Haemodynamic response and pharmacokinetics after the first dose of quinapril in patients with congestive heart failure.

Squire, IB; Rj, MacFadyen; Lees, KR; Hillis, W. S.; Reid, JL

doi:10.1111/j.1365-2125.1994.tb04334.x

Cited by 15 publications

(7 citation statements)

References 28 publications

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“…In addition, the duration of significant (p < 0.05 vs. placebo) BP lowering was longer for enalapril (3-7 hours) than for captopril (0.5-3 hours). In 3 previously mentioned studies, lisinopril produced a reduction in mean maximum BP comparable to that of enalapril 25,26 and quinapril 28 induced a significant (p < 0.05) reduction in mean BP versus placebo.…”

Section: Specific Differences Between Ace Inhibitorsmentioning

confidence: 74%

“…Similarly, in 2 randomized double-blind studies involving a total of 24 patients, there were no significant differences between enalapril and lisinopril 26 or between enalapril and atenolol 27 in the magnitude and time of onset of hypotension after administration. A first-dose hypotensive effect with quinapril has also been demonstrated 28 . Single-dose quinapril 2.5 mg elicited a significant (p < 0.05) fall in mean arterial BP compared with placebo 3 to 10 hours after administration in a randomized double-blind trial involving 24 elderly patients (aged 54 to 88 years) with chronic heart failure.…”

Section: Clinical Consequencesmentioning

confidence: 94%

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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: Specific Differences Between Ace Inhibitorsmentioning

confidence: 74%

Section: Clinical Consequencesmentioning

confidence: 94%

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 NETWORK study indicated that serious first dose hypotension occurred in only 11 of 1566 (0.7%) patients whose treatment was started in hospital 12. Lower rates of first dose hypotension have been reported with perindopril,13 but more data are required to confirm the clinical relevance of this finding.…”

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confidence: 82%

Taking heart failure seriously

Cleland

2000

BMJ

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“…We utilised a database of 144 patients (51–88 years, 99 men) with CHF, each of whom was recruited to one of three randomised, double‐blind, parallel‐group, placebo‐controlled studies of the haemodynamic and neurohumoral response to initiation of ACE inhibitor therapy with one of a number of preparations [18–21]. The design of each study is shown in Table 1.…”

Section: Methodsmentioning

confidence: 99%

“…Further to this, direct comparisons of the haemodynamic responses to alternative ACE inhibitor agents are rare. We have previously shown qualitative and quantitative differences among agents in the pattern of blood pressure response to the first dose of treatment [18–21].…”

Section: Introductionmentioning

confidence: 99%

Determinants of the blood pressure response to the first dose of ACE inhibitor in mild to moderate congestive heart failure

Murray

Squire

Reid

et al. 1998

Brit J Clinical Pharma

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Aims To investigate the relationship in patients with heart failure between BP response to the first dose of ACE inhibitor and (1) plasma drug concentration and (2) baseline clinical and laboratory variables. Methods We studied individual placebo-corrected BP responses to initiation of treatment with one of a number ACE inhibitor preparations in 132 patients with mild to moderate CHF. Various pharmacokinetic/pharmacodynamic models were compared. We assessed the strength of association between baseline physiological and laboratory variables and the BP response as assessed directly from the AUC(0,10 h) and indirectly from the slope of the PK/PD relationship. Predictive models for response variables were developing using regression analysis. Results BP response was primarily related to plasma drug concentration. The association between the fall in BP and baseline variables was weak. The strongest single predictor of BP response was baseline mean arterial pressure (r 2 =5.8%, P= 0.02). The best combinations of predictor variables contained mean arterial pressure, plasma renin activity, creatinine concentration and age (r 2 =14.4%, P=0.37). When the choice of ACE inhibitor was added, the predictive power of the model increased (r 2 =23.6%, P<0.01) but left the majority of the variability in response unexplained. Conclusions The first-dose blood pressure response to ACE inhibition cannot be accurately predicted from baseline pathophysiological variables in patients with mild to moderate CHF. The choice of ACE inhibitor accounts for a small proportion of the variability in response but wide inter-individual variability exists in the response to each treatment.

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Haemodynamic response and pharmacokinetics after the first dose of quinapril in patients with congestive heart failure.

Cited by 15 publications

References 28 publications

Heart Failure and First Dose Hypotension After Angiotensin Converting Enzyme Inhibitors

Heart Failure and First Dose Hypotension After Angiotensin Converting Enzyme Inhibitors

Taking heart failure seriously

Determinants of the blood pressure response to the first dose of ACE inhibitor in mild to moderate congestive heart failure

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