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Effects of the replacement of the angiotensin converting enzyme inhibitor enalapril by the angiotensin II receptor blocker telmisarta  in patients with congestive heart failure

The replacement of angiotensin converting enzyme inhibition (REPLACE) investigators

P.H.J.M. Dunselman*
Working Group on Cardiovascular Research ( WCN), 87 Baronielaan, 4818 PC Breda, The Netherlands
Received 22 March 2000; received in revised form 21 August 2000; accepted 4 September 2000

Abstract Aim: To compare the effects on maximal exercise tolerance of 12 weeks of four dosages of telmisartan (10/20/40/80 mg once daily), an AT specific angiotensin II receptor antagonist, or continuation on the angiotensin converting enzyme inhibitor enalapril, in patients 1 with stable, mild-to-moderate congestive heart failure (NYHA Class II and III and left ventricular ejection fraction #40%).

Design: Multicenter, double-blind, parallel-group trial in 378 patients, randomized to once-daily treatment with telmisartan 10, 20, 40 mg, 80 mg, or continuation of enalapril 10 mg twice daily for 12 weeks. Methods: Primary efficacy parameter: change from baseline to final visit in bicycle exercise duration. Secondary efficacy parameters included left ventricular ejection fraction, quality-of-life parameters, arterial blood pressures, neurohormonal changes and NYHA classification. Patients: The mean age of the patients was 6469 years, 89% male, history of myocardial infarction in 68%, NYHA-II: 63%, NYHA-III: 37%, ejection fraction 26.4(7)%, and a reproducable impaired exercise capacity. All patients were on diuretics and enalapril 10 mg twice daily, and 39% were taking digitalis at study entry.

Results: No clinically relevant or statistically significant (P,0.05) differences were observed in the primary efficacy parameter: mean changes (s) in exercise tolerance were 18.6, 18.2, 12.2, and 17.1 for the telmisartan 10-, 20-, 40-, and 80-mg groups, respectively, and 11.4 for enalapril. There was a small but significant increase in blood pressure in all but the 80 mg telmisartan groups, compared to enalapril. Telmisartan and enalapril had comparable adverse event profiles. Cough occurred in 5.6% of the enalapril patients and in 3% of the telmisartan patients (NS).

Conclusions: (1) In patients with stable, mild-to-moderate congestive heart failure, enalapril could be replaced by telmisartan for a period of 12 weeks without deterioration in exercise capacity or clinical status. (2) No differences were observed in exercise capacity between the four dosages of telmisartan.

2001 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Angiotensin-II receptor blockade; Angiotensin converting enzyme inhibition; Heart failure; Exercise capacity  

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