Safety and tolerability of lisinopril in older hypertensive patients

The safety and tolerability of lisinopril have been assessed in 1,734 hypertensive patients treated with the agent in a number of clinical trials. Here we compare the clinical and laboratory adverse experiences in younger (under 55 years old) and older (at least 55 years old) patients treated with lisinopril monotherapy. The incidence of adverse experiences in these older patients was similar to that in the younger patients. A comparison also was made of clinical adverse experience data for older hypertensive patients treated either with lisinopril monotherapy or with various control agents (atenolol, metoprolol, and hydrochlorothiazide) in double-blind controlled studies. In these studies, the clinical adverse experience incidences and discontinuation percentages seen in the older patients treated with lisinopril were comparable to the data from the patients treated with the control agents. Thus, lisinopril is generally well-tolerated in older hypertensive patients, and should be considered a therapeutic option in the management of these patients.

Lisinopril and captopril in the treatment of heart failure in older patients. Comparison of a long- and short-acting angiotensin-converting enzyme inhibitor

Heart failure is a common cardiovascular disorder that increases in prevalence with age. Older patients may respond differently than younger patients to the various classes of drugs used in the treatment of congestive heart failure (CHF). The responses of older patients (at least 65 years of age) were evaluated as part of a large multicenter trial utilizing angiotensin-converting enzyme (ACE) inhibitors in the treatment of CHF. A prospectively planned subgroup analysis of older CHF patients' therapeutic response to the long-acting (approximately 24-hour) ACE inhibitor lisinopril was compared with their response to captopril, a short-acting (less than eight-hour) ACE inhibitor. Symptomatic improvement occurred in both the lisinopril and captopril groups. Exercise duration also improved for patients treated with both agents. However, there was a tendency for lisinopril to be more effective than captopril (p = 0.08). Thus, the low level of renin activity often found in the plasma of older patients did not decrease the ability of the ACE inhibitors to improve effort tolerance. Left ventricular ejection fraction increased in patients treated with lisinopril but not in those treated with captopril. The improvement in left ventricular ejection fraction with lisinopril may be indicative of a more favorable prognosis in patients with CHF, since another long-acting ACE inhibitor, enalapril, reduces the rate of mortality associated with CHF. ACE inhibitors were generally well-tolerated by the older patients in the study. Therefore, ACE inhibitors appear to offer a useful therapeutic approach to the management of CHF in the older age group.

Modulation of hemodynamic effects with a converting enzyme inhibitor: acute hemodynamic dose-response relationship of a new angiotensin converting enzyme inhibitor, lisinopril, with observations on long-term clinical, functional, and biochemical responses

The hemodynamic effects of varying oral doses of the long-acting converting enzyme inhibitor lisinopril were studied in an acute, single-blind, parallel fashion in 55 patients with moderate to severe congestive heart failure. Doses of 2.5, 5.0, and 10 mg produced a significant increase in cardiac index and significant reductions in pulmonary capillary wedge, right atrial, pulmonary arterial, and systemic arterial pressures and systemic vascular resistance. The changes were present up to 24 hours after dosing for most parameters. There was a clear-cut dose-response relationship observed. Forty-seven patients were followed over a 3-month period, during which functional status and exercise tolerance improved. Although 26% showed some evidence of renal dysfunction with lisinopril, these changes could be normalized by decreasing either the lisinopril or the diuretic dose. These data demonstrate that the hemodynamic changes with the long-acting converting enzyme inhibitor lisinopril can be modulated with dose adjustment in patients with congestive heart failure. They also suggest that renal function changes may be normalized by adjustment of either the dose of lisinopril or the diuretic dose.

Safety profiles of the angiotensin-converting enzyme inhibitors

This review will discuss the safety profiles of the angiotensin-converting enzyme (ACE) inhibitors captopril, enalapril and lisinopril in patients with hypertension. In general, the safety profiles of ACE inhibitors compare favourably with those of other agents used for the treatment of hypertension. Adverse effects are not common when ACE inhibitors are used at the currently recommended doses. The adverse experiences that do occur with ACE inhibitors can be divided into 3 categories. Hypotension, hyperkalaemia and renal impairment are related directly to the blockade of the angiotensin-converting enzyme. Attention to the clinical condition, including concomitant therapy, reduces the risk of these adverse effects of ACE inhibition. Other adverse effects such as cough and angioedema also occur with all ACE inhibitors. The mechanisms are poorly understood, making it difficult to predict in which patients they will occur. Adverse effects such as rash, dysgeusia, neutropenia and proteinuria, which were reported relatively frequently in the early experience with captopril, are reported less frequently with lower doses of captopril and do not appear to be a problem with other ACE inhibitors such as enalapril and lisinopril.

