Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

New onset left bundle branch block after transcatheter aortic valve implantation and the effect on long-term survival – a UK wide experience

Introduction

New onset left bundle branch block (LBBB) is the most common conduction disturbance associated with transcatheter aortic valve implantation (TAVI). It has been shown to adversely affect cardiac function and increase re-hospitalisation, although its impact on mortality remains contentious.

Methods

We conducted an observational cohort analysis of all TAVI procedures performed by 13 heart teams in the United Kingdom from inception of their structural programmes until 31st July 2013. The primary outcome was 1-year all-cause mortality. Secondary outcomes included left ventricular ejection fraction (LVEF) at 30 days and need for a post-TAVI permanent pacemaker (PPM).

Results

1785 patients were eligible for inclusion to the study. The primary analysis cohort was composed of 1409 patients with complete electrocardiographic (ECG) data pre- and post-TAVI. Pre-existing LBBB was present in 200 (14.2%) patients. New LBBB occurred in 323 (22.9%) patients post TAVI, which resolved in 99 (7%) patients prior to discharge. A balloon-expandable device was implanted in 968 (69%) patients, whilst 421 (30%) patients received a self-expandable valve. New LBBB was observed in 120 (12.4%) and 192 (45.6%) patients receiving a balloon- or self-expandable prosthesis respectively.

Overall 1-year all-cause mortality post TAVI was 18.7%. New onset LBBB was not associated with an increase in 1-year all-cause mortality (p=0.416). Factors that were associated with mortality included an increasing logistic EuroScore (p=0.05), history of previous balloon aortic valvuloplasty (p=0.001), renal impairment (p=0.003), previous myocardial infarction with pre-existing LBBB (p=0.028) and atrial fibrillation (p=0.039). Lower baseline peak and mean AV gradients were also associated with greater mortality at 1 year (p=0.001), likely reflecting underlying left ventricular dysfunction.

In the majority of patients, LVEF remained unchanged following TAVI. Interestingly, the presence or absence of new onset LBBB did not affect LVEF improvement at 30 days. 10% of patients required a PPM post TAVI. Predictors of PPM included new LBBB (OR 2.6, p<0.001), pre-TAVI left ventricular systolic impairment (OR 1.2, p=0.037), a self-expandable device (p<0.001), and pre-existing RBBB (OR 4.0, p<0.001).

Conclusions

These findings suggest that new onset LBBB post TAVI does not increase mortality at 1 year or adversely affect LVEF at 30 days.

Funding Acknowledgement

Type of funding source: None

278Clinical outcomes of state-of-the-art percutaneous coronary revascularization in patients with three-vessel disease: 3-year follow-up of the SYNTAX II study

Background

The clinical implication of state-of-art PCI at long term follow-up in patients with three vessel disease is undetermined.

Purpose

The purpose of the study was to investigate whether the favourable outcomes of state-of-the-art PCI in the SYNTAX-II trial, demonstrated up to 2 years, are maintained at 3-year follow-up.

Methods

The SYNTAX-II study was a multicentre, single arm study that investigated the impact of a state-of-art PCI strategy on clinical outcomes in patients with de novo three vessel coronary artery disease, without left main disease. State-of-art PCI includes: heart team decision-making utilizing the SYNTAX score II, hybrid iFR-FFR decision-making strategy, intravascular ultrasound guided stent implantation, contemporary chronic total occlusion revascularization techniques and guideline-directed medical therapy. The primary endpoint is major adverse cardiac and cerebrovascular events (MACCE – a composite of all-cause death, any stroke, myocardial infarction, or revascularization) at 3 years. Clinical outcomes in SYNTAX-II were compared to the predefined PCI (SYNTAX-I PCI) and coronary artery bypass graft (SYNTAX-I CABG) cohorts from the landmark SYNTAX Trial (SYNTAX-I), selected on the basis of equipoise for long-term (4-year) mortality utilising the SYNTAX Score II.

Results

Between February 2014 and November 2015, 454 patients out of 708 screened patients were enrolled in SYNTAX-II. In SYNTAX-I, 643 (58.8%) patients with 3VD without left main disease had an equipoise recommendation for CABG or PCI based on the SYNTAX Score II and were used as the comparator. At 2 years, MACCE rate in SYNTAX-II was significantly lower compared to SYNTAX-I PCI (13.2% vs. 21.9%, p=0.001). Furthermore, similar two-year outcomes for MACCE were evident between SYNTAX II-PCI and SYNTAX-I CABG (13.2 vs. 15.1%, p=0.42). Three-year results will be presented at ESC2019.

Conclusions

Three-year results of his study may offer an attractive option of revascularization strategy in predefined patients with de novo 3VD (SYNTAX Score II inclusion) even if the patients have moderate to severe anatomical complexity (anatomic SYNTAX score >22).

