The role of angiotensin II receptor blockers in the management of heart failure

Angiotensin-converting enzyme inhibitors (ACE-inhibitors) are first-line treatment for chronic heart failure (CHF) with a low left ventricular ejection fraction because they improve symptoms and reduce mortality and admission to hospital. Many CHF patients do not receive these agents because of intolerance. Like ACE-inhibitors, angiotensin II type 1 receptor blockers (ARBs) reduce the action of angiotensin II but achieve this effect by an alternative mechanism, thus they may be effective in patients who are intolerant to ACE-inhibitors. Recommendations concerning the efficacy of ARBs in CHF, in the 2001 European Society of Cardiology (ESC) guidelines, were appropriately cautious and their use has remained limited, reflecting uncertainties concerning their role in CHF. However, a number of large-scale clinical trials (including OPtimal Trial in Myocardial Infarction with the Angiotensin II Antagonist Losartan, VALsartan In Acute Myocardial iNfarcTion, and Candesartan in Heart failure: Assessment of Reduction in Mortality and Morbidity) have been completed since the publication of the 2001 guidelines that support the efficacy and safety of ARBs in CHF. Findings from these trials suggest that ARBs may improve outcomes across the CHF patient spectrum, including those with preserved or low ejection fractions, ACE-intolerant patients, in all cases as part of a polytherapeutic strategy. On the basis of these trial data, the revised 2005 ESC guidelines provide stronger recommendations for the use of ARBs in the management of CHF.