title: Incidence and risk factors of asymptomatic first-dose hypotension with angiotensin-converting enzyme inhibitors in chronic heart failure due to systolic dysfunction.
abstract: BACKGROUND
  In practice, chronic heart failure is often not treated with angiotensin-converting enzyme inhibitors. One reason is the fear of first-dose hypotension. In the majority of patients, this condition is asymptomatic and the consequences are unexpected. Presently, little is known of its epidemiology.
  
  
  RESULTS
  This was a prospective, 48-hour observational study of 160 patients with chronic heart failure due to systolic dysfunction, previously untreated with angiotensin-converting enzyme inhibitors, randomly drawn from the clinical practice of selected cardiologists across India. The primary outcome was a change in the mean arterial pressure during the first 24-hours after the first dose of an angiotensin-converting enzyme inhibitor. In 131/160 patients (81.9%) with no hypotensive symptoms, the incidence of first-dose hypotension (maximum 24-hour fall in mean arterial pressure greater than 10% from baseline) was 56/131 (42.7%). Pre-treatment diastolic pressure had a negative, independent association with 24-hour change in mean arterial pressure, accounting for 29% (R2=0.29, p<0.01) of its variability, and its predictive value was greater with pro-drug angiotensin-converting enzyme inhibitors. The incidence of first-dose hypotension increased from 1 patient (4.8%) at a pre-treatment diastolic pressure of 50-70 mmHg to 35 patients (42.7%) at 71-90 mmHg, p<0.01.
  
  
  CONCLUSIONS
  The incidence of first-dose hypotension with angiotensin-converting enzyme inhibitors in outpatients with chronic heart failure due to systolic dysfunction is high. Pre-treatment diastolic pressure is an independent risk factor, and its predictive value increases with pro-drug angiotensin-converting enzyme inhibitors. This could help physicians to anticipate asymptomatic first-dose hypotension and increase the utilization of these agents in heart failure.
authors.affiliation: Department of Cardiology, Sri Ramachandra Medical College and Research Institute, Chennai.
authors.forename: Sadagopan
authors.initials: S
authors.lastname: Thanikachalam
authors.forename: Subhash C
authors.initials: SC
authors.lastname: Manchanda
mesh_terms: D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage*; D002908:Chronic Disease; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000453:epidemiology / Q000209:etiology*; D006439:Hemodynamics / Q000187:drug effects / Q000502:physiology; D006801:Humans; D007022:Hypotension / Q000139:chemically induced* / Q000453:epidemiology / Q000503:physiopathology*; D015994:Incidence; D007194:India / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D013318:Stroke Volume / Q000187:drug effects / Q000502:physiology; D018487:Ventricular Dysfunction, Left / Q000188:drug therapy* / Q000453:epidemiology / Q000503:physiopathology*
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors