Am Fam Physician. 2004 Jul 15;70(2):261.
to the editor: In the American Family Physician article, “Combination Therapy with ACE Inhibitors and Angiotensin-Receptor Blockers in Heart Failure,”1 the authors state that adding an angiotensin-receptor blocker (ARB) to angiotensin-converting enzyme (ACE) inhibitor therapy for heart failure does not reduce mortality compared with treatment with an ACE inhibitor only. However, when the addition of valsartan to “optimal” pharmacologic therapy for heart failure was tested in the Valsartan Heart Failure Trial (Val-HeFT),2 researchers found that mortality rates were higher in patients who were already receiving an ACE inhibitor and a beta blocker.2,3 Thus, patients who were already receiving the standard recommended heart failure therapy (an ACE inhibitor plus a beta blocker4) actually fared worse with the addition of valsartan. In the Candesartan in Heart Failure: Assessment of Mortality and Morbidity (CHARM)-Added study,5 the investigators report that the addition of candesartan to combination therapy with an ACE inhibitor and a beta blocker reduced mortality; however, the reduction was not statistically significant.5
Thus, the addition of ARBs to therapy with ACE inhibitors plus beta blockers does not decrease mortality. Further, it must be recognized that there is a risk of this combination increasing mortality, making it nonbeneficial and potentially harmful.
1. Scow DT, Smith EG, Shaughnessy AF. Combination therapy with ACE inhibitors and angiotensin-receptor blockers in heart failure. Am Fam Physician. 2003;68:1795–8.
2. Cohn JN. Tognoni G; Valsartan Heart Failure Trial Investigators. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med. 2001;345:1667–75.
3. Cayley WE JR. Valsartan in chronic heart failure. N Engl J Med. 2002;346:1173–4.
4. Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis GS, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2001;38:2101–13.
5. McMurray JJ, Ostergren J, Swedberg K, Granger CB, Held P, Michelson EL, et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial. Lancet. 2003;362:767–71.
editor’s note: This letter was sent to the authors of “Combination Therapy with ACE Inhibitors and Angiotensin-Receptor Blockers in Heart Failure,” who declined to reply.
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