Adding ARB to ACE inhibitor therapy has no overall benefit in heart failure
MedWire News: Any benefit of adding an angiotensin receptor blocker (ARB) to ACE inhibitor therapy in heart failure patients seems to be outweighed by the increased risk for adverse effects, indicate meta-analysis results.
The study found that a combination of ARB and ACE inhibitor therapy in heart failure patients reduces admissions for heart failure compared with ACE inhibitor therapy alone, but does not reduce overall mortality or all-cause hospitalization and is associated with more adverse events.
“Based on current evidence, combination therapy with ARBs and ACE inhibitors may be reserved for patients who remain symptomatic on therapy with ACE inhibitors under strict monitoring for any signs of worsening renal function and/or symptomatic hypotension,” conclude the authors.
Alain Nordmann (University Hospital Basel, Switzerland) and colleagues analyzed eight randomized controlled trials comparing ARB and ACE inhibitor therapy to ACE inhibitor therapy alone, including a total of 18,061 patients.
There was no difference in overall mortality between patients who received combination therapy and those who received ACE inhibitor therapy alone, at a relative risk (RR) of 0.97.
There were fewer hospitalizations due to heart failure among those on combination therapy, at a RR of 0.81, based on data available from all but two small trials. But no difference was seen between groups in hospitalizations for any reason (RR=0.92).
Two trials found a significant improvement in quality of life with ARB and ACE inhibitor therapy combined, as measured by the Minnesota Living with Heart Failure Questionnaire; three other trials that assessed this outcome using different instruments found no difference between groups.
Meanwhile patients treated with combination therapy had an increased risk for worsening renal function (RR=1.91), symptomatic hypotension (RR=1.57), and hyperkalemia (RR=1.95) compared with patients who received ACE inhibitor therapy alone, report Nordmann and co-authors in the online journal PLoS One.
They comment that, although the benefit in terms of heart failure hospitalization may be important in view of the high costs associated with recurrent hospitalizations, data on the cost-effectiveness of the combination therapy are scant.
Indeed, they write: “Treatment decisions favoring either therapy cannot be based on solid evidence due to the lack of any cost-utility analysis incorporating quality-of-life data comparing combination to ACE inhibitor therapy alone.”
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By Caroline Price