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Drug therapy reduces mortality by 10% in heart failure patients with preserved ejection fraction

The use of ACE inhibitors or angiotensin-receptor blockers could be widened to all patients with heart failure after a study showed the drugs significantly reduced mortality in patients with preserved ejection fraction.

The landmark study showed ACE inhibitors or ARBs reduced the risk of all-cause mortality by 9% in patients with heart failure and a preserved ejection fraction (HFPEF), compared with controls not taking any medication.

Current advice from NICE urges GPs to manage patients with HFPEF by managing co-morbid conditions such as blood pressure through cardiac rehabilitation programmes and education.

But in their one-year study, Swedish researchers showed patients with HFPEF in primary care had reduced mortality.

The findings are in contrast to a number of trials on the subject which could find no difference between study groups in outcomes of death, and fuel the debate over the treatment of patients with preserved ejection fraction. The researchers said those studies were either underpowered or had selection bias.

The CHARM-Preserved trial from 2003 found no difference between patients taking candesartan and those not when assessing an outcome of cardiovascular death.

This latest trial looked at 16,216 patients with HFPEF visiting primary care outpatient clinics from the Swedish Heart Failure Registry treated with ACE inhibitors or ARBs, and matched controls not treated with drugs.

Overall the crude survival rates were 86% for the treated group and 69% for the non-treated group, this translated to a statistically significant 10% reduction in the risk of all-cause mortality in patients treated with ACE inhibitors or ARBs, compared with those who were not.

When treated patients were compared with matched controls, the rate of one year survival was slightly reduced, but remained statistically significant, at 77% for treated patients and 72% for matched controls.

The researchers concluded: ‘Our results, together with the signal toward benefit in randomised controlled trials, suggest that renin angiotensin system (RAS) antagonists may be beneficial in patients with HFPEF.’

Dr Ahmet Fuat, a cardiology GPSI in Darlington, said the result was interesting, but there needed to be trial evidence before ACE inhibitors or ARBs are included as an option for patients with HFPEF.

He added: ‘We do still use them in these patients, but mainly the elderly cohort with co-morbidities.

‘I think it is important that we look at the co-morbidities with this patient group before using RAS antagonists.’

Dr Clare Taylor, GP in Birmingham and clinical research fellow in cardiovascular disease, said: ‘The findings suggest a mortality benefit associated with use of these drugs however the results should be interpreted with some caution.

As the authors acknowledge, several randomised controlled trials have failed to show a benefit of ACE inhibitors and ARBs albeit with limitations in the studies themselves. Patients who are generally more unwell may also be less likely to be prescribed ACE inhibitors and ARBs and more likely to die earlier than more healthy patients in which these drugs can be used safely.’

JAMA 2012, online 28 November


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