Acute Blood Pressure Response to Trandolapril and Captopril
Objective. Our purpose was to compare the blood pressure response to short-term treatment with captopril or trandolapril in patients with left ventricular (LV) dysfunction after acute myocardial infarction (AMI).
Methods. A multicenter, randomized, double-blind, double-dummy, parallel group study was performed. Treatment was initiated 3 to 10 days after the onset of symptoms. On day 1, patients received a single dose of captopril 6.25 mg, trandolapril 0.5 mg, or placebo in the morning. Treatment was then titrated upward over the next 5 days. Blood pressure was monitored with an automated device for the first 12 hours after dosing on day 1. Conventional blood pressure measurements were performed throughout the study.
Results. Of 205 patients treated in the study, 193 patients were evaluated for first-dose effects. In the captopril group, the maximum decrease in blood pressure occurred after 2 hours, and the magnitude of this decrease was significantly greater than in the other 2 groups: 8.8 ± 12/6.3 ± 8 mm Hg (captopril) versus 5.4 ± 10/3.1 ± 8 mm Hg (trandolapril) versus 2.4 ± 9/1.4 ± 7 mm Hg (placebo) (P < .01). In the trandolapril group, the maximum decrease occurred after 7 hours and the magnitude of this effect was similar in all 3 groups: 5.9 ± 11/3.6 ± 8 mm Hg (trandolapril) versus 4.3 ± 10/3.5 ± 8 mm Hg (captopril) versus 3.1 ± 11/2.8 ± 8 mm Hg (placebo) (not significant). Although there was a higher incidence of hypotension on day 1 in the captopril group, the overall incidence of hypotension during the study period was similar in both active treatment groups.
Conclusion. Because of differences in initial blood pressure response profiles, short-term treatment with trandolapril tended to be better tolerated than captopril in post-AMI patients with LV dysfunction. (Am Heart J 2002;143:313-8.)

Angiotensin converting enzyme (ACE) inhibitors are widely used in patients with evidence of congestive heart failure or left ventricular (LV) dysfunction after acute myocardial infarction (AMI). Indeed, several placebo-controlled trials have confirmed that high daily doses of various ACE inhibitors confer significant mortality and morbidity benefits in these populations. Although the short-acting ACE inhibitor captopril was originally regarded as the reference treatment, problems in compliance have led to a clinical preference for long-term treatment with long-acting ACE inhibitors.

The risk of initial sustained hypotension during the first few days after drug initiation has led to the use of ACE inhibitors in clinical practice at less-than-optimal doses. Furthermore, captopril is often prescribed during hospitalization to better manage this risk because peak effects occur earlier and are of shorter duration. Captopril may then be substituted after several days with a once-daily ACE inhibitor. However, inappropriately low doses are often administered after the substitution to limit the risk of hypotension as well as to avoid a prolongation of the hospital stay.

Trandolapril, a once-daily ACE inhibitor with prolonged pharmacologic and clinical effects, is effective in the treatment of patients with evidence of LV dysfunction after AMI. This randomized prospective study was designed to compare the acute tolerability of recommended doses of trandolapril and captopril in this patient population.