Drugs for patients with chronic heart failure: making evidence-based choices

- Kenny Lin, MD, MPH

Two regular features in the July 1 issue of AFP addressed medication management for patients with chronic heart failure.

In Cochrane for Clinicians, Dr. Pamela Obi discussed a 2018 Cochrane review that evaluated whether therapies that improve outcomes in patients with heart failure with reduced ejection fraction (HFrEF) also help patients with heart failure with preserved ejection fraction (HFpEF). The review included 37 randomized controlled trials (RCTs) with more than 18,000 patients; outcomes assessed included cardiovascular mortality, heart failure hospitalization, all-cause mortality, and quality of life. Beneficial drug classes included mineralocorticoid receptor antagonists (reduce hospitalizations, NNT=42) and beta blockers (reduce cardiovascular mortality, NNT=26). Curiously, although the review found no benefits from angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), the American College of Cardiology recommends considering ARB treatment to reduce hospitalizations in persons with HFpEF.

In FPIN's Help Desk Answers, Drs. Scott Christensen and Rebecca Davis investigated whether the combination of an ACE inhibitor and an ARB improves cardiovascular or overall mortality in patients with symptomatic HFrEF or HFpEF. A 2012 meta-analysis of 7 RCTs (n=8,260) comparing dual therapy vs. monotherapy found that dual therapy was associated with fewer myocardial infarctions and heart failure hospitalizations, but no changes in mortality. Dual therapy was also associated with a greater risk of patients withdrawing from trials due to adverse drug effects (RR=1.34). A small 2008 RCT found that patients with heart failure who received irbesartan in addition to an ACE inhibitor had improvements in disease-oriented outcomes (6-minute walk test distance, metabolic equivalents achieved) and quality of life, but no difference in a composite outcome of mortality and cardiovascular hospitalizations. Overall, the benefits of dual therapy seem to be outweighed by the harms.

Clinicians seeking additional information on diagnosis and management of acute and chronic heart failure should also check out our AFP By Topic collection.