AB0900 A temporary antirheumatic drugs withdrawal does not cause an excess of disease flares in patients with psoriatic arthritis undergoing Covid-19 mRNA vaccination

Background

The best way to manage disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatic and musculoskeletal diseases (RMDs) undergoing the Coronavirus disease (Covid)-19 vaccination and the recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination are still a matter of debate, due to the difficulties in balancing the vaccination efficacy and safety.

Objectives

To assess the impact of different strategies of antirheumatic treatment management on disease activity around the time of vaccination for Coronavirus disease (Covid)-19 in patients with psoriatic arthritis (PsA).

Methods

We prospectively evaluated patients with PsA in remission or low-disease activity candidate to receive Covid-19 vaccination with mRNA vaccines. Methotrexate (MTX) and leflunomide were withheld 7 days after each dose, whilst biological DMARDs (bDMARDs), were either continued (46.8% of the patients) or withheld (53.2%) from the day of the first dose until 7 days after the second dose. Patients were reassessed after 3 months from enrollment or in case of disease flare.

Results

After the second dose of Covid-19 vaccination 7 patients (5.6%) (6 females) had an articular disease flare each (mean involved joints: 1.29), one patient presented a concomitant worsening of psoriasis, and four patients had an isolated worsening of their psoriasis. All patients received additional treatments with oral GC (n=2) or non-steroidal anti-inflammatory drugs (n=5). Two flares lasted more than one week and required a modification of the ongoing bDMARD. Articular flare incidence (6.8% vs 3%, p=0.259), involved joints (1.4 vs 1.5, p=0.846), disease flare severity, and changes in antirheumatic therapies (1 vs 1, p=0.928) did not differ significantly between the two different bDMARD management strategy groups (continued vs temporary withheld). There was no significant difference in disease activity score for psoriatic arthritis (DAPSA) and C-reactive protein (CRP) after vaccination, but patients who flared up had a higher mean basal DAPSA (7.3 vs 4.1, p=0.046). On binomial logistic regression analysis, we did not find any significant association with gender, age, basal CRP, basal DAPSA, active psoriasis, conventional synthetic DMARDs, or bDMARDs and disease flare.

Conclusion

Our findings suggest that a temporary short halt of bDMARDs could be a viable option in patients with well-controlled PsA undergoing Covid-19 vaccination without increasing the risk of flares, which could be useful to increase T cell response and antibody titres after Covid-19 vaccination.

Disclosure of Interests

None declared

OP0055 ULTRASOUND HALO SIGN AS A POTENTIAL MONITORING TOOL FOR PATIENTS WITH GIANT CELL ARTERITIS: A PROSPECTIVE ANALYSIS

Background:

Ultrasound of the temporal ± axillary arteries showing a non-compressible halo sign is recommended for diagnosing patients with giant cell arteritis (GCA); however, its value for monitoring disease activity is still poorly understood.

Objectives:

To assess the sensitivity to change of ultrasound halo features and their association with disease activity and glucocorticoid (GC) treatment in patients with newly diagnosed GCA.

Methods:

Two centre prospective study of new patients with ultrasound confirmed-GCA who underwent serial ultrasound assessments of the temporal (TA) and axillary (AX) arteries at fixed time-points. The number of arterial segments with halo and the maximum halo intima-media thickness (IMT) per segment was recorded at each visit. Only time-points in which >80% of patients were assessed were considered for analysis. Sensitivity to change of the halo sign was calculated as standardised mean difference (SMD) for each time-point separately. Correlation between ultrasound findings and erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Birmingham Vasculitis Activity Score (BVAS), and GC treatment was performed using Spearman’s correlation coefficient. Logistic regression was used to determine the probability of being in remission for each unit increase (standardised) of the halo feature of interest. Remission was defined as the absence of relapse with a prednisolone dose <30 mg/day, and relapse as the recurrence of GCA-related symptoms or rise of CRP/ESR values not otherwise explained and requiring GC increase. Halo features at disease onset and first relapse were compared using Wilcoxon test.

