Association of Candesartan vs Losartan With All-Cause Mortality in Patients With Heart Failure

Study Questions:

What is the association of candesartan versus losartan with all-cause mortality in patients with heart failure (HF)?

Methods:

The study authors used the Swedish Heart Failure Registry of 30,254 unique patients registered from 62 hospitals and 60 outpatient clinics. They found that a total of 5,139 patients (mean [standard deviation] age, 74 [11] years; 39% women) were treated with candesartan (n = 2,639) or losartan (n = 2,500). They analyzed survival (as of December 14, 2009) by angiotensin-receptor blocker (ARB) agent using the Kaplan-Meier method, and predictors of survival were determined by univariate and multivariate proportional hazard regression models, with and without adjustment for propensity scores and interactions. They also performed stratified analyses and quantification of residual confounding. The main outcome measures were all-cause mortality at 1 and 5 years.

Results:

The investigators found that 1-year survival was 90% (95% confidence interval [CI], 89%-91%) for patients receiving candesartan and 83% (95% CI, 81%-84%) for patients receiving losartan, and 5-year survival was 61% (95% CI, 54%-68%) and 44% (95% CI, 41%-48%), respectively (log-rank p < 0.001). The multivariate analysis with adjustment for propensity scores showed that the hazard ratio for mortality for losartan compared with candesartan was 1.43 (95% CI, 1.23-1.65; p < 0.001). These results persisted in stratified analyses.

Conclusions:

The authors concluded that in this registry of patients with HF, the use of candesartan compared with losartan was associated with a lower mortality risk.

Perspective:

This study suggests that the so-called ‘class effect’ has limitations. Not all statins are the same; cerivastatin (Baycol) was withdrawn from the market. And not all beta-blockers are the same; bucindolol did not have the same benefits in HF, unlike other beta-blockers in the BEST study. This paper suggests that randomized controlled trials are needed to determine which ARB is ‘best-of-breed’ in the management of HF.

Clinical Topics: Heart Failure and Cardiomyopathies, Novel Agents, Acute Heart Failure

Keywords: Outcome Assessment (Health Care), Losartan, Registries, Propensity Score, Benzimidazoles, Angiotensin II Type 1 Receptor Blockers, Heart Failure, Pyridines, Propanolamines, Tetrazoles


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