The Pharmaceutical Journal
Vol 269 No 7214 p310
7 September 2002

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European Society of Cardiology (www.escardio.org)
The Lancet (www.thelancet.com)

ACE inhibitors should remain first choice for treating MI patients

The angiotensin II antagonist losartan (Cozaar) cannot be generally recommended for treatment of high-risk patients who have suffered a heart attack. Furthermore, angiotensin-converting enzyme (ACE) inhibitors should remain the first-line treatment, according to the results of a major clinical trial.

Results from OPTIMAAL (optimal trial in myocardial infarction with the angiotensin II antagonist losartan) showed there was no difference between losartan and the ACE inhibitor captopril with respect to the incidence of reinfarction, revascularization and all-cause hospital admission. There was a non-significant difference in total mortality in favour of captopril, but losartan was better tolerated, with fewer discontinuations due to adverse events.

The trial involved over 5,400 patients aged 50 years or more from seven European countries, who had suffered an acute myocardial infarction and had evidence of heart failure or left ventricular dysfunction. Patients received either losartan 50mg daily or captopril 50mg three times daily. Over a mean follow-up period of 2.7 years, there were 499 deaths (18 per cent) in the losartan group and 447 (16 per cent) deaths in the captopril group. Only 17 per cent of patients taking losartan discontinued their medication, compared to 23 per cent of those taking captopril. The research team conclude that ACE inhibitors should remain the first choice therapy for high-risk patients following acute MI, and that further research is needed to ascertain the role of losartan in this specific group of patients. Study lead Dr Kenneth Dickstein, professor of medicine at Bergen University, Norway, told delegates: "We feel this was a fair and appropriately conservative conclusion to draw."

However, Professor Helmut Drexler, professor of medicine at the cardiology department of Hannover University Medical School, Germany, argued: "Using 50mg of losartan is probably too low and other trials, such as VALIANT (valsartan in acute myocardial infarction trial) are using higher concentrations. Within one year we should have the definitive answer."

Professor Drexler suggested that angiotensin II antagonists could be used in cases of ACE inhibitor intolerance and that higher doses should be considered.

The results of OPTIMAAL were presented at the European Society of Cardiology congress in Berlin this week, and published in an early online edition of The Lancet (www.thelancet.com).