consistent across several demographic subgroups: age, Tanner stage, gender, and race. In this study, lisinopril
was generally well-tolerated.
In the above pediatric studies, Zestril was given either as tablets or in a suspension for those children and infants
who were unable to swallow tablets or who required a lower dose than is available in tablet form [see Dosage
and Administration (2.1)].
14.2 Heart Failure
In two placebo controlled, 12-week clinical studies compared the addition of Zestril up to 20 mg daily to
digitalis and diuretics alone. The combination of Zestril, digitalis and diuretics reduced the following signs and
symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention. In one
of the studies, the combination of Zestril, digitalis and diuretics reduced orthopnea, presence of third heart
sound and the number of patients classified as NYHA Class III and IV; and improved exercise tolerance. A
large (over 3000 patients) survival study, the ATLAS Trial, comparing 2.5 mg and 35 mg of lisinopril in
patients with systolic heart failure, showed that the higher dose of lisinopril had outcomes at least as favorable
as the lower dose.
During baseline-controlled clinical trials, in patients with systolic heart failure receiving digitalis and diuretics,
single doses of Zestril resulted in decreases in pulmonary capillary wedge pressure, systemic vascular resistance
and blood pressure accompanied by an increase in cardiac output and no change in heart rate.
14.3 Acute Myocardial Infarction
The Gruppo Italiano per lo Studio della Sopravvienza nell’Infarto Miocardico (GISSI-3) study was a
multicenter, controlled, randomized, unblinded clinical trial conducted in 19,394 patients with acute myocardial
infarction (MI) admitted to a coronary care unit. It was designed to examine the effects of short-term (6 week)
treatment with lisinopril, nitrates, their combination, or no therapy on short-term (6 week) mortality and on
long-term death and markedly impaired cardiac function. Hemodynamically- stable patients presenting within
24 hours of the onset of symptoms were randomized, in a 2 x 2 factorial design, to six weeks of either 1) Zestril
alone (n=4841), 2) nitrates alone (n=4869), 3) Zestril plus nitrates (n=4841), or 4) open control (n=4843). All
patients received routine therapies, including thrombolytics (72%), aspirin (84%), and a beta blocker (31%), as
appropriate, normally utilized in acute myocardial infarction (MI) patients.
The protocol excluded patients with hypotension (systolic blood pressure ≤ 100 mmHg), severe heart failure,
cardiogenic shock, and renal dysfunction (serum creatinine > 2 mg per dL and/or proteinuria > 500 mg per 24
h). Patients randomized to Zestril received 5 mg within 24 hours of the onset of symptoms, 5 mg after 24 hours,
and then 10 mg daily thereafter. Patients with systolic blood pressure less than 120 mmHg at baseline received
2.5 mg of Zestril. If hypotension occurred, the Zestril dose was reduced or if severe hypotension occurred
Zestril was stopped [see Dosage and Administration (2.3)].
The primary outcomes of the trial were the overall mortality at 6 weeks and a combined end point at 6 months
after the myocardial infarction, consisting of the number of patients who died, had late (day 4) clinical
congestive heart failure, or had extensive left ventricular damage defined as ejection fraction ≤ 35% or an
akinetic-dyskinetic [A-D] score ≥ 45%. Patients receiving Zestril (n=9646), alone or with nitrates, had an 11%
lower risk of death (p=0.04) compared to patients who did not receive Zestril (n=9672) (6.4% vs. 7.2%,
respectively) at six weeks. Although patients randomized to receive Zestril for up to six weeks also fared
numerically better on the combined end point at 6 months, the open nature of the assessment of heart failure,
Reference ID: 4127985