First-dose response to angiotensin-converting enzyme inhibition in congestive cardiac failure: A Malaysian experience

Despite their proven value in reducing morbidity and mortality in different grades of heart failure, angiotensin converting enzyme (ACE) inhibitors co ntinue to be underused. One reason for this is clinicians' apprehension of first-dose hypotension. We conducted a double-blind, randomised, placebo-co ntrolled parallel group study to investigate the effect of various ACE inhi bitors on first-dose hypotension. Eighty unselected patients were randomise d into five treatment groups: placebo, captopril 6.25 mg, enalapril 2.5 mg, perindopril 2 mg and lisinopril 2.5 mg. Blood pressure was measured at bas eline, half hourly for two hours and hourly for three hours after drug trea tment. The maximum drops in mean arterial pressure (in mmHg +/- SD) were pl acebo 5.89 +/- 2.65, perindopril 5.29 +/- 2.49, enalapril 13.28 +/- 3.31, l isinopril 15.04 +/- 5.74 and captopril 16.76 +/- 5.74 tall p < 0.05 vs plac ebo except for perindopril). Perindopril, unlike the other ACE inhibitors s tudied, did not produce first-dose hypotension following its initiation in patients with congestive heart failure.