Losartan improved exercise duration and quality of life compared with placebo or hydrochlorothiazide in 2 small RCTs totaling 60 patients.4,5
In the I-PRESERVE Trial, irbesartan didn’t improve primary or secondary outcomes, including death from any cause or hospitalization for a cardiovascular cause (P=.35), death or hospitalization from heart failure, or quality of life (P=.44).6 However, concomitant use of other medications could have been a factor because 39%, 28%, and 73% of patients in the irbesartan group and 40%, 29%, and 73% in the placebo group were taking an ACEI, spironolactone, or a beta-blocker, respectively.
Propranolol reduces mortality, but data on other beta-blockers are lacking
One prospective randomized trial of heart failure patients with LVEF ≥40% already treated with an ACEI and a diuretic, found that propranolol reduced total mortality by 35% after 1 year of therapy (absolute risk reduction=20%; NNT=5).7 Studies of other beta-blockers haven’t reported patient-oriented outcomes as an end point.
Diuretics alone outperform diuretics plus other meds
A study that randomized 150 elderly patients with symptomatic heart failure and LVEF >45% to diuretics alone (80% were given furosemide), diuretics plus irbesartan, or diuretics plus ramipril found that diuretics alone improved the quality of life score by 46% after 52 weeks and also improved symptoms of heart failure.8 No significant symptomatic or other benefit was noted with the addition of irbesartan or ramipril.
Statins are linked to lower mortality
A prospective cohort study followed 137 patients with heart failure and ejection fraction >50% for a mean of 21 months.9 After adjustment for differences in baseline clinical variables between groups, therapy with various statins (68% of patients were on atorvastatin) was associated with lower mortality (NNT=5).
Little evidence exists to support the use of calcium channel blockers, digoxin, or other vasodilators in diastolic heart failure.
Recommendations
The TABLE summarizes recommendations of the American College of Cardiology Foundation and the American Heart Association.1
TABLE
Treating the patient with heart failure and normal LVEF: Recommendations from the ACCF and AHA
| Recommendation | Level of evidence |
|---|---|
| Control systolic and diastolic hypertension | Good supportive evidence |
| Control ventricular rate in patients with atrial fibrillation | Expert opinion/limited evidence |
| Use diuretics for pulmonary congestion and peripheral edema | Expert opinion/limited evidence |
| Perform coronary revascularization if ischemia is having an adverse effect | Expert opinion/limited evidence |
| Rhythm control in patients with atrial fibrillation may be useful | Expert opinion/limited evidence |
| Beta-adrenergic blocking agents, ACEIs, angiotensin II receptor blockers, or calcium antagonists may be effective | Expert opinion/limited evidence |
| Digitalis isn’t clearly effective | Expert opinion/limited evidence |
| ACCF, American College of Cardiology Foundation; ACEIs, angiotensin-converting enzyme inhibitors; AHA, American Heart Association; LVEF, left ventricular ejection fraction. | |
| Adapted from: Hunt SA et al. J Am Coll Cardiol. 2009.1 | |