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Although many studies have shown acute hemodynamic improvement in patients with congestive heart failure treated with vasodilating drugs, long-term controlled studies with both hemodynamic and exercise capacity measurements are not available. We studied the converting-enzyme inhibitor captopril in 16 ambulatory patients in New York Heart Association functional class II-IV heart failure who were clinically stable on digoxin and diuretics. The acute response to open-label captopril was quantified by blood pool scintigraphy, right-heart catheterization at rest and during exercise, and measurements of exercise capacity. The patients were then randomized to maintenance therapy with captopril or matching placebo and were restudied after 3 months. The two groups were similar in their clinical characteristics and pretreatment rest and exercise hemodynamic measurements. Both displayed similar acute beneficial responses to captopril at rest, with a mean reduction in left ventricular filling pressure from 24 9 to 14 6 mm Hg (p < 0.001) and increases in cardiac index, from 2.1 0.5 to 2.5 + 0.61/min/m2 (p < 0.01), and stroke index, from 25 8 to 34 + 8 mI/M2 (p < 0.001). Directionally similar hemodynamic improvement was noted during exercise.After 3 months, these beneficial hemodynamic changes were sustained only in the patients randomized to captopril. Concomitantly, the captopril patients increased their exercise capacity as measured by the duration of bicycle exercise (9.0 2.2 vs 11.7 1.4 min, p < 0.01), maximal work load (360 80 vs 460 50 kpm/min, p < 0.005) and oxygen consumption (12.9 2.3 vs 15 + 1.8 ml/kg/min). The placebo group showed either no change or a worsening over the 3 months compared to their pretreatment measurements.These findings demonstrate that captopril is an effective adjunctive agent for the treatment of chronic heart failure and that it produces long-term hemodynamic improvement together with an increase in exercise capacity.

Controlled trial of captopril in chronic heart failure: a rest and exercise hemodynamic study.