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CLINICAL STUDIES

Effects of early captopril administration after thrombolysis on regional wall motion in relation to infarct artery blood flow

^a Department of Cardiology, Green Lane Hospital, Auckland, New Zealand

Manuscript received July 28, 1998; revised manuscript received September 7, 1998, accepted September 15, 1998.

Address for correspondence: Dr. John French, Department of Cardiology, Green Lane Hospital, Auckland 1003, New Zealand
johnf{at}ahsl.co.nz

Objectives. To determine whether early administration of captopril lessens infarct zone regional wall motion abnormalities when infarct artery blood flow is abnormal.

Background. The interaction between angiotensin-converting enzyme (ACE) inhibitor therapy, ventricular function and infarct artery blood flow has not been well described.

Methods. A total of 493 patients aged 75 years with first infarctions, presenting within 4 h of symptom onset, were randomized to receive 6.25 mg captopril, increasing to 50 mg t.d.s. or a matching placebo 2.1 ± 0.4 h after commencing intravenous streptokinase (1.5 x 10⁶ U over 30 to 60 min). Trial therapy was stopped 48 h prior to angiography at 3 weeks, to determine regional wall motion and infarct artery flow.

Results. There were no differences in ejection fractions or end-systolic volumes between patients randomized to receive captopril and those randomized to receive a placebo. Among patients with anterior infarction (n = 216), randomization to captopril resulted in fewer hypokinetic chords (40 ± 13; vs. 44 ± 13; p = 0.028) and a trend toward fewer chords >2 SD below normal (26 ± 17 vs. 30 ± 17; p = 0.052) in the infarct zone. In patients randomized to receive captopril who had anterior infarction and Thrombolysis in Myocardial Infarction (TIMI) 0–2, flow there were fewer hypokinetic chords (44 ± 12 vs. 50 ± 9; p = 0.043) and a trend toward fewer chords >2 SD below normal (33 ± 15 vs. 39 ± 13; p = 0.057). Patients receiving captopril who had anterior infarction and corrected TIMI frame counts >27 had fewer hypokinetic chords (42 ± 13 vs. 46 ± 12; p = 0.015) and fewer chords >2 SD below normal (27 ± 17 vs. 32 ± 17; p = 0.047). Captopril had no effect in patients with inferior infarction. There were 20 late cardiac deaths (median follow-up 4 years) in the captopril group and 35 in the placebo group (p = 0.036).

Conclusions. Randomization to receive captopril 2 h after streptokinase improved regional wall motion at 3 weeks. The greatest benefit was seen in patients with anterior infarction particularly when infarct artery blood flow is reduced.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   TIMI = Thrombolysis in Myocardial Infarction   MI = myocardial infarction

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