Results:

A total of 49 patients (73.5% females) with a mean age of 78.2 ± 7.4 years at baseline were assessed at 354 visits. TA involvement was reported in 47 (95.9%) patients and AX involvement in 11 (22.4%); 220 arterial segments with halo were recorded (201 TA, 19 AX). Halo sensitivity to change was calculated for weeks 1, 3, 6, 12 and 24, and showed a significant SMD between all time-points and baseline for the TA halo features, but only after week 6 for the AX halo features (Table and Figure). The number of TA segments with halo, sum of TA halo IMT and maximum TA halo IMT showed a significant correlation with ESR (0.41; 0.44; 0.48), CRP (0.34; 0.39; 0.41), BVAS (0.29; 0.36; 0.35) and GC cumulative dose (-0.34; -0.37; -0.32). The likelihood of achieving disease remission was lower in patients with a higher number of TA segments with halo (OR 0.39, p<0.05) and increased values of sum and maximum TA halo IMT (OR 0.34, p<0.05). By contrast, AX halo features showed no correlation with disease activity, nor any association with attaining clinical remission. During the study period, 32 relapses were observed (mean time for first relapse of 31.8 weeks ± 18.5 days). Halo sign was present in 16/17 (94.1%) cases of first disease relapse, all showing an increased halo IMT (sum and maximum) in relation to the previous ultrasound assessment performed. When compared to disease onset, a lower mean number of segments with halo and mean sum of halo IMT was reported for patients presenting with their first clinical relapse (2.93 ± 1.59 vs. 4.85 ± 1.51, p=0.0012; 2.01 ± 1.13 vs. 4.49 ± 1.95 mm, p=0.0012).

Table 1.

SMD of halo features between baseline and different time-points

Week 1Week 3Week 6Week 12Week 24N of arterial segmentsSum of all segments with halo (n=49)-0.51-0.78-1.13-1.69-1.52Sum of TA segments with halo (n=47)-0.49-0.78-1.18-1.87-1.69Sum of AX segments with halo (n=11)-0.35--0.62-0.73-0.91Halo thickness (mm)Sum of all halo IMT (n=49)-0.98-1.44-1.37-1.60-1.48Sum of TA halo IMT (n=47)-1.01-1.55-1.54-1.81-1.69Sum of AX halo IMT (n=11)-0.15-0.45-0.81-0.84-0.98Max. TA halo IMT (n=47)-1.07-1.32-1.47-1.91-2.19Max. AX halo IMT (n=11)-0.04-0.29-0.94-1.13-1.01

In bold p<0.05; n=n at baseline

Conclusion:

Ultrasound is a reliable imaging tool to assess disease activity and response to treatment in patients with GCA. Future clinical trials in GCA should evaluate direct treatment effect on halo features as an outcome measure of interest.

Acknowledgements:

The first two authors contributed equally to this work

Disclosure of Interests:

None declared

POS0250 SIGNIFICANT DAMAGE OCCURS EARLY IN THE COURSE OF EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS AND IS MAINLY DUE TO DISEASE-RELATED SEQUELAE

Background:

Following the introduction of effective immunosuppressive treatments, ANCA-associated vasculitides (AAV) have become chronic diseases with a remitting-relapsing course. Therefore, preventing chronic damage accrual during follow-up is critical, as relapses, treatment-related side effects, and comorbidities may significantly affect the long-term outcomes of AAV patients. At present, no study specifically evaluated the burden of damage in patients with eosinophilic granulomatosis with polyangiitis (EGPA).

Objectives:

To describe short-term (6 months) and long-term (5 years) damage accrual in patients with newly diagnosed EGPA.

Methods:

Patients diagnosed with EGPA, according to ACR criteria and/or Chapel Hill definitions and regularly followed-up in our vasculitis center for ≥5 years were included. Damage accrual was assessed with the Vasculitis Damage Index (VDI). Short-term and long-term damage accrual was defined by VDI at 6 months and at 5 years, respectively, and categorized as related to vasculitis or its treatment.

Results:

VDI data at 6 months were available for 45 EGPA patients: 24 (53.3%) female, mean age at diagnosis 51.6±13.0 years. ANCA were positive in 17 patients (37.8%), with MPO being the only detected enzyme immunoassay (EIA)-specificity. At 6 months mean VDI was 2.8±1.3; 25/45 (55.6%) and 6/45 patients (13.3%) presented ≥3 and ≥5 items, respectively, whilst only 1 patient (2.2%) showed no items of damage. VDI data at 5 years were available for 32/45 EGPA patients (71.1%): 16 (50%) female, mean age at diagnosis 51.5±13.1 years. MPO-ANCA were positive in 13 patients (40.6%). At 5 years mean VDI was 3.5±1.3, with 26/32 (81.3%) and 7/32 patients (21.9%) presenting ≥3 and ≥5 items, respectively; notably, no patients presented a VDI=0 at 5 years.

