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Which Antihypertensives Are Better at Preventing Heart Failure?
Am Fam Physician. 2012 Apr 1;85(7):online.
Background: The incidence of hypertension-induced heart failure is as common as that of stroke, especially in patients with diabetes mellitus, older persons, and those at higher risk of cardiovascular disease. Numerous trials have shown that all principal antihypertensive agents reduce the incidence of heart failure in patients with hypertension; however, it is unclear which antihypertensive strategy is best for this purpose. Sciarretta and colleagues performed a network meta-analysis of recent trials to determine which antihypertensive drug is most effective for heart failure prevention.
The Study: The authors first performed a series of traditional meta-analyses of studies comparing antihypertensive drugs for the prevention of heart failure. They next performed a network meta-analysis to compare the effect of these different antihypertensive agents with placebo and with each other. All studies were randomized controlled trials involving patients with hypertension or a population at high cardiovascular risk with more than 65 percent having hypertension, and included information on the absolute incidence of heart failure. A total of 223,313 patients were enrolled in the selected studies.
Results: In the pooled studies, 8,554 cases of heart failure (3.8 percent of all patients) were evaluated during follow-up. In the conventional meta-analyses, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and diuretics were superior to placebo in preventing heart failure. Diuretics were more effective than ACE inhibitors, ARBs, alpha blockers, and calcium channel blockers at preventing heart failure. The renin-angiotensin system inhibitors (i.e., ACE inhibitors and ARBs) were more effective than calcium channel blockers. The network meta-analysis confirmed the trends noted in the direct comparisons: all active treatments (except alpha blockers) were more effective than placebo for heart failure prevention. Diuretics were the most effective, closely followed by the renin-angiotensin system inhibitors. Calcium channel blockers and beta blockers were less effective at preventing heart failure than the other agents; however, the benefit of beta blockers compared with placebo was not statistically significant (see accompanying table).
Table. Relative Effectiveness of Antihypertensive Agents in Preventing Heart Failure in Patients with Hypertension
Relative Effectiveness of Antihypertensive Agents in Preventing Heart Failure in Patients with Hypertension
|Agent||Odds ratio vs. placebo|
Angiotensin-converting enzyme inhibitors
Angiotensin receptor blockers
Calcium channel blockers
0.88 (not significant)
1.22 (not significant)
Conclusion: Diuretics and renin-angiotensin system inhibitors should be considered first-line therapies for preventing heart failure in patients with hypertension, whether used alone or in combination. These agents are preferable to calcium channel blockers and beta blockers in patients with hypertension at high risk of heart failure. The authors observed that the magnitude of variations in blood pressure reduction did not correlate with prevention of heart failure.
Sciarretta S, et al. Antihypertensive treatment and development of heart failure in hypertension: a Bayesian network meta-analysis of studies in patients with hypertension and high cardiovascular risk. Arch Intern Med. March 14, 2011;171(5):384–394.
EDITOR'S NOTE: End-stage heart failure has a worse prognosis than many cancers.1 Apart from the data in this study, which show that diuretics and renin-angiotensin system–inhibiting agents are the most effective antihypertensive agents at reducing the risk of developing heart failure, an equally intriguing point is that beta blockers did not show any significant benefit. However, before dismissing beta blockers, it must be noted that this study did not separately examine the effect of beta blockers with and without cardioselective properties. Another recent meta-analysis reported that cardioselective beta blockers did exert a protective effect in persons with preexisting coronary heart disease, whereas nonselective beta blockers did not.2 This point should be considered when adjusting individual patient therapy.—k.t.m.
1. Frankenstein L. The difficult task of finding the best antihypertensive agent. Arch Intern Med. 2011;171(5):394–395.
2. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665.
Copyright © 2012 by the American Academy of Family Physicians.
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