Acknowledgement/Funding

European Cardiovascular Research Institute (ECRI) with unrestricted research grants from Volcano and Boston Scientific

The impact of continuous haemofiltration with high-volume fluid exchange during cardiopulmonary bypass surgery on the recovery of patients with impaired renal function: a pilot randomised trial

BACKGROUND

There is widespread variability in clinical practice within cardiac surgery units worldwide on the use of haemofiltration. The clinical impact and safety of this modality is, however, unknown.

OBJECTIVES

The primary pilot trial objectives were as follows: to assess the feasibility of randomising 60 patients with impaired kidney function undergoing on-pump coronary artery bypass graft (CABG) surgery within 6 months; to assess the suitability and reliability of our chosen outcome measures; to explore issues that may impact on recruitment into a definitive trial; and to undertake an exploratory economic evaluation.

DESIGN

A pilot, single-centre, open-label randomised trial.

SETTING

Liverpool Heart and Chest Hospital NHS Foundation Trust between November 2010 and March 2012.

PARTICIPANTS

Men and women, aged > 18 years of age, undergoing on-pump CABG surgery, who had pre-operative impaired kidney function indicated by an estimated glomerular filtration rate (eGFR) of < 60 ml/minute adjusted for 1.73 m(2) of body surface area.

INTERVENTIONS

Group 1: patients who received haemofiltration during bypass (experimental group). Group 2: patients who did not receive haemofiltration during bypass (control group).

MAIN OUTCOME MEASURES

(1) Feasibility outcome measures: barriers to recruitment to a larger trial were documented as observations made during the recruitment period of the trial. Reliability of data collection methods was monitored using a 13-point case record form validation check for data entry against the patient clinical notes and the trial database. (2) The main clinical outcomes were frequency of intensive care unit (ICU) stay of duration > 3 days and the length of ICU stay days. (3) Other clinical outcomes were the need for postoperative haemofiltration in the ICU, mechanical ventilation time, hospital stay, composite of outcome of unfavourable perioperative events and eGFR values at 6 weeks' follow-up. (4) Secondary health economic feasibility outcomes.

RESULTS

Recruitment into the pilot trial was from 21 November 2010 to 30 March 2012. Thirty-seven eligible patients were consented and successfully randomised into the trial arms (30%). The main issues impacting on recruitment were the high volume of off-pump CABG surgery within the centre; recruitment being restricted to research nurses' working hours of the week; issues arising associated with the screening process for identifying prospective eligible patients based on eGFR values; protocol deviations/treatment crossovers; and unexpected outbreaks of pandemic influenza and other infectious conditions. The data collection process was sufficiently robust, with few errors detected. The length of ICU stay days was deemed a suitable primary outcome. There was an overall trend towards reduction in the length of ICU stay for patients who were given intraoperative haemofiltration, more so for those with diabetes. The economic evaluation estimated that the incremental costs per person were £1744 lower for the intraoperative haemofiltration group, while the incremental benefits per person increased by 0.11.

CONCLUSION

Given sufficient resources and broadening of the inclusion criteria, the recruitment into a larger multicentre trial is feasible and may demonstrate potential clinical and cost benefits of using intraoperative haemofiltration in this group of patients. However, owing to the small sample size in this pilot trial, no firm conclusions can be drawn from the findings at this stage. The outcomes of this pilot study are very encouraging and suggest that it is feasible to design a continuous superiority trial with the length of ICU stay days or time to tracheal extubation as the primary outcome measure, provided that guidelines for avoiding bias are implemented. An alternative primary outcome measure that avoids bias is mortality. The inclusion criteria should also be widened to include all cardiac surgery patients with impaired renal function.

TRIAL REGISTRATION

ISRCTN49513454.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 49. See the HTA programme website for further project information.

A pilot randomised controlled trial in intensive care patients comparing 7 days' treatment with empirical antibiotics with 2 days' treatment for hospital-acquired infection of unknown origin

BACKGROUND

Management of cardiac intensive care unit (ICU) sepsis is complicated by the high incidence of systemic inflammatory response syndrome, which mimics sepsis but without an infective cause. This pilot randomised trial investigated whether or not, in the ICU, 48 hours of broad-spectrum antibiotic treatment was adequate to safely treat suspected sepsis of unknown and unproven origin and also the predictive power of newer biomarkers of sepsis.

OBJECTIVE

The main objective of this pilot study was to provide preliminary data on the likely safety and efficacy of a reduced course of antibiotics for the treatment of ICU infections of unknown origin.

DESIGN

A pilot, single-centre, open-label randomised trial.

SETTING

This study was carried out in the ICU of a tertiary heart and chest hospital.

PARTICIPANTS

Patients being treated within the ICU were recruited into the trial if the intensivist was planning to commence antibiotics because of evidence of systemic inflammatory response syndrome and a strong suspicion of infection but there was no actual known source for that infection.