The most frequent disease-related VDI items at 6 months and at 5 years were asthma, chronic sinusitis, peripheral neuropathy, cardiomyopathy, pulmonary function tests abnormalities and nasal blockage (Figure 1). Osteoporotic fractures, diabetes and systemic hypertension were the most commonly reported treatment-related items at 6 months and at 5 years (Figure 1). Damage accrual progressively rose during the 5-year follow-up (P=0.023), mainly due to disease-related items rather than treatment-related items both at 6 months (disease related VDI 2.6±1.2, treatment-related VDI 0.3±0.6) and at 5 years (disease related VDI 2.9±1.2, treatment-related VDI 0.6±0,7). No significant difference in terms of damage accrual was observed between ANCA-positive and ANCA-negative patients (P >0.5).

Conclusion:

In our cohort of EGPA patients damage accrual occurs early, with more than half of the patients displaying ≥3 VDI items already at 6 months. Poor control of previous disease activity, particularly ENT and respiratory manifestations, contributes to progressive damage accrual more than treatment side effects.

Figure 1.

Disease-related and treatment-related VDI items at 6 months and at 5 years in patients with EGPA.

Disclosure of Interests:

None declared

POS0830 FACTORS INFLUENCING PATIENT-REPORTED OUTCOMES IN ANCA-ASSOCIATED VASCULITIS

Background:

Patient-reported outcomes (PROs) are currently poorly integrated in the clinical evaluation of disease activity in patients with ANCA-associated vasculitis (AAV).

Objectives:

To assess the distribution of the Patient Global Assessment (PtGA) in patients with AAV in stable remission, and to identify correlates of PtGA; to assess the discordance between PtGA score and PhGA.

Methods:

Patients with a diagnosis of AAV [eosinophilic granulomatosis with polyangiitis, granulomatosis with polyangiitis, microscopic polyangiitis] in stable, complete remission (defined by a BVAS=0) and with a Physician Global Assessment (PhGA)=0 were included. A questionnaire including several aspects of disease captured by PROs was collected. PtGA on a 0-100 mm visual analogue scale (VAS) was assessed, with higher scores representing higher/worse levels of disease activity. Similarly, VAS for pain, chronic damage according to the patient’s opinion, general health (GH), fatigue, and sleep quality were collected. The worst symptom in the patient’s opinion affecting the overall assessment of disease activity was recorded. The Cragg Hurdle model was used to assess the predictors of PtGA.

Results:

65 patients were included, female 57%, mean age 61±12 years. Mean disease duration at enrollment was 8±6 years. Mean vasculitis damage index (VDI) was 4.4 ±2.3, with 45% of patients having a VDI ≥ 5. Despite having been classified as being in remission, PtGA was elevated in 37% of patients. We explored several correlates of PtGA. Higher degree of damage accrual (VDI) did not influence the patient’s evaluation of current disease activity. Similarly, we did not identify a correlation between older age, educational level, number of organ-systems involved, number of comorbidities, the number of previous major or minor relapses, higher disease duration, nor the type of AAV diagnosis (figure 1, panel A). Only sex significantly correlated with PtGA scores: 19 (51%) of female patients reported an elevated PtGA compared to only 5 (18%) of male (p=0.009). PtGA resulted to be significantly correlated with other (mostly modifiable) PROs including VAS pain, perception of the level of chronic damage accrual, GH, and fatigue (figure 1, panel B). The agreement between patients’ and physicians’ assessments of disease activity was 63%. Patients reported pain, followed by chronic respiratory symptoms to be the worst-experienced ongoing manifestations affecting their evaluation of disease activity.

Conclusion:

A significant proportion of patients with AAV considered to be in remission by the physician still declares to have persistent aspects of uncontrolled disease. PtGA is significantly influenced by persistent pain and fatigue, which warrant better assessment in the future.

