Comparison of Captopril and Enalapril in Patients with Severe Chronic Heart Failure

Packer, Milton; Lee, Wai Hung; Yushak, Madeline; Medina, Norma

doi:10.1056/nejm198610023151402

Cited by 282 publications

(68 citation statements)

References 34 publications

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“…In the majority of clinical trials of ACE inhibitors in patients with heart failure, the reported incidence of symptomatic first-dose hypotension ranged from 2 to 33 % 8, 14, 21-24 . The randomized comparative trial by Packer et al confirmed the results of earlier non-comparative studies that demonstrated an increased frequency of early severe symptomatic hypotension, associated with renal failure and myocardial ischemia, in heart failure patients 24 . Subsequent studies, including 2 large, randomized controlled trials, also demonstrated this first-dose BP response.…”

Section: Clinical Consequencesmentioning

confidence: 64%

“…In this trial, the main reasons for lisinopril withdrawal were hypotension (9.7 % of patients) and renal impairment (2 %). Although it was not stated in either trial whether these effects were directly related to the first dose of the ACE inhibitor, there is evidence that the BP response to repeated administrations is directly related to the first-dose response 24,39 . Weber et al compared BP response in 205 patients with left ventricular dysfunction after AMI captopril and trandolapril.…”

Section: Myocardial Infarctionmentioning

confidence: 95%

See 1 more Smart Citation

Heart Failure and First Dose Hypotension After Angiotensin Converting Enzyme Inhibitors

Vítovec¹,

Špinar²

2004

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub

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The first-dose induced decrease in blood pressure in some patients following the administration of ACE inhibitors is a fact causing some concern among clinicians prescribing these drugs. However, an overview of clinical trials and the authors' own experience clearly point to the possibility of reducing the incidence and/or severity of first-dose hypotension. Apart from appropriate clinical measures to be taken, the choice of the ACE inhibitor seems to be of crucial importance as some (fosinopril, perindopril) produce less hypotension than others. Thus, with due circumspection, ACE inhibitors can safely retain their position as the cornerstone of the treatment of chronic heart failure.First-dose hypotension has been recognized as a potential limiting factor in the use of ACE inhibitors in the treatment of chronic heart failure (CHF) and after acute myocardial infarction (AMI). Concerns regarding firstdose hypotension may increase the risk of renal, myocardial, or cerebral hypoperfusion that may result. The incidence of first-dose hypotension after ACE inhibitors reported in large clinical trials is small, varying from 0.7 % in the SAVE trial to 13.3 % in the OPTIMAAL trial 1,2 . This variation reflects differences in study design, in patient selection, in the definition of first-dose hypotension, and in drug selection. The major reason for the low number of these events reported is a very infrequent use of ambulatory blood pressure monitoring, and thus the incidence of less than 10 % reflects only symptomatic or casually measured hypotension. A number of smaller trials have reported a much higher incidence of first-dose hypotension, affecting as many as one third of the patients. SYMPTOMS OF FIRST-DOSE HYPOTENSIONThe most frequently reported symptoms of drug-induced hypotension are those related to cerebral hypoperfusion. These include light headiness, dizziness, headache, general weakness and visual disturbances 3 . In elderly patients, drug-induced hypotension has also been associated with falling. Several studies conducted in the community and in long-term residential care facilities have found drug-induced hypotension to be the primary cause of falling in both fit and frail elderly patients [4][5][6] . The clinical consequences of first-dose hypotension assume particular relevance in this patient population because the compensatory circulatory response to hypotensive stimuli, pre-existing vascular disease or both declines with age 7,34 . With more severe first-dose hypotension, the subsequent drop in cerebral blood flow can lead to a sudden brief loss of consciousness (syncope), often accompanied by bradycardia 8 . This may be especially dangerous in patients with heart failure. The incidence of syncope following initiation of an ACE inhibitor appears to have decreased dramatically over the last decade to between 0.5 and 2.2 %, although this may reflect changes in reporting practices 9,10 . Many clinicians continue to monitor closely the response to the first dose of an ACE inhibitor in patients with grade 3 ...