INTERVENTIONS

Broad-spectrum antibiotic treatment administered for 48 hours (experimental) compared with treatment for 7 days (control).

MAIN OUTCOME MEASURES

The primary outcome was a composite outcome of the rate of death or initiation of antibiotic therapy after the completion of the treatment schedule allocated at randomisation. Secondary outcomes included the duration of mechanical ventilation and ICU and hospital stay; the incidence of infection with Clostridium difficile (B. S. Weeks & E. Alcamo) Jones & Bartlett International Publishers, 2008, or methicillin-resistant Staphylococcus aureus (MRSA) (B. S. Weeks & E. Alcamo) Jones & Bartlett International Publishers, 2008; resource utilisation and costs associated with each of the two pilot arms; the ratio of patients screened to patients eligible to patients randomised; the incidence of crossover between groups; and the significance of newer biomarkers for sepsis for predicting patients' need for further antibiotics.

RESULTS

A total of 46 patients were recruited into the trial, with 23 randomised to each group. There was no significant difference between the two groups in terms of the composite primary outcome measure. The risk difference was 0.12 [95% confidence interval (CI) 0.11 to 0.13; p = 0.3]. In the 2-day group, four patients (17.4%) required further antibiotics compared with three (13%) in the 7-day group. Four patients died within the trial period and the deaths were not trial related. Patients who died during the trial period received no additional antibiotics in excess of their trial allocation. There were no documented incidences of MRSA or C. difficile infection in either group. No significant differences in adverse events were observed between the groups. Key economic findings were mean antibiotic costs per patient of £168.97 for the 2-day group and £375.86 for the 7-day group. The potential per annum cost saving for the ICU of 2-day treatment was estimated to range from £108,140 to £126,060. Patient screening was considered the biggest barrier to recruitment. There was no crossover between the two randomised groups. Data verification ascertained > 98% accuracy in data collection. Baseline procalcitonin was found to be predictive of the composite outcome (death and needing further antibiotics) (odds ratio 1.79, 95% CI 1.20 to 2.67; p = 0.005). Analysis of baseline procalcitonin also indicated a trend towards it being a predictor of restarting antibiotics, with an odds ratio of 1.45 (95% CI 1.04 to 2.02; p = 0.01).

CONCLUSIONS

Data from this pilot study suggest that there could be significant benefits of reducing broad-spectrum antibiotic use in the ICU without it undermining patient safety, with a potential cost saving in our unit of over £100,000 per year. Evidence from this pilot trial is not definitive but warrants further investigation using a large randomised controlled trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN82694288.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 36. See the HTA programme website for further project information.

Issues in online patient self-reporting of health status

Patient self-reporting of symptoms and quality of life following surgical interventions is generally delivered in the form of paper-based questionnaires to be completed in the outpatient clinic or at home. A commonly used tool for patient self-reporting of quality of life is the EQ5D health status questionnaire which, while limited in scope, has general applicability across a range of health interventions. In this article we examine the issues relating to online patient self-reporting using this questionnaire and the wider implications for the online reporting of health status.

Femoral haemostasis after transcatheter therapeutic intervention: a prospective randomised study of the angio-seal device vs. the femostop device

BACKGROUND

A number of haemostatic devices are available to facilitate early haemostasis following transfemoral interventional procedures.

METHODS AND RESULTS

We have prospectively compared 150 patients (age: 57+/-12 years, mean+/-S.D.) who were randomly assigned to either external compression using the FemoStop device or direct closure of the arterial puncture using the Angio-Seal device. The Angio-Seal was deployed in the catheter laboratory after the conclusion of the procedure. Patients, randomised to FemoStop, had their sheath removed when the activated clotting time (ACT) was less than 100 s before applying the device. The primary endpoint was the composite of bleeding, haematoma formation, bruise, requirement for blood transfusion, clinical indication for ultrasound examination at 2 h and 24 h following the procedure and crossover to either method at 2 and 24 h after the device deployment. The 95% of the Angio-Seal and 96% of FemoStop patients were discharged on the day following the procedure. An increased number of patients in the Angio-Seal group reached a clinical end-point within the first 2 h (45% vs. 3%, P<0.0001). This difference became insignificant at 24 h (25% vs. 30%, P=0.6).

CONCLUSION

Although less comfortable, the overall efficacy of the FemoStop appeared to be higher than that of the Angio-Seal device.

Non-elective intra-coronary stenting: are the clinical outcomes comparable to elective stenting at 6 months?

