commentary for the new millennium

Regardless of whether a statistician believes in letting a data set speak for itself through nominal p-values or believes in strict alpha conservation, the interpretation of experiments which are negative for the primary endpoint but positive for secondary endpoints is the source of some angst. The purpose of this paper is to apply the notion of prospective alpha allocation in clinical trials to this difficult circumstance. An argument is presented for differentiating between the alpha for the experiment ('experimental alpha' or alpha(E)) and the alpha for the primary endpoint (primary alpha, or alpha(P)) and notation is presented which succinctly describes the findings of a clinical trial in terms of its conclusions. Capping alpha(E) at 0.10 and alpha(P) at 0.05 conserves sample size and preserves consistency with the strength of evidence for the primary endpoint of clinical trials. In addition, a case is presented for the well defined circumstances in which a trial which did not reject the null hypothesis for the primary endpoint but does reject the null hypothesis for at least one of the secondary endpoints may be considered positive in a manner consistent with conservative alpha management.

Medical and surgical therapy for cardiac remodeling

Ventricular remodeling refers to changes in ventricular geometry, volume, mass, and myocellular structure in response to myocardial injury or alteration in loading conditions. Although initially adaptive as a consequence of the initial damage to the myocardium, progressive ventricular remodeling is ultimately a maladaptive process that is associated with significant cardiovascular morbidity and mortality. Treatment with an aim to halt or reverse remodeling with mainly two classes of medications, angiotensin-converting enzyme inhibitors and beta-adrenergic blockers, has been shown to improve the long-term outcome. The role of pharmacologic and surgical therapy in remodeling is evolving and may have an important impact on the development of new directions of therapy for heart failure, myocardial infarction, and hypertension.

The role of organic nitrates in the treatment of heart failure

Nitrates have been widely used in the treatment of patients with chronic congestive heart failure. Although the use of these drugs has not been approved by the Food and Drug Administration, multiple studies have shown their favorable effects. Organic nitrates have been shown to have a beneficial effect on ischemia, hemodynamic profile, magnitude of a mitral regurgitation, endothelial function, and cardiac remodeling. These drugs, when used in combination with hydralazine, have improved exercise capacity and survival. Recent studies have shown that the use of nitrates in patients already treated with standard heart failure therapy, including angiotensin converting enzyme (ACE) inhibitors, resulted in hemodynamic improvement, marked enhancement of exercise tolerance, reduction of left ventricular size, and augmentation of systolic function. These data suggest a role for organic nitrates as an adjunctive therapy to ACE inhibitors in patients with chronic heart failure and for nitrates in combination with hydralazine as an alternative treatment in patients who are intolerant to ACE inhibitors.