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Angiotensin-Converting Enzyme Inhibitors, Angiotensin-II Receptor Antagonists, and Pneumonia in Elderly Hypertensive Patients With StrokeAngiotensin-Converting Enzyme Inhibitors, Angiotensin-II Receptor Antagonists, and Pneumonia in Elderly Hypertensive Patients With Stroke FREE TO VIEW

Tadashi Arai, MD, PhD; Yo Yasuda, MD, PhD; Tadatake Takaya, MD, PhD; Satoshi Toshima, CT, IAC; Yoshitomo Kashiki, MD, PhD; Maroki Shibayama, MD, PhD; Naoki Yoshimi, MD, PhD; Hisayoshi Fujiwara, MD, PhD
Author and Funding Information

Affiliations: Gihoku General Hospital Gifu College of Medical Technology Gifu University School of Medicine Gifu, Japan,  Tohoku University School of Medicine Sendai, Japan

Correspondence to: Tadashi Arai, MD, PhD, Department of Internal Medicine, Gihoku General Hospital, 1187–3 Takatomi-Cho Yamagata, Gifu 501 2105, Japan; e-mail: gihoku-arai@nifty.com



Chest. 2001;119(2):660-661. doi:10.1378/chest.119.2.660
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Published online

To the Editor:

Symptomless dysphagia and swallowing disorders play a very important role in the pathogenesis of aspiration pneumonia. Symptomless dysphagia is one of the main causes of pneumonia in elderly people with stroke, and either cough or swallowing reflexes can prevent aspiration pneumonia.

Pneumonia in the elderly is often caused by destruction of the defensive mechanisms such as cough and swallowing reflexes.1We have previously reported that in hypertensive patients with stroke, treatment with angiotensin-converting enzyme (ACE) inhibitors led to improvement in the symptomless dysphagia.2We also reported on the relation between ACE inhibitors and prevention of pneumonia in elderly people. The rate of pneumonia in the ACE inhibitors-treated group was significantly lower than that in the calcium-channel blockers-treated group.34 Moreover, we have also reported in CHEST (June 2000)5 about the relation between ACE inhibitors, angiotensin-II receptor antagonists (Ang II) and symptomless dysphagia. We investigated the prevention of symptomless dysphagia by treatment with various antihypertensive drugs in hypertensive patients with stroke. Our results suggested that ACE inhibitors have advantage over Ang II in prevention of symptomless dysphagia.

In the present study on elderly patients treated with ACE inhibitors only or Ang II only, we compared the prevention of new pneumonia in hypertensive patients with stroke. In 404 elderly hypertensive patients with stroke, we examined the inhibitory activity of ACE inhibitors against pneumonia. Two hundred nine of the 404 patients (98 men and 111 women) were given ACE inhibitors only, and the other 195 patients (97 men and 98 women) were given Ang II only. The BP of the patients in both groups was well controlled by the respective drugs. The incidence of pneumonia was compared between these two groups for 2 years, from January 1998 to May 2000. In the ACE inhibitors-treated group, 10 patients (4.4%) had new pneumonia. In the Ang II treated-group, on the other hand, 23 patients (11.2%) had new pneumonia. The incidence of pneumonia in the ACE inhibitors-treated group was significantly lower than that in the Ang II-treated group (p = 0.013 by theχ 2 test).

We concluded that ACE inhibitors have advantage over Ang II in prevention of pneumonia in elderly hypertensive patients with stroke.

Sekizawa, K, Ujiie, Y, Itabashi, S, et al (1990) Lack of cough reflex in aspiration pneumonia.Lancet335,1228-1229
 
Arai, T, Yasuda, Y, Takaya, T, et al ACE inhibitors and symptomless dysphagia.Lancet1998;352,115-116. [CrossRef] [PubMed]
 
Arai, T, Yasuda, Y, Takaya, T, et al ACE inhibitors and pneumonia in elderly people.Lancet1998;352,1937-1938
 
Arai, T, Yasuda, Y, Takaya, T, et al ACE inhibitors and reduction of the risk of pneumonia in elderly people.Am J Hypertens2000;13,1050-1051. [CrossRef] [PubMed]
 
Arai, T, Yasuda, Y, Takaya, T, et al Angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, and symptomless dysphagia [letter]Chest2000;117,1819-1820. [CrossRef] [PubMed]
 

