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Continuing Education in Anaesthesia, Critical Care & Pain 2007 7(6):203-207; doi:10.1093/bjaceaccp/mkm039
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© The Board of Management and Trustees of the British Journal of Anaesthesia [2007]. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Phosphodiesterase inhibitors and the cardiovascular system

Rob Feneck, MB BS FESC FRCA
Department of Anaesthesia
St Thomas' Hospital
Lambeth Palace Road
London SE1 7 EH
UK
Tel: +44 207 928 9292 Fax: +44 207 633 0757 E-mail: rob_feneck@msn.com

Key Words: Drugs which inhibit the action of phosphodiesterase (PDE) promote a reduction in cAMP breakdown with a variety of tissue specific effects. • Increasing the concentration of cyclic 3,5 adenosine monophosphate and hence activation of protein kinase A in cardiac tissue may have a significant inotropic effect. • Drugs available in clinical practice for improving cardiac performance inhibit either phosphodiesterase isoenzyme III (milirinone) or IV (enoximone). • PDE inhibitors produce vasodilatation which may result in hypotension, particularly in the vasoconstricted or hypovolaemic patient. • PDE inhibitors have a useful role in the management of acute right ventricular failure.

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Phosphodiesterase is a ubiquitous enzyme that catalyses the hydrolysis of phosphodiester bonds. It is responsible for the hydrolysis of cyclic 3,5 adenosine monophosphate (cAMP) and 3,5 cyclic guanosine monophosphate (cGMP). Both cAMP, and to a lesser extent cGMP, have an important role in the regulation of inotropic mechanisms in the human myocardium. However, cAMP has numerous effects in other tissues, and different phosphodiesterase iso-enzymes are found in many other tissues (Table 1).


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  		Table 1 Caffeine, theophylline, and papaverine are examples of non-specific PDEI. Other PDE subtypes, their tissue origin and effective inhibitors are shown below

 
Drugs which inhibit the action of phosphodiesterase (thus reducing the breakdown of cAMP) have a therapeutic action on the heart, lung, and vasculature as well as on platelet function and inflammatory mechanisms. Many of these drugs affect more than one iso-enzyme, and many tissues have more than one iso-enzyme present. As a result, phosphodiesterase inhibitors (PDEI) . . . [Full Text of this Article]


   Inotropic mechanisms
 

   Phosphodiesterase inhibitors in clinical use
 
Milrinone

Enoximone


   Clinical use and haemodynamic effects
 
Chronic heart failure

Acute heart failure

Comparison with catecholamines

Combinations of PDEI and catecholamines

Right ventricular function and pulmonary hypertension

Vascular effects


   Effects on inflammation
 

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