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Questioning a Class Effect: Does ACE Inhibitor Tissue Penetration Influence the Degree of Fibrinolytic Balance Alteration following an Acute Myocardial Infarction?

From the Texas Tech University Health Sciences Center Schools of Pharmacy (Dr. Tsikouris, Mr. Ziska, Mr. Fike) and Medicine (Dr. Suarez, Dr. Meyerrose, Dr. Smith), Lubbock, Texas.

There is a common belief in a class effect among angiotensin-converting enzyme (ACE) inhibitors. This is unsubstantiated for acute myocardial infarction (AMI). Because vascular tissue is a source of the endogenous fibrinolytic markers, and ACE inhibition in vascular tissue favorably influences the fibrinolytic system, the authors hypothesized that a high-tissue-penetrating ACE inhibitor would provide a more favorable reduction in plasminogen activator inhibitor-1 (PAI-1) and an increase in tissue plasminogen activator (t-PA) after AMI compared to a low-tissue-penetrating ACE inhibitor. In a randomized open-label trial, patients received the high-tissue-penetrating quinapril (n = 15) or low-tissue-penetrating enalapril (n = 15) immediately following an AMI. PAI-1 and t-PA antigen (ng/mL) were measured at baseline and through 14 days of treatment. There was no difference in baseline PAI-1 or t-PA antigen between treatments. PAI-1 antigen trended toward being lower with quinapril versus enalapril on day 1 (24.44 ± 14.96 vs. 36.94 ± 19.49, respectively, p = 0.059) and was significantly lower on day 3 (17.32 ± 9.57 vs. 27.49 ± 9.61, respectively, p = 0.009). Analysis of PAI-1 antigen over time by two-factor ANOVA with replication found significantly lower concentrations of PAI-1 antigen over the entire treatment period with quinapril versus enalapril (p < 0.003). This investigation of ACE inhibitor tissue-penetrating influence on markers of reinfarction risk suggests there may be a greater early reduction in PAI-1 with a more highly tissue-penetrating ACE inhibitor.

Key Words: Myocardial infarction • plasminogen activator inhibitor • ACE inhibitor

Address for reprints: James P. Tsikouris, PharmD, Assistant Professor of Pharmacy Practice, Texas Tech University School of Pharmacy, 3601 4th Street, Suite 1C162, Lubbock, TX 79430.

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