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HEART FAILURE: VIEWPOINT

A hard look at angiotensin receptor blockers in heart failure

Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA

Manuscript received April 9, 2004; revised manuscript received July 19, 2004, accepted July 28, 2004.

^* Reprint requests and correspondence: Dr. Christian N. Gring, c/o Dr. Brian Griffin, Cleveland Clinic Foundation, Desk F-15, 9500 Euclid Avenue, Cleveland, Ohio 44195 (Email: gringc{at}ccf.org).

Multiple trials over the past several years have examined indications for angiotensin receptor blockers (ARBs) in the treatment of left ventricular dysfunction, both acutely after myocardial infarction and in chronic heart failure. Yet despite these data, there is still confusion regarding the efficacy of ARBs as monotherapy in these patient populations, as well as the specific indications for combination ARB/angiotensin-converting enzyme (ACE) inhibitor therapy. We examine the key differences among the trials—including the ACE inhibitor dose, the ARB and its dose, blood pressure reduction, and patient populations—to present our perspective on ARB use, alone or in combination with ACE inhibitors, in patients with chronic heart failure and post-myocardial infarction left ventricular dysfunction. We conclude that ACE inhibitors remain the first-line therapy for left ventricular dysfunction. Angiotensin receptor blockers should be reserved for monotherapy in ACE intolerant patients and for combination therapy in symptomatic class II/III patients with chronic heart failure.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   ARB = angiotensin receptor blocker   ATLAS = Assessment of Treatment with Lisinopril And Survival trial   LV = left ventricle/ventricular   RAAS = renin-angiotensin-aldosterone system   SOLVD = Studies Of Left Ventricular Dysfunction

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