ACE inhibitors or AT-1 antagonists – which is OPTIMAAL after acute myocardial infarction?

OPTIMAAL (Optimal Trial in Myocardial Infarction with the Angiotensin II Antagonist Losartan) is the first major study to compare an angiotensin II Type 1 antagonist losartan (Cozaar trade mark, Merck) with an ACE inhibitor captonpril (Capoten trade mark, Elan) after myocardial infarction in patients with left ventricular dysfunction. Patients were assigned to a target dose of losartan 50 mg/day and captopril 50 mg t.i.d., as tolerated. The primary end point was all-cause mortality and there were 499 (18%) and 447 (16%) deaths in the losartan and captopril group, respectively (p = 0.07). However, there were significantly more cardiovascular deaths with losartan (420, 15%) than with captopril (363, 13%; p = 0.03). Losartan was better tolerated than captopril with fewer patients discontinuing medication (17 versus 23% for losartan and captopril, respectively). In conclusion, if tolerated, captopril should remain the preferred treatment for patients after complicated acute myocardial infarction.