Hemodynamic and central blood pressure differences between carvedilol and valsartan added to lisinopril at rest and during exercise stress

There is little information about the hemodynamic and exercise-response implications of renin-angiotensin system blocker combinations. After a 3-week lisinopril (L; 40 mg/day) run-in, carvedilol (C; 20 then 40 mg/day) or valsartan (V; 160 then 320 mg/day) was added to L for 4 weeks each in a forced-titration, random order-entry crossover study in 30 subjects. Arterial tonometry (central pressures and time-tension index, TTI); impedance cardiography (steady-state hemodynamics), and ultrasound (carotid flow) were performed at rest and during supine bicycle exercise at 30 and 60 watts. At rest, both V and C lowered TTI similarly (7% to 9%, P =.05 compared with L, in part because they lowered blood pressure (3 to 7/3 to 4 mm Hg). V lowered central systolic pressure, augmentation pressure (AP), and systemic vascular resistance (SVR, all P <.02); C lowered heart rate but not central systolic pressure or SVR. During exercise, V persistently lowered central systolic pressure, AP, and SVR, whereas C did not. Neither drug affected exercise responses or carotid blood flow. Adding V or C to an angiotensin-converting enzyme inhibitor reduced cardiac workload by different mechanisms: vasodilation and reduced central blood pressure with V and lower heart rate with C.