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Am Fam Physician. 2012;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).

AgentOdds ratio vs. placebo
Diuretics0.60
Angiotensin-converting enzyme inhibitors0.72
Angiotensin receptor blockers0.76
Calcium channel blockers0.84
Beta blockers0.88 (not significant)
Alpha blockers1.22 (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.

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