Key result
The choice between adding an angiotensin receptor blocker or an aldosterone blocker to standard ACE inhibitor and beta-blocker therapy in mild, symptomatic heart failure remains a matter of clinical judgment.
Why the study?
Does adding an angiotensin receptor blocker or aldosterone blocker improve outcomes in patients with mild but symptomatic heart failure on standard ACE inhibitor and beta blocker treatment?
Does adding an angiotensin receptor blocker or aldosterone blocker improve outcomes in patients with mild but symptomatic heart failure on standard ACE inhibitor and beta blocker treatment?
This review highlights the clinical dilemma of choosing between ARBs and aldosterone blockers as a third neuroendocrine-blocking agent in mild symptomatic heart failure, leaving the decision to clinical judgment based on existing trial evidence.
Individualized choice of add-on agent persists in mild symptomatic HF; leaves open head-to-head outcome trials.
Recent clinical trials have explored whether angiotensin receptor blockers (ARBs) or aldosterone blockade should be added to standard angiotensin-converting enzyme (ACE) inhibitor/beta blocker treatment in heart failure. Both strategies are of some value but it is unclear which strategy should be used first in patients with mild but symptomatic heart failure. The arguments for and against each strategy are discussed. The strongest argument for aldosterone blockade is the consistency in the results of the RALES (Randomized Aldactone Evaluation Study) and EPHESUS (Eplerenone Post-acute Myocardial Infarction Heart Failure Efficacy and Survival Study) studies, but what is lacking is a trial of aldosterone blockade in patients with mild, symptomatic heart failure as such. The strongest argument for ARBs is that the CHARM (Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity) Added trial result was positive in the precise patient population of interest (mild, symptomatic heart failure). The strength of this argument is diminished by the somewhat different results in Val-HeFT (Valsartan Heart Failure Trial). A third possibility is to use neither an ARB nor an aldosterone blocker and arguments can be marshalled for this position also. Clinicians should now assess these various arguments to select what they believe would be best for their patients.
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Allan D. Struthers (2005) conducted a review in mild but symptomatic heart failure. Angiotensin receptor blockers (ARBs) or aldosterone blockade vs. standard angiotensin-converting enzyme (ACE) inhibitor/beta blocker treatment was evaluated. The choice between adding an angiotensin receptor blocker or an aldosterone blocker to standard ACE inhibitor and beta-blocker therapy in mild, symptomatic heart failure remains a matter of clinical judgment.
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