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REVIEW

Meta-Analysis: Angiotensin-Receptor Blockers in Chronic Heart Failure and High-Risk Acute Myocardial Infarction

Victor C. Lee, MD; David C. Rhew, MD; Michelle Dylan, PhD; Enkhe Badamgarav, MD, MPH; Glenn D. Braunstein, MD; and Scott R. Weingarten, MD, MPH

2 November 2004 | Volume 141 Issue 9 | Pages 693-704

Background: The role of angiotensin-receptor blockers (ARBs) in treating patients with chronic heart failure and high-risk acute myocardial infarction (MI) has been controversial, and recent clinical trials provide more information on this topic.

Purpose: To quantify the effect of ARBs when compared with placebo (with and without background angiotensin-converting enzyme [ACE] inhibitors) and ACE inhibitors on all-cause mortality and heart failure hospitalizations in patients with chronic heart failure and high-risk acute MI.

Data Sources: Data from original research published through 13 November 2003.

Study Selection: Predefined criteria were used to identify 24 trials.

Data Extraction: 2 reviewers independently collected information on study characteristics and data on all-cause mortality and heart failure hospitalization.

Data Synthesis: 24 trials involving 38 080 patients were included. Analysis of chronic heart failure trials revealed that 1) ARBs were associated with reduced all-cause mortality (odds ratio [OR], 0.83 [95% CI, 0.69 to 1.00]) and heart failure hospitalizations (OR, 0.64 [CI, 0.53 to 0.78]) as compared with placebo; 2) for ARBs versus ACE inhibitors, all-cause mortality (OR, 1.06 [CI, 0.90 to 1.26]) and heart failure hospitalization (OR, 0.95 [CI, 0.80 to 1.13]) did not differ; 3) and for combinations of ARBs plus ACE inhibitors versus ACE inhibitors alone, all-cause mortality was not reduced (OR, 0.97 [CI, 0.87 to 1.08]) but heart failure hospitalizations were reduced (OR, 0.77 [CI, 0.69 to 0.87]). For patients with high-risk acute MI, 2 randomized trials compared ARBs with ACE inhibitors but did not reveal differences in all-cause mortality or heart failure hospitalization.

Limitations: Comparative economic data between ARBs and ACE inhibitors are lacking.

Conclusions: Because ACE inhibitors and ARBs do not differ in efficacy for reducing all-cause mortality and heart failure hospitalizations in patients with chronic heart failure and in patients with high-risk acute MI, ARBs should be regarded as suitable alternatives to ACE inhibitors.

Author and Article Information

From Zynx Health Incorporated and Cedars-Sinai Health System, Los Angeles, California; David Geffen School of Medicine at the University of California, Los Angeles, Westwood, California; and Cerner Health Insights, Beverly Hills, California.

Acknowledgments: The authors thank Anacleto Gano Jr., MPH, for technical assistance in preparation of the manuscript and Cris Sevilla-Pappas for managing the reference database.

Grant Support: By a research grant from Cedars-Sinai Health System.

Potential Financial Conflicts of Interest: Stock ownership or options (other than mutual funds): D.C. Rhew (Merck, Pfizer); Grants received: Zynx Health Incorporated has received grants from AstraZeneca, Aventis, Bristol-Myers Squibb, Merck, Novartis, and Pfizer.

Requests for Single Reprints: Victor C. Lee, MD, Zynx Health Incorporated, 10880 Wilshire Boulevard, Suite 1450, Los Angeles, CA 90024; e-mail, vlee{at}zynx.com.

Current Author Addresses: Drs. Lee, Rhew, and Weingarten: Zynx Health Incorporated, 10880 Wilshire Boulevard, Suite 1450, Los Angeles, CA 90024.

Drs. Dylan and Badamgarav: Cerner Health Insights, 9100 Wilshire Boulevard, Suite 655E, Beverly Hills, CA 90212.

Dr. Braunstein: Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048.

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