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Angiotensin-Converting Enzyme Inhibitors and Angiotensin-Receptor Blockers in Chronic Heart Failure
- Victor C. Lee, MD;
- David C. Rhew, MD; and
- Glenn D. Braunstein, MD
- From Zynx Health Incorporated, Los Angeles, CA 90024, and Cedars-Sinai Health System, Los Angeles, CA 90048.
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IN RESPONSE:
We are pleased to hear that CMS, JCAHO, and several other collaborating organizations concur that ARBs should no longer be excluded from the CMS and JCAHO quality indicators for heart failure and acute MI. The implementation of the revised heart failure and acute MI measures in 2 phases makes practical sense as described by McClellan and colleagues as well as on the JCAHO Web site (1).
We respectfully disagree with the statement of Drs. Peeters and Tsikouris that the current quality indicators should remain unchanged. A previous meta-analysis by Jong and colleagues (2) showed no statistically significant difference in mortality or heart failure hospitalization rates between ARBs and placebo in patients with heart failure and left ventricular dysfunction. Thus, it was logical that ARB therapy was not part of the JCAHO and CMS quality measures for CHF and acute MI at that time. However, current data show that ARB therapy results in statistically significant reductions in mortality and heart failure hospitalizations for patients with heart failure and left ventricular dysfunction. Regardless of whether ARBs are considered to be first- or second-line agents to ACE inhibitors, ARBs should be included as part of the heart failure and acute MI quality indicators because they improve clinical outcomes.
We agree with Drs. Peeters and Tsikouris, Mr. Regier, and Mr. Jensen that the efficacy of ACE inhibitors and ARBs may depend on their relative dosing. We did not perform separate analyses based on dosing, however, because the target doses for the ARBs in our study varied widely and we are not aware of standardized criteria for the interconversion of ARB doses.
Finally, we agree with Mr. Regier and Mr. Jensen that in our Table, the doses of valsartan and captopril in the VALIANT study were reported as the target doses from the initial hospitalization but should have been the target doses on 3-month follow-up, which were twice as high.
Victor C. Lee, MD
David C. Rhew, MD
Zynx Health Incorporated; Los Angeles, CA 90024
Glenn D. Braunstein, MD
Cedars-Sinai Health System; Los Angeles, CA 90048
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