The safety and tolerability of lisinopril in clinical trials

The safety and tolerability of lisinopril were assessed in 1,476 patients [1,165 hypertensives and 311 patients with congestive heart failure (CHF)] and 211 normal volunteers. The duration of lisinopril therapy ranged from 1 day to 16 months, with a mean duration of 105 days. In the hypertensive population, the most frequent clinical adverse experiences on lisinopril alone were headache, dizziness, cough, and diarrhea. Not all of these adverse experiences were thought to be drug related. Five percent of patients were discontinued because of adverse clinical experiences; cough and dizziness were the most common reasons for discontinuation. Two of 1,165 (0.17%) hypertensive patients treated with lisinopril died, compared to 0.41% of hypertensive patients on other therapies. Neither case was considered to be drug related. In patients with CHF, the most frequent clinical adverse experiences were dizziness, diarrhea, hypotension, fatigue, headache, and rash. Not all of these adverse experiences were thought to be drug related. The percent of CHF patients discontinuing because of an adverse clinical experience was 7.4%; the most frequent causes for discontinuation were hypotension, dizziness, or renal impairment. Twelve deaths occurred in 311 CHF patients treated with lisinopril (3.9%) compared to 4/104 (3.8%) of CHF patients treated with placebo and 2/65 (3.1%) treated with captopril. Hypotension, orthostatic effects, or dizziness following the initial lisinopril dose occurred infrequently in patients treated with lisinopril. In hypertensive patients with normal renal function, including those treated previously or concomitantly with diuretic therapy, a first-dose hypotensive episode was reported in six of 955, or 0.6%. The incidence was higher (6.7%) in hypertensive patients with impaired renal function.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in QRS complex in dogs with normal and exaggerated tidal volumes

The influence of normal and exaggerated ventilation on the QRS was studied in 10 dogs. Peak-to-peak amplitudes of QRS in 4 circumferential unipolar and 2 limb lead ECG were obtained during eupnea and during hyperinflation produced by intermittent positive pressure ventilation or negative extrathoracic pressure. Marked changes were not observed in any lead during eupnea. During hyperinflation to a transpulmonary pressure of 10 mm of Hg (whether by intermittent positive pressure ventilation or negative extrathoracic pressure), voltages decreased in leads I, V10, rV3, and aVF and were variable in leads V3 and V5. Radiography revealed that during the hyperinflation the heart was displaced to the nondependent side of the thorax further from the dependent electrodes and that the heart became generally smaller. Changes in voltage could be attributed to alterations in relationships between the heart and electrodes on the torso surface or to changes in volume conductor properties of the heart and torso.

Effects of graded pleural effusion on QRS in the dog

Six anesthetized healthy dogs were placed in right lateral recumbency. Electrocardiographic leads I, aVF, V10, rV3, V3, and V5 were obtained during a control period and after introduction of pleural effusions ranging between 0.66 and 55 ml of isotonic saline solution/kg of body weight. Peak-to-peak amplitudes of QRS were measured, and the effusion required to decrease this amplitude by more than 1 SD from the mean of healthy dogs was determined for each lead tested. Sensitivity of detecting pleural effusion was greatest in lead I in which an effusion of 2.75 ml/kg could be detected. The QRS amplitudes in leads V10 and aVF were decreased to a significant level only at large effusions. Leads V3 and V5 were "blind," even to the greatest pleural effusions. Radiographs taken with the graded pleural effusion documented that the heart "floated" away from rV3 and toward V3 and V5, thus explaining the sensitivity of rV3 and insensitivities of V3 and V5. It seems that pleural effusion can be detected by using these leads in dogs in right lateral recumbency, that detection is best if serial recordings are taken, and that relatively high sensitivities are achieved using lead I.

Tolerance and safety of enalapril

Enalapril is the result of a targeted research programme to develop a non-mercapto converting enzyme inhibitor with a long duration of action and an improved safety profile for use in the therapy of hypertension and congestive heart failure. Over 3500 patients world-wide have received enalapril or enalaprilat. Long-term experience at present includes over 2500 patients. While enalapril and captopril produce similar efficacy, enalapril is better tolerated and appears not to be associated with occurrence of captopril-type side-effects, particularly the skin rash, taste loss, leukopenia and proteinuria. Enalapril and other converting enzyme inhibitors may be associated with renal insufficiency when given to patients with bilateral renovascular hypertension.