Disclosure of Interests:

None declared

SAT0256 THE ROLE OF FAST-TRACK ULTRASOUND IN PREVENTING EARLY COMPLICATIONS AND RELAPSES IN GIANT CELL ARTERITIS

Background:

Giant Cell Arteritis (GCA) is the most common form of primary systemic vasculitis, mainly affecting adults over 50 years old. Permanent visual loss (PVL) is one of the most feared complications, occurring in about 20% of cases, typically prior to initiation of high-dose glucocorticoid (GC) therapy. Color-duplex sonography (CDS) of temporal arteries (TAs) and large vessels (LVs) is recognized as a first-line diagnostic tool for patients with suspected GCA. A fast track approach (FTA), incorporating CDS has been associated to a significant reduction of PVL in two retrospective studies1,2.

Objectives:

To assess the impact of FTA on PVL and risk of relapses during follow-up compared to conventional care prior to the introduction of the FTA in our rheumatology clinic.

Methods:

Patients with new-onset GCA evaluated in our department from January 1998 to September 2019 were included in the study. The FTA approach for GCA was implemented since October 2016. The diagnosis of GCA was based on positive TAs and/or LVs CDS and/or a positive TA biopsy and clinical signs and symptoms of GCA. All patients were clinically examined by the same rheumatologist who performed the CDS. PVL was defined as total visual impairment in one or both eyes. Data on baseline clinical features and later outcomes were collected.

Results:

153 patients were included: 115 females (75.2%), mean age at diagnosis 71.6±8.2 years. Of these, 112 patients (73%) were evaluated conventionally and 41 (27%) with FTA. Patients in the FTA group were older (P=0.0002), presented more frequently with polymyalgia rheumatica symptoms, weight loss, jaw or tongue claudication and scalp tenderness (P<0.05 for all comparisons). The median duration of follow-up in the FTA group was shorter compared with the conventional group (1.5 vs 5.8 years). PVL occurred in 22 (19.6%) patients in the conventional group compared to 5 patient (12.2%) in the FTA, leading to a reduction of 37.9% in the relative risk of PVL with the FTA approach. Cumulative incidence of relapses and time to first relapse did not change after FTA introduction (P>0.05) (Fig. 1).

Conclusion:

The application of a FTA in GCA resulted in a significant reduction of PVL. However, the relapse rate did not seem to be influenced by the FTA, highlighting the need to implement further management strategies, besides earlier diagnosis and prompt initiation of GC, that would impact the course of the disease during long-term follow-up

References:

[1]Patil P, Williams M, Maw WW et al. Fast track pathway reduces sight loss in giant cell arteritis: results of a longitudinal observational cohort study. Clin Exp Rheumatol 2015;33(Suppl 89):S-103-6.

[2]Diamantopoulos AP, Haugeberg G, Lindland A, Myklebust G. The fast-track ultrasound clinic for early diagnosis of giant cell arteritis significantly reduces permanent visual impairment: towards a more effective strategy to improve clinical outcome in giant cell arteritis? Rheumatology 2016;55:66_70.

Fig. 1.

Time to first relapse in patients with GCA and evaluated with a FTA compared to conventionally approached patients.

Disclosure of Interests:

None declared

Melorheostosis and Osteopoikilosis Clinical and Molecular Description of an Italian Case Series

Melorheostosis (MEL) is an uncommon, sclerosing disease, characterised by hyperostosis of long bones, resembling the flowing of candle wax. The disease is sporadic and the pathogenesis is still poorly understood. Occasionally, the same family can include individuals with MEL and Osteopoikilosis (OPK), a disease characterised by multiple round foci of increased bone density. LEMD3 gene mutations are related to OPK and Buschke-Ollendorff Syndrome, a genetic condition in which an association between MEL, OPK and skin lesions is observed. In rare cases, LEMD3 mutations and recently mosaic MAP2K1 gene mutations have been correlated to MEL suggesting that somatic mosaicism could be causative of the disease. In this study, we described the clinical, radiological and molecular findings of 19 individuals with MEL and 8 with OPK and compared the results to the medical literature. The molecular analyses of this case series corroborate the available data in the medical literature, indicating that LEMD3 germline mutations are not a major cause of isolated MEL and reporting five further cases of OPK caused by LEMD3 germline mutations.

Genotype-phenotype correlation study in 529 patients with multiple hereditary exostoses: identification of "protective" and "risk" factors

BACKGROUND

Multiple hereditary exostoses is an autosomal dominant skeletal disorder characterized by wide variation in clinical phenotype. The aim of this study was to evaluate whether the severity of the disease is linked with a specific genetic background.

