OPTIMAAL (Optimal Trial in Myocardial Infarction with the Angiotensin II Antagonist Losartan )

• This compared losartan 50mg once daily with captopril 50mg three times daily:
  • 5477 patients 50 years of age or older (mean age 67.4 years [SD 9.8]), with confirmed acute myocardial infarction and heart failure during the acute phase or a new Q-wave anterior infarction or reinfarction, were recruited from 329 centres in seven European countries. Patients were randomly assigned and titrated to a target dose of losartan (50 mg once daily) or captopril (50 mg three times daily) as tolerated
  • a multicentre, randomised trial to test the hypothesis that the angiotensin II antagonist losartan would be superior or non-inferior to the ACE inhibitor captopril in decreasing all-cause mortality in high-risk patients after acute myocardial infarction
  • patients were randomised to one of the two treatments and followed for 2.7 years
  • the primary end point of all-cause mortality, trended in favour of captopril, but was not statistically significant
  • most other end points also showed trends in favour of captopril
  • all the mortality difference occurred in the first seven months; after this the curves ran parrallel
  • losartan was significantly better tolerated than captopril - there were fewer discontinuations of treatment due to adverse drug reactions in the losartan group (7% vs. 14%)

• the study authors (1) conclude that there was a a non-significant difference in total mortality in favour of captopril, and ACE inhibitors should remain first-choice treatment in patients after complicated acute myocardial infarction. Losartan cannot be generally recommended in this population. However, it was better tolerated than captopril, and was associated with significantly fewer discontinuations. Although the role of losartan in patients intolerant of ACE inhibition is not clearly defined, it can be considered in such patients

Reference:

1. Lancet 2002 Sep 7;360(9335):752-6