CLINICAL STUD: HEART FAILURE
Angiotensin receptor blockers in heart failure: meta-analysis of randomized controlled trials
Philip Jong, MD*,
Catherine Demers, MD, MSc ,
Robert S. McKelvie, MD, PhD and
Peter P. Liu, MD, FACC*,*
* Heart & Stroke/Richard Lewar Centre of Excellence, Division of Cardiology, University Health Network, University of Toronto, Toronto, Canada
Division of Cardiology, Hamilton Health Sciences Corporation, McMaster University, Hamilton, Canada
Manuscript received July 24, 2001;
revised manuscript received October 17, 2001,
accepted November 2, 2001.
* Reprint requests and correspondence: Dr. Peter Liu, Heart & Stroke/Richard Lewar Centre of Excellence, EN 12-324, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4.
peter.liu{at}utoronto.ca
OBJECTIVES: We sought to determine the effect of angiotensin receptor blockers (ARBs) on mortality and hospitalization in patients with heart failure (HF).
BACKGROUND: There is uncertainty regarding the efficacy of ARBs as substitute or adjunctive therapy to angiotensin-converting enzyme inhibitors (ACEIs) in the treatment of HF.
METHODS: We conducted a meta-analysis of all randomized controlled trials that compared ARBs with either placebo or ACEIs in patients with symptomatic HF. The pooled outcomes were all-cause mortality and hospitalization for HF.
RESULTS: Seventeen trials involving 12,469 patients were included. Overall, ARBs were not superior to controls in the pooled rates of death (odds ratio: 0.96; 95% confidence interval: 0.75 to 1.23) or hospitalization (0.86; 0.69 to 1.06). Stratified analysis, however, showed a non-significant trend in benefit of ARBs over placebo in reducing mortality (0.68; 0.38 to 1.22) and hospitalization (0.67; 0.29 to 1.51) when given in the absence of background ACEI therapy. When compared directly with ACEIs, ARBs were not superior in reducing either mortality (1.09; 0.92 to 1.29) or hospitalization (0.95; 0.80 to 1.13). In contrast, the combination therapy of ARBs and ACEIs was superior to ACEIs alone in reducing hospitalization (0.74; 0.64 to 0.86) but not mortality (1.04; 0.91 to 1.20).
CONCLUSIONS: This meta-analysis cannot confirm that ARBs are superior in reducing all-cause mortality or HF hospitalization in patients with symptomatic HF, particularly when compared with ACEIs. However, the use of ARBs as monotherapy in the absence of ACEIs or as combination therapy with ACEIs appears promising.
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Abbreviations and Acronyms
| | OPTIMAAL | | ACEI | | angiotensin-converting enzyme inhibitor | | ADEPT | | Addition of the AT1 Receptor Antagonist Eprosartan to ACE Inhibitor Therapy in Chronic Heart Failure trial | | ARB | | angiotensin receptor blocker | | CHARM | | Candesartan in Heart Failure—Assessment of Reduction in Mortality and Morbidity trial | | CI | | confidence interval | | ELITE | | Evaluation of Losartan In The Elderly study | | HF | | heart failure | | NYHA | | New York Heart Association | | OPTIMAAL | | Optimal Therapy in Myocardial Infarction with the Angiotensin II Antagonist Losartan trial | | OR | | odds ratio | | RESOLVD | | Randomized Evaluation of Strategies for Left Ventricular Dysfunction pilot study | | SPICE | | Study of Patients Intolerant of Converting Enzyme inhibitors | | STRETCH | | Symptom, Tolerability, Response to Exercise Trial of Candesartan cilexetil in Heart failure | | V-HeFT | | Vasodilator Heart Failure Trial | | Val-HeFT | | Valsartan Heart Failure Trial | | VALIANT | | Valsartan in Acute Myocardial Infarction |
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