The aim of this study was to compare prospectively the clinical outcome of patients treated with intra-coronary stents as a non-elective/bailout procedure for acute or threatened vessel closure, with those undergoing elective stenting at 6 months. Sixty-four patients (60.2+/-11.7 y) who underwent non-elective stenting for abrupt or threatened vessel closure and/or sub-optimal results were prospectively compared with 68 patients (62+/-10.0 y) who were stented electively. All patients had broadly similar pre-procedural clinical profiles. However, patients in the elective group had a higher incidence of previous PTCA (10.2% vs. 0%, P = 0.01) and bypass surgery (30.9% vs. 6.3%, P = 0.0003) compared with the non-elective group. A total of 158 stents (1.19 per patient) were implanted in 132 patients with a procedural success rate of 99.3%. At 6 months follow-up there was no statistical difference in the primary composite end-point of death, myocardial infarction and the need of repeat revascularisation (10.9% vs. 5.8%, P = 0.35) between the two groups. However, patients in the non-elective group showed a higher incidence of unstable angina compared with the elective group (25% vs. 1.4%, P = 0.0004). The findings of this study suggest that stents (single or multiple) can be effectively implanted in non-elective situations with no increase in the incidence of death, non-fatal myocardial infarction, and the need of repeat revascularisation at 6 months compared with elective stenting.

Emergency coronary artery stenting for coronary dissection complicating diagnostic cardiac catheterisation

Dissection of a coronary artery is a recognised and significant complication of diagnostic coronary angiography that often requires emergency coronary artery bypass grafting. A coronary stent was used to treat this complication. This technique has potential advantages in terms of speed of reperfusion and availability in centres performing diagnostic angiography without surgical cover on site.

Gastric anti-secretory, mucosal protective, anti-pepsin and anti-Helicobacter properties of ranitidine bismuth citrate

Ranitidine bismuth citrate is a novel compound formed from ranitidine and a bismuth citrate complex. In conscious dogs, ranitidine bismuth citrate had similar activity to ranitidine hydrochloride as an inhibitor of histamine-induced gastric acid secretion when oral doses containing equivalent amounts of ranitidine base (0.1 or 0.3 mg/kg) were compared. In the rat, ranitidine bismuth citrate (3-30 mg/kg p.o.) prevented gastric mucosal damage induced by ethanol (fundic damage) and indomethacin (antral damage). Ranitidine hydrochloride and tripotassium dicitrato bismuthate were also effective against indomethacin-induced damage, but were both significantly less potent than ranitidine bismuth citrate in this model. Ranitidine hydrochloride was inactive against ethanol-induced damage. In vitro, ranitidine bismuth citrate (1 mmol/L) inhibited human pepsin isoenzymes 1, 2, 3 and 5. Pepsin 1 was inhibited to a similar extent by ranitidine bismuth citrate, bismuth citrate and tripotassium dicitrato bismuthate at concentrations equivalent to 1 mmol/L bismuth, but ranitidine (1 mmol/L) was inactive. Ranitidine bismuth citrate was more potent than tripotassium dicitrato bismuthate as an inhibitor of pepsins 2, 3 and 5. Ranitidine bismuth citrate inhibited both Helicobacter pylori (effective concentration 4-32 micrograms bismuth/ml) and H. mustelae (1-4 micrograms bismuth/ml); similar results were obtained with tripotassium dicitrato bismuthate. Bismuth citrate was slightly less effective, and ranitidine hydrochloride was inactive (> 125 micrograms/ml). In ferrets naturally colonized with H. mustelae, oral treatment with ranitidine bismuth citrate, 12 or 24 mg/kg twice daily for 4 weeks, caused a dose related clearance of H. mustelae. Qualitatively similar results were obtained in a small study with tripotassium dicitrato bismuthate and bismuth citrate.

Transmucosal electrical resistance in rabbit isolated gastric mucosa during exposure to acid

1. Transmucosal electrical resistance (Rt) and short-circuit current (Isc) were determined in rabbit isolated fundic mucosa. Under basal conditions, with a HCO(3-)-free HEPES-buffered solution (pH 7.4) bathing both sides of the mucosae, Rt was 161.5 + 5.0 omega cm2 and Isc 41.8 +/- 1.8 microA cm-2, and these values were not significantly different to values observed in HCO(3-)-buffered Krebs-Hensleit solution. 2. The basal Isc was inhibited by the Cl- channel blocker diphenylamine-2-carboxylate, and ouabain, but unaffected by the Na+ channel blocker amiloride (10(-5) M), consistent with electrogenic chloride secretion dependent upon a sodium gradient. Prostaglandin E2 (10(-7) M) stimulated an increase in Isc which was susceptible to inhibition by diphenylamine-2-carboxylate, but not amiloride, again consistent with Cl- secretion. 3. Stepwise acidification of the mucosal solution to pH 2.8 resulted in an increase in Rt of 43%, as compared with that measured with mucosal pH 7.4. Isc did not change during the acidification to pH 2.8, indicating retention of tissue viability. Increased Rt while Isc remained constant is consistent with an acid-induced decrease in the shunt (paracellular) conductance in this Cl(-)-secreting tissue. At pH less than 2.8, Rt declined rapidly and Isc declined and reversed, consistent with H+ back-diffusion. Scanning electron microscopic investigation of tissue exposed to mucosal pH 2.8 revealed little difference from control (pH 7.4) tissue, but there was considerable evidence of cellular damage and membrane disruption in tissue exposed to pH 1.8. 4. Acidification of the serosal solution did not increase Rt, which was maintained until pH 3.7, and then rapidly declined at pH less than 3.7. Bilateral acidification produced a mixed response; Rt increased, as for mucosal acidification, down to pH 2.8, after which there was a rapid decline in Rt following the pattern observed for serosal acidification. 5. Compared at a mucosal pH approximately 2.8, DIDS (4 x 10(-4) M) and amiloride (10(-3) M) inhibited the acid-induced increase in Rt, suggesting a role for both Cl(-)-HCO3- and Na(+)-H+ exchange in the response. In contrast, the acid-induced increase in Rt was unaffected by a lower concentration of amiloride (10(-5) M), acetazolamide and ouabain. Therefore, neither Na+ channels nor a Na+ gradient appear to be involved in the acid-induced increase in Rt.(ABSTRACT TRUNCATED AT 400 WORDS)

