Antihypertensive Treatment and Development of Heart Failure in Hypertension: A Bayesian Network Meta-Analysis of Studies in Patients With Hypertension and High Cardiovascular Risk

Study Questions:

What is the comparative efficacy of the various antihypertensive strategies in heart failure (HF) prevention?

Methods:

Randomized, controlled trials published from 1997 through 2009 in peer-reviewed journals indexed in the PubMed and EMBASE databases were selected. Selected trials included patients with hypertension or a high-risk population with a predominance of patients with hypertension. Network meta-analysis was performed using the Bayesian hierarchical model to compare different antihypertensive drug-based therapies (angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor blockers [ARBs], diuretics, calcium channel blockers [CCBs], beta-blockers, conventional treatment, and alpha-blockers) to placebo and one to each other.

Results:

A total of 223,313 patients were enrolled in the selected studies. Network meta-analysis showed that diuretics (odds ratio [OR], 0.59; 95% credibility interval [CrI], 0.47-0.73), ACE inhibitors (OR, 0.71; 95% CrI, 0.59-0.85), and ARBs (OR, 0.76; 95% CrI, 0.62-0.90) represented the most efficient classes of drugs to reduce the HF onset compared with placebo. On the one hand, a diuretic-based therapy represented the best treatment because it was significantly more efficient than that based on ACE inhibitors (OR, 0.83; 95% CrI, 0.69-0.99) and ARBs (OR, 0.78; 95% CrI, 0.63-0.97). On the other hand, diuretics (OR, 0.71; 95% CrI, 0.60-0.86), ARBs (OR, 0.91; 95% CrI, 0.78-1.07), and ACE inhibitors (OR, 0.86; 95% CrI, 0.75-1.00) were superior to CCBs, which were among the least effective first-line agents in HF prevention, together with beta-blockers and alpha-blockers.

Conclusions:

The authors concluded that diuretics represented the most effective class of drugs in preventing HF, followed by renin-angiotensin system (RAS) inhibitors.

Perspective:

The primary finding of this analysis is that all antihypertensive strategies are better than placebo in HF prevention, with the exception of alpha-blockers. Diuretics and RAS inhibitors (ACE inhibitors, ARBs) appear to be the most effective class of drugs, a diuretic-based treatment being the more effective first-line antihypertensive intervention for preventing HF. The analysis also shows that CCBs and beta-blockers are significantly less effective than diuretics as first-line agents, and they also tend to be inferior to RAS inhibitors. These results seem to support the use of diuretics and RAS-inhibiting drugs alone or in combination as first-line therapies for HF prevention in hypertension. Additional prospective studies are indicated to confirm these findings.

Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension

Keywords: Diuretics, Heart Failure, Cardiovascular Diseases, Renin-Angiotensin System, Bayes Theorem, Risk Factors, Hypertension


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