Drugs for chronic heart failure with preserved ejection fraction

Beta-blockers may improve cardiovascular mortality and mineralocorticoid receptor antagonists (MRA) may reduce heart failure hospitalisation in heart failure patients with preserverd ejection fraction.

The quality of evidence is downgraded by study limitations (unclear allocation concealment and blinding), and by imprecise results.

Summary

A Cochrane review included 37 studies with a total of 18 311 subjects with chronic heart failure with preserved ejection fraction. Ten studies (n=3 087) investigated beta-blockers, 12 (n=4 408) mineralocorticoid receptor antagonists (MRA; 9 spironolactone, 2 eplerenone, and 1 canrenone), 8 (n=2 061) angiotensin converting enzyme inhibitors (ACEI), and 8 studies (n=8 755) investigated angiotensin receptor blockers (ARB).

Beta-lockers reduced cardiovascular mortality compared to control (15% vs. 19%; RR 0.78, 95% CI 0.62 to 0.99; NNTB 25; 3 studies, n=1 046). However, no effect was observed when the analysis was limited to the only study with a low risk of bias (RR 0.81, 95% CI 0.50 to 1.29; 1 study n=643). All-cause mortality seemed to be statistically non-significantly lower with beta-blockers compared to control (RR 0.82, 95% CI 0.67 to 1.00; 4 studies, n=1 105). There was no effect on heart failure hospitalisation (RR 0.73, 95% CI 0.47 to 1.13; 4 studies, n=449) or quality of life. MRA treatment reduced heart failure hospitalisation compared to control (11% vs. 14%; RR 0.82, 95% CI 0.69 to 0.98; NNTB 41; 3 studies, n=3 714), but little or no effect on all-cause (RR 0.91, 95% CI 0.78 to 1.06; 5 studies, n=4 207) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11, 3 studies, n=4 070) and quality of life was observed. MRA treatment was associated with a greater risk of hyperkalaemia (16% vs. 8%; RR 2.11, 95% CI 1.77 to 2.51; 6 studies, n=4 291) compared to control. ACEI treatment had little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 2 studies, n=954), all-cause mortality (RR 0.99, 95% CI 0.71 to 1.38; 4 studies, n=1 079), heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 3 studies, n=1 019), or quality of life. ARBs had little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.90 to 1.14; 3 studies, n=7 254), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 4 studies, n=7 964), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 3 studies, n=7 254), or quality of life. ARB was associated with an increased risk of hyperkalaemia (0.9% vs. 0.5%; RR 1.88, 95% CI 1.07 to 3.33; 2 studies, n=7 148).

Clinical comments

Date of latest search:

Ədəbiyyat

1. Martin N, Manoharan K, Thomas J et al. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2018;(6):CD012721.