In vitro cultivation of Cryptosporidium parvum and screening for anticryptosporidial drugs

Sporozoites of Cryptosporidium parvum which were excysted in vitro from oocysts isolated from calves or patients with acquired immune deficiency syndrome underwent development in monolayers of the mouse fibroblast cell line L929. Asexual multiplication occurred, with the maximum numbers of parasites usually being observed between 24 and 48 h after infection. Gametocytes were also found, but their numbers were relatively small compared with those of the asexual stages. A study was made of the effect on parasite development of 20 antimicrobial agents, most of which were anticoccidial or antimalarial agents. The majority of the drugs had a limited inhibitory effect on parasite development, but usually only at high concentrations. The two most active drugs were monensin and halofuginone, which reduced parasite multiplication by more than 90% at high concentrations. In the case of monensin, however, inhibition of parasite development at higher concentrations was due, at least in part, to a toxic effect of the drug on the host cells.

Antiemetic properties of the 5HT3-receptor antagonist, GR38032F

GR38032F is a highly selective 5HT3-receptor antagonist which inhibits vomiting induced by cisplatin, cyclophosphamide or X-radiation in the ferret. Since cisplatin selectively increased the levels of 5HT and 5HIAA in the intestinal mucosa, a possible site of the antiemetic action of GR38032F may be on 5HT3-receptors on vagal afferents in the small intestine. The potent antiemetic action of GR38032F should be of clinical value in reducing the nausea and vomiting associated with radiotherapy or chemotherapy of cancer.

Thromboxane receptors can modulate gastric acid secretion in the rat

The effects of PGE2 and the thromboxane A2 mimetic, U-46619, have been investigated on gastric secretion in the rat isolated gastric mucosa. Both compounds produced concentration-related inhibitions of histamine-induced secretion whereas only U-46619 inhibited methacholine-stimulated and basal secretion, and neither compound had any effect on the secretory response to dbcAMP. Indomethacin had no effect on the antisecretory activity of PGE2 but markedly reduced the potency of U-46619 suggesting that endogenous prostaglandins play a role in the U-46619 responses. However, direct inhibitory effects of U-46619 were seen at high concentrations. The thromboxane receptor antagonist AH23848, at concentrations selective for thromboxane receptors, had no effect on responses to PGE2 but markedly inhibited the effects of U-46619. We conclude that the antisecretory profile of U-46619 differs from that of PGE2. U-46619 has both direct and indirect antisecretory effects and these are mediated via thromboxane receptors in the rat gastric mucosa.

The antisecretory profile of action of the H2-receptor antagonists, famotidine, loxtidine, ranitidine and L-643,441 on the rat isolated gastric mucosa

Four H2-receptor antagonists, famotidine, loxtidine, ranitidine and L-643,441 were tested against gastric secretory concentration-response curves to histamine, methacholine and dibutyryl cyclic AMP (dbcAMP) on the rat isolated gastric mucosa. All four drugs inhibited the secretory response to histamine, but the nature of this H2-receptor antagonism differed according to the drug. Ranitidine and famotidine were competitive, fully surmountable antagonists of histamine, but loxtidine and L-643,441 were unsurmountable antagonists. At high concentrations, the H2-receptor antagonists caused a small inhibition of the secretory response to methacholine but had no effect on the secretory response to dbcAMP. The rat isolated gastric mucosa is a useful preparation for characterisation of the antisecretory effects of H2-receptor antagonists.

