Antihypertensive Treatment and Development of Heart Failure in Hypertension: A Bayesian Network Meta-Analysis of Studies in Patients With Hypertension and High Cardiovascular Risk
What is the comparative efficacy of the various antihypertensive strategies in heart failure (HF) prevention?
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.
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.
The authors concluded that diuretics represented the most effective class of drugs in preventing HF, followed by renin-angiotensin system (RAS) inhibitors.
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.
Keywords: Diuretics, Heart Failure, Cardiovascular Diseases, Renin-Angiotensin System, Bayes Theorem, Risk Factors, Hypertension
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