METHODS

Five hundred and twenty-nine patients with multiple hereditary exostoses from two different European referral centers participated in the study. According to a new clinical classification based on the presence or absence of deformities and functional limitations, the phenotype of the patients was assessed as mild (the absence of both aspects), intermediate, or severe (the concurrent presence of both aspects). An identical molecular screening protocol with denaturing high-performance liquid chromatography and multiplex ligation-dependent probe amplification was performed in both institutions.

RESULTS

In our cohort of patients, variables such as female sex (odds ratio = 1.840; 95% confidence interval, 1.223 to 2.766), fewer than five skeletal sites with exostoses (odds ratio = 7.588; 95% confidence interval, 3.479 to 16.553), EXT2 mutations (odds ratio = 2.652; 95% confidence interval, 1.665 to 4.223), and absence of EXT1/2 mutations (odds ratio = 1.975; 95% confidence interval, 1.051 to 3.713) described patients with a mild phenotype; in contrast, a severe phenotype was associated with male sex (odds ratio = 2.431; 95% confidence interval, 1.544 to 3.826), EXT1 mutations (odds ratio = 6.817; 95% confidence interval, 1.003 to 46.348), and more than twenty affected skeletal sites (odds ratio = 2.413; 95% confidence interval, 1.144 to 5.091). Malignant transformation was observed in 5% of patients, and no evidence of association between chondrosarcoma onset and EXT mutation, sex, severity of disease, or number of lesions was detected.

CONCLUSIONS

The identified "protective" and "risk" factors, as well as the proposed classification system, represent helpful tools for clinical management and follow-up of patients with multiple hereditary exostoses; moreover, homogeneous cohorts of patients, useful for studies on the pathogenesis of multiple hereditary exostoses, have been identified.

Endothelin-1 and endothelin-3 stimulate insulin release by isolated rat pancreatic islets

Endothelins (ETs) are potent vasoconstrictive peptides released from the endothelium and other tissues, which act on target cells by receptorial calcium-mediated mechanisms. ET-1 levels are increased in diabetes, and observations suggest the involvement of ETs in the pathogenesis of diabetic angiopathy. However, it is not possible to exclude that ETs might also influence insulin secretion or function. In vivo infusion of ET-1 in rats induces hypoglycaemia and hyperinsulinemia and in vitro incubation with ET-1 stimulates insulin release by mouse islets. Therefore, ETs might be involved in a circulus vitiosus, resulting in hyperinsulinemia and diabetic angiopathy. The purpose of our study was to verify the effect of ET-1 on rat islets, in both the presence and absence of physiological glucose concentration. Moreover, we tested the effect of another isoform of endothelins, ET-3, and verified the involvement of extracellular calcium in such events. Islets were incubated with increasing ET-1 or ET-3, with or without glucose 5.6 mM. Other samples were prepared using calcium-free medium. Incubation in medium containing ET-1 and ET-3, in the presence of glucose and calcium, induced an increase in insulin release. When ET-1 and ET-3 were incubated without glucose and calcium, insulin release was not modified. Our studies demonstrate that: 1) ET-3, like ET-1, stimulates insulin release by rat isolated islets; 2) direct insulin stimulating effect on islets of both ET-1 and ET-3 is evident with physiological glucose concentrations and is calcium mediated. These results support the hypothesis of ET involvement in the regulation of insulin secretion.

Transesophageal echocardiographic evaluation of the morphologic and hemodynamic cardiac changes during ventricular fibrillation