Effects of indomethacin, piroxicam and selected prostanoids on gastric acid secretion by the rat isolated gastric mucosa

The effects of the cyclo-oxygenase inhibitors indomethacin and piroxicam have been investigated on histamine- and dibutyryl cyclic AMP-induced acid secretion in the rat isolated gastric mucosa. The relative potencies of a number of prostanoids as inhibitors of histamine-induced acid secretion were determined in an attempt to classify the prostaglandin receptor mediating this response. Indomethacin (8 X 10(-9) - 2.7 X 10(-6) M) and piroxicam (3 X 10(-6) M) potentiated the secretory responses elicited by histamine. This effect might be due to inhibition of the biosynthesis of antisecretory prostanoids. Indomethacin (2.7 X 10(-6) M) and piroxicam (3 X 10(-6) M) also potentiated the secretory response to dibutyryl cyclic AMP, but since prostaglandin E2 (PGE2, 10(-5) M) did not inhibit this secretory response, the mechanism of the potentiation may differ from that of histamine. The potency of the thromboxane mimetic U-46619 as an inhibitor of histamine-induced acid secretion was markedly reduced in the presence of indomethacin, suggesting that U-46619 may release endogenous antisecretory prostanoids. In the presence of indomethacin (2.7 X 10(-6) M) all the prostanoids tested produced concentration-related inhibitions of histamine-induced gastric acid secretion. PGE-analogues were the most potent compounds, the rank order of potency being 16, 16 dimethyl PGE2 greater than PGE2 greater than PGF2 alpha greater than U-46619 greater than PGD2 greater than PGI2. This order of potency is very similar to that obtained in smooth muscle preparations containing 'EP' receptors, suggesting that this receptor type also mediates inhibition of histamine-induced acid secretion in the rat.

Pharmacological basis for the induction of gastric carcinoid tumours in the rat by loxtidine, an insurmountable histamine H2-receptor blocking drug

The very late occurrence of gastric carcinoids in a life-span carcinogenicity study with loxtidine in the rat might have resulted from continuous achlorhydria induced by this long-acting unsurmountable histamine H2-antagonist. The nature of the anti-secretory activity of loxtidine was compared with that of ranitidine on histamine-induced acid secretion in the perfused stomach preparation of the rat and in the rat isolated gastric mucosa preparation. Ranitidine and loxtidine had qualitatively different inhibitory effects on acid secretion, ranitidine being a competitive antagonist of histamine even at high concentrations, whereas the effect of loxtidine on both preparations was unsurmountable at relatively low concentrations. These results support the hypothesis that the late formation of gastric carcinoids in rats receiving loxtidine is a consequence of persistent achlorhydria caused by unsurmountable blockade of parietal cell H2-receptors.

Comparison of antisecretory potency and duration of action of the H2-receptor antagonists AH 22216, cimetidine, ranitidine and SK & F 93479 in the dog

The antisecretory potency and duration of action of the new histamine H2-receptor antagonist AH 22216 have been compared with those of cimetidine, ranitidine and SK & F 93479 against histamine-induced gastric acid secretion in the conscious Heidenhain pouch dog. Ranitidine was 4-6 times more potent than cimetidine, with a similar duration of action. SK & F 93479 was approximately twice as potent as ranitidine and had a slightly longer duration of action. AH 22216 was most potent of the four H2-antagonists, some 20-30 times more active than cimetidine, and had an extremely prolonged duration of action.

Effects of H2-receptor antagonists and anticholinoceptor drugs on gastric and salivary secretion induced by bethanechol in the anaesthetized dog

1 The H2-receptor antagonists, ranitidine and cimetidine, have been compared with atropine and pirenzepine for their effects on gastric acid output, and on salivary secretion from the left parotid gland in the anaesthetized dog. Gastric and salivary secretions were elicited by intravenous infusion of bethanechol. 2 Atropine (0.3-1 microgram/kg) or pirenzepine (3-10 micrograms/kg) reduced both gastric and salivary secretions, pirenzepine showing little evidence of any selectivity for gastric secretion. 3 The H2-receptor antagonists, ranitidine (30-1000 micrograms/kg) and cimetidine (100-3000 micrograms/kg), selectively inhibited gastric secretion and even at relatively high dose levels did not alter salivary volume.

Pharmacological interactions between ranitidine, cimetidine, metiamide and tiotidine at histamine H2-receptor sites in guinea-pig atria

Cumulative concentration-response curves to histamine or dimaprit were constructed on guinea-pig isolated right atria and agonist dose-ratios were determined following addition of ranitidine, cimetidine, metiamide or tiotidine alone or a combination of any two of these H2-receptor blocking drugs. The observed histamine or dimaprit dose-ratios for combinations of any two of the H2-antagonists tested were consistent with results predicted from the equation, DR1+2 = DR1 + DR2 - 1, for two antagonists competing for the same receptor sites. Therefore we conclude that all four H2-antagonists compete for the same histamine H2-receptor.

