Renin-angiotensin blockade in heart failure with preserved ejection fraction: a systematic review and meta-analysis

• Type of Material: Article
• Authors: Muhammad Shahzeb Khan, Hospital of Cook County; Gregg C. Fonarow, University of California Los Angeles; Hassan Khan, Emory University; Stephen J. Greene, Duke University; Stefan D. Anker, University Medical Center Göttingen; Mihai Gheorghiade, Northwestern University; Javed Butler, Emory University
• Language: English
• Date: 2017-11-01
• Publisher: Wiley Periodicals Inc.
• Publication Version: Final Published Version
• Copyright Statement: © 2017 The Authors.
• License: Creative Commons Attribution-NonCommercial 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1002/ehf2.12204
• Title of Journal or Parent Work: ESC Heart Failure
• Volume: 4
• Issue: 4
• Start Page: 402
• End Page: 408
• Keywords: OUTCOMES; SYSTOLIC FUNCTION; Cardiac & Cardiovascular Systems; Cardiovascular System & Cardiology; IRBESARTAN; Angiotensin receptor blockers; ANTAGONISTS; Renin-angiotensin system; Heart failure; Angiotensin-converting enzyme inhibitors; Life Sciences & Biomedicine; OLDER PATIENTS; Science & Technology; QUALITY; CONVERTING ENZYME-INHIBITORS; TRIAL; DOUBLE-BLIND; Preserved ejection fraction; MORTALITY
• Research Categories: Health Sciences, Medicine and Surgery

Abstract

ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology. Studies with angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) in patients with heart failure with preserved ejection fraction (HFpEF) have yielded inconsistent results. To conduct a systematic review and meta-analysis of all evidence for ACE-I and ARBs in patients with HFpEF, we searched PubMed, Ovid SP, Embase, and Cochrane database to identify randomized trials and observational studies that compared ACE-I or ARBs against placebo or standard therapy in HFpEF patients. Random-effect models were used to pool the data, and I2 testing was performed to assess the heterogeneity of the included studies. A total of 13 studies (treatment arm = 8676 and control arm = 8608) were analysed. Pooled analysis of randomized trials for ACE-I and ARBs (n = 6) did not show any effect on all-cause mortality [relative risk (RR) = 1.02, 95% confidence interval (CI) = 0.93–1.11, P = 0.68, I2 = 0%], while results from observational studies showed a significant improvement (RR = 0.91, 95% CI = 0.87–0.95, P = 0.005, I2 = 81.5%). In pooled analyses of all studies, ACE-I showed a reduction of all-cause mortality (RR = 0.91, 95% CI = 0.87–0.95, P = 0.01). There was no reduction in cardiovascular mortality seen, but in pooled analysis of randomized trials, there was a trend towards reduced HF hospitalization risk (RR = 0.91, 95% CI = 0.83–1.01, I2 = 0%, P = 0.074). These data suggest that ACE-I and ARBs may have a role in improving outcomes of patients with HFpEF, underscoring the need for future research with careful patient selection, and trial design and conduct.