To analyze cardiac motion during ventricular fibrillation (VF), we used transesophageal echocardiography to study nine male subjects, aged 44 +/- 7 years, affected by heart disease who have poor left ventricular function, during implantation of an Implantable Cardioverter Defibrillator, when VF is induced several times to determine the defibrillation threshold. Wall and valvular motion, transmitral and transaortic blood flow, and blood echoreflectivity were evaluated in all patients. Moreover, in basal conditions, during VF, 1 and 5 minutes after restoration of basal rhythm, we calculated the left ventricular end-diastolic volume (EDLVV) and area (EDLVA), the left ventricular end-systolic volume and area, the ejection fraction, and the fractional area change with a four-chamber echocardiographic view. At the onset of VF, the myocardium and valves exhibited a chaotic motion. About 10 seconds later the oscillatory movement of the heart walls became more ample and regular; the mitral valve showed a cyclic closure and opening with a forward flow, and the aortic valve exhibited similar behavior, although at a lower intensity. A spontaneous echo contrast appeared inside the atrial and ventricular cavities, gradually becoming an incrt homogeneous mass that was completely flushed away with the restoration of the basal rhythm. When VF started, EDLVV (286 +/- 98 ml) and EDLVA (50 +/- 16.5 cm2) decreased abruptly (EDLVV = 182 +/- 65 ml, p < 0.02; EDLVA = 38 +/- 9.2 cm2,p < 0.05); so did ejection fraction (31.8% +/- 15% versus 11% +/- 5%; p < 0.003) and fractional area change (25.8% +/- 6.5% versus 7% +/- 3.4%; p < 0.001). When the basal rhythm was restored, the heart extended again and EDLVV, EDLVA, ejection fraction, and fractional area change after 1 and 5 minutes were similar to those calculated before induction of VF. This behavior was observed during both the first and last induced VF. Thus during VF, great variations of heart morphology and dynamics, as well as blood echoreflectivity, occur; the heart seems to make attempts to organize its dynamics during the arrhythmia. Repeated episodes of VF and defibrillation with low energies do not seem to worsen left ventricular dynamics even in impaired hearts.

[Effects of nifedipine in patients with chronic obstructive bronchitis and pulmonary hypertension undergoing artificial respiration]

During an acute decompensation of chronic obstructive pulmonary disease (COPD) associated with pulmonary arterial hypertension (PAHP), the right cardiac ventricle is unable to tolerate the increased workload required to overcome the increase in pulmonary arterial pressure (Ppa). As a result, the cardiac (CI) and systolic (SI) indices decrease much more than in those patients without PAHP. This study aimed to evaluate the effects of nifedipine on haemodynamic parameters and oxygen availability (QO2) when given to mechanically ventilated COPD patients with PAHP during an acute decompensation. The series included 14 patients aged 68 +/- 8 yr, admitted to an intensive care ward for an acute decompensation of COPD, with Ppa greater than 20 mmHg. They remained haemodynamically stable throughout the study period. The measurements were made 20 min after the Swan-Ganz and radial artery catheters were set up (t0), and one hour after administration of 10 mg sublingual nifedipine (t1). Thereafter this agent was given three times a day. A further set of measurements were carried out in seven patients, 24 h after the first dose of nifedipine (t2). At t1, there was a significant increase in CI (+12.3%) and QO2 (+14.1%), whereas Ppa, indexed pulmonary vascular resistances, indexed systemic vascular resistances (SVRI) and PaO2 decreased significantly (-9.2%; -20%; -12.8% and -6.4% respectively). At t2, QO2 was significantly higher (+18.4%), whereas Ppa and SVRI were significantly lower, than at t0. PaO2 and the shunt fraction (Qs/Qt) returned to basal values, with a significant decrease in Qs/Qt when compared with t1.(ABSTRACT TRUNCATED AT 250 WORDS)

[Case report of a stage IV S neuroblastoma regressing without any aggressive treatment]

The authors describe a case of stage IV-S neuroblastoma in a boy forty days old with impressive enlargement of the liver whose left lobe was initially mistaken for splenomegaly. Regression was obtained without active treatment. Factors affecting the prognosis and treatment are briefly discussed. Is reported the association with persistent elevation of serum acid phosphatase.

[Acute and chronic cardiac decompensation: is vasodilator therapy useful?]

Systemic vasodilators represent a new approach in the treatment of the acute and chronic heart failure, as they reduce the afterload acting on the aortic impedance and/or the venous return to the heart. Vasodilators have been classified as venodilators (nitrates), which reduce left ventricular filling pressure and relieve pulmonary congestion; arteriolar dilators (hydralazine, phentolamine) which enhance cardiac output; and balanced vasodilator (nitroprusside, prazosin), which dilate both resistance and capacitance vessels. While nitroprusside and phentolamine are used in the treatment of the acute myocardial infarction, nitrates, hydralazine and prazosin are used in the long term treatment of the chronic congestive heart failure. Presumably, the renin-angiotensin system plays an important role in increasing peripheric vascular resistance in congestive heart failure. For this reason the inhibitors of the angiotensin-converting enzyme, such as captopril and teprotide, are also used. The treatment with vasodilators, recommended to patients with severe heart failure, is not an alternative to that with digitalis and diuretics: such a combination may in fact result as a very useful one.