Relationship between lesion formation and permeability of rat gastric mucosa to H+ and other cations

The relationship between lesion formation and ionic permeability has been investigated in rat gastric mucosa in vivo. Changes in these parameters were measured in the mucosa treated topically with prostaglandins E2 and A2 and/or aspirin. Particular attention was paid to the net flux of H+ ions across the gastric mucosa. The effect of aspirin concentrations of 5 mM, 20 mM and '40 mM' (the latter, a suspension in a saturated solution) was investigated. Aspirin concentrations of 20 mM and '40 mM' produced a marked increase in lesion formation and increased the net mucosal to serosal flux of H+ ions. Aspirin 5 mM produced a significant increase in lesion formation but did not cause a significant change in net H+ ion flux. This result suggests that aspirin can have a direct irritant effect on the gastric mucosa and that the back diffusion of H+ ions is not a pre-requisite for the development of overt mucosal ulceration. The effect of topically applied prostaglandin E2 (PGE2) on aspirin-induced gastric mucosal damage was investigated. Concentrations of PGE2 of 10(-5) M and 10(-4) M ameliorated aspirin-induced damage, but these changes were not necessarily accompanied by a significant reduction in net H+ ion flux. Again, this result is not consistent with a direct relationship between lesion formation and mucosal permeability to H+ ions. Since PGA2 did not ameliorate aspirin-induced mucosal damage, the protective effect of PGE2 could not be attributed to its conversion to PGA2 in the acidic environment of the gastric lumen. 5 Changes in gastric mucosal potential difference (p.d.) and net fluxes of Na+ and K+ ions may occur without a concomitant change in the permeability of the gastric mucosa to acid back-diffusion. Thus, the assumption cannot be made that a change in the permeability of the gastric mucosa to one particular ion reflects a general increase in ionic permeability.

The effect of ranitidine on gastric acid secretory response curves to histamine, pentagastrin or bethanechol in the dog with a Heidenhain pouch

The H2-receptor antagonists ranitidine and cimetidine were tested against gastric secretory dose-response curves to histamine, pentagastrin and bethanechol in the Heidenhain-pouch dog. Histamine-induced gastric secretion was antagonized in a competitive manner by both ranitidine and cimetidine, but ranitidine was approximately 8 times more potent than cimetidine. Pentagastrin -induced secretion was markedly reduced by ranitidine and cimetidine but this antagonism was not competitive in nature. Bethanechol-induced gastric secretion was slightly reduced by both drugs. These findings are discussed in relation to the physiological control of gastric secretion.

H2-receptor antagonists protect against aspirin-induced gastric lesions in the rat

Gastric mucosal lesions were produced in rats by dosing orally with aspirin, 300 mg/kg. Predosing orally with either ranitidine or cimetidine inhibited this lesion formation; the respective ED50 values were 0.8 and 3.9 mg/kg p.o. Oral ranitidine also inhibited lesion formation in the presence of exogenous 160 mM HCl, with an ED50 value of 23.2 mg/kg p.o. Subcutaneous injection of ranitidine inhibited the formation of aspirin-induced lesions both in the presence and in the absence of excess HCl. The ED50 values were respectively 3.4 and 0.9 mg/kg s.c. Mepyramine maleate (5 mg/kg p.o.) alone had no effect on gastric lesion formation, and did not influence the level of inhibition produced by ranitidine either in the absence of presence of exogenous acid.

Antagonism of vasodepressor and gastric secretory responses to histamine by the H2-receptor antagonists, ranitidine and cimetidine, in the anaesthetized dog

1 The new H2-receptor antagonist, ranitidine, has been compared with cimetidine as an inhibitor of gastric acid secretion in the anaesthetized dog. 2 Both ranitidine and cimetidine given intravenously inhibited histamine-induced gastric secretion in a dose-related manner. Ranitidine was 4.2 times more potent than cimetidine when given as an intravenous infusion and 9.6 times more potent as an intravenous bolus dose. 3 In a separate series of experiments, ranitidine was compared with cimetidine as an antagonist of vasodepressor responses to histamine. Mepyramine alone displaced the histamine dose-response curve to the right. After a maximally effective dose of mepyramine, further displacement could be achieved with ranitidine and cimetidine, ranitidine being 19.2 times more potent than cimetidine. 4 Ranitidine alone has no effect on vasodepressor response curves to histamine, acetylcholine or (-)-isoprenaline or on vasopressor response curves to phenylephrine. 5 These results indicate that displacement of the histamine dose-response curve after mepyramine blockade by ranitidine and cimetidine is due to selective H2-receptor antagonism.