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Section: Clinical Consequencesmentioning

confidence: 64%

Section: Myocardial Infarctionmentioning

confidence: 95%

Heart Failure and First Dose Hypotension After Angiotensin Converting Enzyme Inhibitors

Vítovec¹,

Špinar²

2004

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub

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“…21 Other studies have demonstrated that high doses of ACEI had a similar frequency of side effects to low doses in heart failure. 3,9,19 In contrast to those findings, it has been suggested that low doses of ACEI might be as effective as high doses, 8,16,17,20 but produce fewer side effects, especially the serious hypotensive effects 6,[21][22][23] that can compromise cerebral and renal function.…”

Section: Discussionmentioning

confidence: 97%

“…25 On the basis of these findings, we suggest that when ACEI are used in the treatment of patients with severe chronic heart failure, long-acting agents might reduce mortality more successfully than short-acting agents. 23 Notably, it remains to be evaluated why enalapril was superior to captopril, but factors such as ACEI lipophicidity and tissue converting enzyme inhibition, 26,27 rather than merely dose effect, may be important.…”

Section: Discussionmentioning

confidence: 99%

Long-Term Survival of Non-Elderly Patients With Severe Heart Failure Treated With Angiotensin-Converting Enzyme Inhibitors. Assessment of Treatment With Captopril and Enalapril Survival Study (ACESS).

Huang

Young

2002

Circ J

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The present study examined the effect of treatment with angiotensin-converting enzyme inhibitors (ACEIs) on the long-term prognosis in 119 patients with dilated cardiomyopathy (DCM). Conventional therapy was used in 29 patients and 90 patients were treated with ACEIs: 50 were taking captopril and 40 were taking enalapril; 24 were taking ≥75 mg captopril or ≥20 mg enalapril daily (high-dose group) and 66 patients received smaller doses (low-dose group). No significant differences between groups were detected with respect to demographics and clinical signs of congestive heart failure (CHF). During follow-up, 65 patients survived and 54 patients died: 34 patients were in group 1 and 20 patients were in the placebo group. Patients treated with ACEIs had a significantly better survival during the first to third year, but the difference was not significant between the high-and low-dose groups. Comparison of the cumulative probability of death in the enalapril and captopril groups showed a trend of significant reduction of mortality by 13% in the enalapril group (p<0.10). These data indicate that ACEIs have a beneficial effect on prolonging the short-and long-term survival in DCM patients, so it is strongly recommended that all patients with DCM should be treated with ACEIs unless contraindicated. In this study, lower doses of ACEI seemed prognostically equivalent to higher doses, and enalapril appeared to be preferable to captopril in the treatment of severe CHF. Additional prospective large studies are necessary to verify the relationship observed here between the optimal dosage as well as the duration of action of different ACEIs and their outcomes. (Circ J 2002; 66: 886 -890)

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“…However, the clear dissociation during chronic treatment between plasma angiotensin II and blood pressure reduction just discussed above demonstrates that this goal does not need to be reached. In fact, in some patients with congestive heart failure, it turned out that a marked and prolonged ACE inhibition may even be deleterious by increasing the incidence of renal failure (Packer et al, 1986). …”

Section: 'mentioning

confidence: 99%

Pharmacokinetics of angiotensin converting enzyme inhibitors.

Burnier

Waeber

Nussberger

et al. 1989

Brit J Clinical Pharma

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Comparison of Captopril and Enalapril in Patients with Severe Chronic Heart Failure

Cited by 282 publications

References 34 publications

Heart Failure and First Dose Hypotension After Angiotensin Converting Enzyme Inhibitors

Heart Failure and First Dose Hypotension After Angiotensin Converting Enzyme Inhibitors

Long-Term Survival of Non-Elderly Patients With Severe Heart Failure Treated With Angiotensin-Converting Enzyme Inhibitors. Assessment of Treatment With Captopril and Enalapril Survival Study (ACESS).

Pharmacokinetics of angiotensin converting enzyme inhibitors.

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