Angiotensin-Converting Enzyme Inhibitors, Angiotensin-II Receptor Antagonists, and Pneumonia in Elderly Hypertensive Patients With Stroke

To the Editor:

We agree that angiotensin-converting enzyme (ACE) inhibitors lead to improving dysphagia in symptomless patients, as stated by Arai et al.1They reported that the administration of an ACE inhibitor could increase serum substance P and could improve symptomless dysphagia in patients with hypertension and previous stroke, but angiotensin-II receptor antagonists could not. We have reported a case of cough syncope associated with dysphagia, in which cough syncope was successfully treated with the ACE inhibitor.2 A 75-year-old man with cerebral infarction was suspected of having swallowing problems, because of coughing and choking with oral feeds. The patient developed choking and coughing while attempting to drink water. After treatment with an ACE inhibitor, cough syncope subsided, and the patient had no difficulty in swallowing water. ACE inhibitors inhibit not only activation of angiotensin-II, but also the degradation of substance P and bradykinin. We did not examine serum substance P concentration in the patient with syncope associated with dysphagia. However, the experiment by Arai et al1 clearly demonstrates the relation between serum substance P and symptomless dysphagia. Therefore, ACE inhibitors may improve the dysphagia in cough syncope patients as well as in symptomless patients, through the inhibition of substance P degradation.

Arai et al1 also report that the ACE inhibitors could have an advantage over angiotensin-II receptor antagonists in preventing pneumonia in elderly hypertensive patients with stroke. These findings are consistent with a previous report by Nakayama et al,3 that ACE inhibitors could upregulate impaired swallowing reflex and could reduce the risk of pneumonia by about one third, compared with results of other antihypertensive drugs used in the treatment of patients with hypertension and stroke.4 Therefore, ACE inhibitors may be more beneficial than other antihypertensive drugs, including angiotensin-II receptor antagonists, in preventing aspiration pneumonia in elderly patients with hypertension and stroke.

References
Arai, T, Yasuda, Y, Takaya, T, et al Angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonist, and symptomless dysphagia [letter]Chest2000;117,1819-1820. [CrossRef] [PubMed]
 
Ishizuka, S, Yanai, M, Yamaya, M, et al Cough syncope treated with imidapril in an elderly patients with dysphagia [letter]. Chest. 2000;;118 ,.:279. [CrossRef] [PubMed]
 
Nakayama, K, Sekizawa, K, Sasaki, H ACE inhibitors and swallowing reflex [letter]. Chest. 1998;;113 ,.:1425
 
Sekizawa, K, Matsui, T, Nakagawa, T, et al ACE inhibitors and pneuminia [letter]. Lancet. 1998;;352 ,.:1069
 

Figures

Tables

References

Sekizawa, K, Ujiie, Y, Itabashi, S, et al (1990) Lack of cough reflex in aspiration pneumonia.Lancet335,1228-1229
 
Arai, T, Yasuda, Y, Takaya, T, et al ACE inhibitors and symptomless dysphagia.Lancet1998;352,115-116. [CrossRef] [PubMed]
 
Arai, T, Yasuda, Y, Takaya, T, et al ACE inhibitors and pneumonia in elderly people.Lancet1998;352,1937-1938
 
Arai, T, Yasuda, Y, Takaya, T, et al ACE inhibitors and reduction of the risk of pneumonia in elderly people.Am J Hypertens2000;13,1050-1051. [CrossRef] [PubMed]
 
Arai, T, Yasuda, Y, Takaya, T, et al Angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, and symptomless dysphagia [letter]Chest2000;117,1819-1820. [CrossRef] [PubMed]
 
Arai, T, Yasuda, Y, Takaya, T, et al Angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonist, and symptomless dysphagia [letter]Chest2000;117,1819-1820. [CrossRef] [PubMed]
 
Ishizuka, S, Yanai, M, Yamaya, M, et al Cough syncope treated with imidapril in an elderly patients with dysphagia [letter]. Chest. 2000;;118 ,.:279. [CrossRef] [PubMed]
 
Nakayama, K, Sekizawa, K, Sasaki, H ACE inhibitors and swallowing reflex [letter]. Chest. 1998;;113 ,.:1425
 
Sekizawa, K, Matsui, T, Nakagawa, T, et al ACE inhibitors and pneuminia [letter]. Lancet. 1998;;352 ,.:1069
 
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