Some in vitro and in vivo actions of the new histamine H2-receptor antagonist, ranitidine

1 Ranitidine has been investigated as an antagonist of the H2-receptor-mediated responses to histamine of guniea-pig atrium and rat uterus in vitro and as an inhibitor of gastric acid secretion in the rat. 2 Ranitidine competitively antagonized histamine-induced increases in contraction frequency of the guinea-pig isolated rat atrium. Ranitidine had a pA2 of 7.2 and was 7.9 and 4.5 times more potent than metiamide and cimetidine respectively. 3 Ranitidine competitively antagonized histamine-induced relaxations of the rat isolated uterine horn. Ranitidine had a pA2 of 6.95 and was 3.6 and 5.9 times more potent than metiamide and cimetidine respectively. 4 Ranitidine, even at high concentrations, did not affect responses of the guinea-pig isolated atrium or rat isolated uterus to (-)-isoprenaline. Similarly it was without effect on either histamine or bethanechol-induced contractions of guinea-pig isolated ileum. 5 Ranitidine inhibited histamine- and pentagastrin-induced gastric acid secretion in the perfused stomach preparation of the anaesthetized rat. Ranitidine was 5.2 and 7.0 times more potent on a molar basis than metiamide and cimetidine respectively, as an inhibitor of histamine-induced gastric acid secretion. 6 It is concluded that ranitidine is a potent, competitive and selective antagonist of histamine at H2-receptor sites and and effective inhibitor of gastric acid secretion in vivo.

Inhibition of gastric acid secretion in the dog by the H2-receptor antagonists, ranitidine, cimetidine, and metiamide

The new H2-receptor antagonist, ranitidine, has been compared with cimetidine and metiamide as an inhibitor of gastric acid secretion in the dog. All three compounds were effective both intravenously or by mouth in inhibiting secretion induced by histamine, pentagastrin, or bethanechol. This inhibition was mainly attributable to a reduction in the volume of secretion, although there was also a significant reduction in the concentration of acid secreted. Metiamide was slightly less active than cimetidine, but ranitidine was four to nine times more potent than cimetidine, depending on the secretagogue used. The antisecretory activity of ranitidine does not result from a limitation in blood flow to the gastric mucosa.

In vitro actions of ranitidine, a new histamine H2-receptor antagonist

Ranitidine has been tested on isolated guinea-pig right atrium and rat uterine horn, tissues known to possess histamine H2-receptors; and on isolated guinea-pig ileum a tissue containing histamine H1-receptors. These experiments have shown ranitidine to be a potent competitive antagonist of histamine at H2-receptor sites in vitro. This action is selective since high concentrations of ranitidine do not affect beta-adrenoceptor, histamine H1-receptor and muscarinic receptor mediated responses.

Inhibition of gastric acid secretion in the dog by the histamine H2-receptor antagonists ranitidine and cimetidine

The H2-receptor antagonists ranitidine and cimetidine inhibit gastric acid secretion elicited by a test meal in the dog. Ranitidine is approxiamtely 10 times more potent than cimetidine in this respect.

An improved apparatus for intragastric titration in the conscious dog

An apparatus for automatic intragastric titration with on-line display of results has been described. The apparatus has been validated by titration of exogenous acid injected into the test meal in a reservoir and in vivo by assessing the secretory response of a dog with a gastric fistula to a test meal. A titration display unit provides a record of the secretory response both as a digital printout and a bar chart display. Cimetidine (2 mg kg-1h-1) significantly reduced the secretory response to a test meal.

The role of beta1- and beta2-adrenoceptors in the inhibition of gastric acid secretion in the dog

1. Characterization of the beta-adrenoceptors mediating inhibition of gastric acid secretion in the conscious Heidenhain pouch dog has been investigated by determination of the effects of propranolol, (+)-propranolol, practolol and H35/25 on salbutamol and isoprenaline-induced inhibition of gastric acid secretion. 2. The gastric antisecretory effect of salbutamol was significantly blocked by propranolol and H35/25 but not by practolol or (+)-propranolol. The effect of isoprenaline was significantly blocked by propranolol and practolol but not by H35/25 or (+)-propranolol. 3. It is concluded that both beta1- and beta2-adrenoceptors can mediate inhibition of pentagastrin-induced gastric secretion in conscious dogs with a Heidenhain pouch. Salbutamol exerts its antisecretory effect through beta2-adrenoceptors, whereas isoprenaline mediates its effects primarily through beta1-adrenoceptors. 4. The results are discussed with regard to the sub-classification of beta-adrenoceptors and to the possible role of adrenoceptors in the physiological control of gastric secretion. 5. In this study it is concluded that the tachycardia induced by isoprenaline or salbutamol is mediated primarily through reflexes activated by beta2-adrenoceptor mediated vasodilatation.

The effect of (-)-isoprenaline and (+/-)-salbutamol on pepsinogen and acid secretion in the dog

1 The beta-adrenoceptor agonists, (-)-isoprenaline and (+/-)-salbutamol, reduced pepsinogen secretion induced by pentagastrin in conscious dogs with Heidenhaim pouches. 2 (-)-Isoprenaline and (+/-)-salbutamol also reduced gastric acid secretion while producing a moderate tachycardia.