Key result
ARBs show no survival advantage over ACE inhibitors in heart failure.
Why the study?
It remains unresolved whether ARBs alone or combined with an ACE inhibitor reduce mortality and morbidity more effectively than an ACE inhibitor alone in heart failure.
Are ARBs alone or in combination with an ACE inhibitor more effective in reducing mortality and morbidity than an ACE inhibitor alone in patients with heart failure?
Are ARBs alone or in combination with an ACE inhibitor more effective in reducing mortality and morbidity than an ACE inhibitor alone in patients with heart failure?
This review reinforces that ACE inhibitors remain the standard of care for RAAS modulation in heart failure, pending further trials on ARBs.
ACE inhibitors remain standard for RAAS modulation in HF; leaves open ARB positioning alone or combined pending prospective trials.
Heart failure therapy in the new millenium: which role play ARBs? The activation of the renin-angiotensinaldosternone system (RAAS) is an important factor in the pathogenesis and progression of heart failure. The principal effector for the RAAS, angiotensin Il, is elevated in the plasma of heart failure patients and has multiple undesirable effects such as cell proliferation and growth. Attenuating angiotensin Il levels by use of angiotensin-converting enzyme (ACE) inhibitors is proven to significantly reduce mortality and morbidity in patients with heart failure. However, despite adequate therapy with ACE inhibitors many heart failure patients suffer progressive disease and death. Angiotensin Il receptor antagonists (ARB) are now available and should have the advantage of a more specific and selective blockade of the renin-angiotensin system. The suggestion that ARB may be superior over ACE inhibitors in lowering heart failure mortality and morbidity was stimulated by a subgroup analysis in the ELITE-I trial. However, the ELITE-I study was a small trial and was not designed to show surVival superiority. The consecutive ELITE-II study, however, which was designed to confirm the results of the ELITE-I study, did not show a survival advantage of the ARB over the ACE inhibitor in heart failure patients. Although the results of the ELITE-I trial did not justify that ARBs should replace ACE-inhibitors, the results of the ELITE-II trial should not prevent us from further investigating whether these compounds play a role in heart failure therapy. An important question in heart failure therapy remains unresolved: Are ARBs alone or in combination with an ACE inhibitor more effective in reducing mortality and morbidity than an ACE inhibitor alone? Even if ARBs are equally effective as ACE inhibitors, these compounds might eventually be preferred over ACE inhibitors since ARBs are likely better tolerated by heart failure patients. Fortunately, several ongoing trials investigating ARBs in heart failure patients should give us further insights into their role in heart failure therapy. For now, however, the well studied ACE inhibitors should remain the standard for modulating the RAAS in patients with heart failure.
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Suter et al. (2000) conducted a review in Heart failure. Angiotensin II receptor antagonists (ARBs) vs. ACE inhibitors was evaluated on Mortality and morbidity. Angiotensin II receptor antagonists have not yet demonstrated a survival advantage over ACE inhibitors, which should remain the standard therapy for modulating the RAAS in heart failure patients.
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