[Hyperhidrosis].

Plasma norepinephrine levels, which reflect sympathetic nervous system activity, are almost universally elevated in patients with left ventricular dysfunction. This elevation occurs in patients with overt, symptomatic heart failure (HF) and in patients with asymptomatic left ventricular dysfunction. Evidence suggests that the elevation in plasma norepinephrine levels can be at least partly attributed to an increase in sympathetic nervous system activity. It has become evident that elevated plasma norepinephrine levels are directly related to prognosis; patients with levels > 900 pg/ml have a poor prognosis and shortened life expectancy. However, plasma norepinephrine levels bear little relationship to physiologic and clinical variables observed in HF, including ejection fraction and exercise capacity. Data from the V-HeFT II show that at 2-year follow-up, a progressive rise of plasma norepinephrine was observed in both treatment arms, suggesting that disease progresses despite treatment with either an angiotensin-converting enzyme inhibitor, enalapril, or vasodilator therapy with hydralazine/isosorbide dinitrate. It is possible that interventions aimed at the progressive neurohormonal activation that occurs in HF may improve the course of illness. Further study is needed to test this hypothesis.

Enalapril↗

PubMed1994

Tolerability of enalapril initiation by patients with left ventricular dysfunction: results of the medication challenge phase of the Studies of Left Ventricular Dysfunction.

Although converting-enzyme inhibitors are useful for the treatment of congestive heart failure (CHF), there are concerns about adverse reactions especially on initiation of therapy. In the Studies of Left Ventricular Dysfunction, enalapril, 2.5 mg twice per day was given on an open-label outpatient basis for 7 days (mean 6.1, range 2 to 7, and median 7) as a prerandomization drug challenge to 7487 patients with left ventricular dysfunction (ejection fraction < or = 0.35). Four hundred forty-four (5.93%) patients reported side effects, including symptoms attributed to hypotension (in 166 patients [2.2%]). The majority (346 [77.9%] of 444 and 129 [77.7%] of 166 with symptoms attributed to hypotension) of patients who reported side effects were willing to participate in the study and to continue receiving enalapril. Thus only 98 (1.3%) of 7487 patients (0.5% because of symptoms attributed to hypotension) were not willing to continue because of side effects. Women and patients of CHF class III or IV were more likely to report side effects. In conclusion, enalapril is well tolerated by patients with left ventricular dysfunction; treatment can be initiated on an outpatient basis in the majority of patients.

Enalapril↗