1. The efficacy of captopril and isosorbide dinitrate (ISDN) as adjunctive therapy to digoxin and diuretics in mild heart failure was compared in a double‐blind study. 2. Twenty‐one patients were randomly allocated to captopril (twice or three times daily) or ISDN. Eighteen patients completed a protocol of placebo run‐in, dose titration and maintenance treatment for 3 months. 3. Symptom‐limited exercise tolerance, ejection fraction and radionuclide indices of diastolic function estimated by gated blood pool scan did not change with either treatment. 4. Captopril improved functional class (Canadian Cardiovascular Society) and reduced requirements for increased diuretic dosage at both 1 and 3 months of maintenance treatment. Patients treated with ISDN required increased diuretic and did not improve their functional class. Differences between the treatments were significant only for diuretic dosage requirements. 5. We conclude that adjunctive therapy of mild heart failure with captopril administered twice daily provides a diuretic‐sparing effect and may improve functional class during 3 months of maintenance treatment.

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Regional wall motion was examined by angiography after 3 weeks in 154 patients taking part in the Thrombolysis in Coronary Occlusion (TICO) Trial. Coronary patency rate was greater after administration of recombinant tissue plasminogen activator, (rt-PA 62/77pts 81%) than after a placebo (P 49/77pts 64% P = 0.02), particularly for the left anterior descending artery compared with the right coronary artery (LAD 27/28 96% vs RCA 28/40 70% P = 0.006). Left ventricular ejection fraction (LVEF) was preserved after rt-PA (rt-PA 59 +/- 14% vs P 53 +/- 15% P = 0.01), predominantly because of more effective non-infarct zone contraction (rt-PA 0.52 +/- 1.16 SD/cord vs P 1.01 +/- 1.07 SD/cord P = 0.008). Infarct zone scores differed little (rt-PA 2.88 +/- 0.95 SD/cord vs P 3.16 +/- 1.11 SD/cord P = 0.09). Left ventricular ejection fraction and non-infarct zone function were best preserved after rt-PA compared with the placebo, particularly in patients with single vessel disease and in patients in whom the infarct-related artery was the left anterior descending vessel.

The incidence of reversible ischaemia was assessed four weeks after primary coronary occlusion in 36 patients who had not required earlier revascularisation after randomisation to receive rTPA (n = 19) or placebo (n = 17). Coronary arteriography was performed at three weeks and thallium scintigraphy with dynamic stress testing at four weeks. Patients were followed for one year without planned intervention in the absence of symptoms. Managing physicians remained blinded to thrombolytic therapy. Patency rate of the infarct related artery at three weeks was greater after rTPA (rTPA 16, placebo 9; p = 0.04). Reversible perfusion defects within infarct related artery territory occurred with similar frequency in both treatment groups (rTPA 7, placebo 8). Multivessel disease was frequent (rTPA 11, placebo 12) but associated with a low incidence of reversible perfusion defects outside infarct related artery territory (rTPA 3, placebo 2). Thallium scintigraphy identified six of seven patients requiring subsequent revascularisation (sensitivity 86%, specificity 59%, negative predictive value 94%). Dynamic stress testing was positive for reversible ischaemia in 28% (rTPA 6, placebo 4) and identified two patients requiring revascularisation (sensitivity 29%, specificity 72%, negative predictive value 81%). The greater patency rate achieved with rTPA at three weeks after primary coronary occlusion was not associated with a significantly greater incidence of reversible perfusion defects at four weeks in patients who had not required prior revascularisation. The absence of reversible perfusion defects at four weeks was associated with a low incidence of revascularisation procedures during one year follow-up.