Experts debate first-line therapy for heart failure

Results of new clinical trials are reinforcing the role of the angiotensin receptor blockers (ARBs) in the treatment of patients with heart failure (HF).

Previously, the angiotensin converting enzyme inhibitors (ACEi) were considered as first-line drug in HF patients. Now, heart experts are debating if ARBs can also be considered as another first-line drug to be given with ACEi or to replace it altogether in those who cannot tolerate ACEi due to side-effects, which can be as many as 35 percent of HF patients.

This debate on ARB versus ACEi in HF was one of the highlights of the recent annual convention of the Heart Failure Society of the Philippines (HFSP) at the Robinson Galleria Suites.

Dr. May Donato-Tan, HFSP director, presided over the debate which was participated in by Dr. Rafael Castillo, president of the CHARTER Research Foundation; and Dr. Felix Eduardo Punzalan, consultant of the University of the Philippines-Philippine General Hospital.

Dr. Romeo Divinagracia, HFSP president, stressed the importance of medications for HF which can really improve the clinical outcome of patients in terms of improved survival and less incidence of cardiovascular complications.

Among the most common causes of HF are high blood pressure and coronary heart disease characterized by narrowing of the arteries supplying the heart.

The chances of HF increases when one develops a heart attack, which may lead to weakening of the heart muscles. "In HF, the heart is no longer able to fulfill adequately its function of pumping the blood into the circulation to nourish all the parts of the body," explained Donato-Tan.

Candesartan is a member of the ARB family cited for its beneficial effects in all groups of patients with heart failure. A recently published extensive clinical trial program of candesartan among patients with heart failure showed benefits on top of other concomitant therapies, including ACEi and beta-blockers.

The study, with the acronym CHARM (Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity), was also recently presented in the European Congress of Cardiology in Vienna and many heart experts are confident that this will be a strong argument for an increased usage of ARBs in HF patients.

The study’s co-chairman, Professor Karl Swedberg, MD, of Goteborg University and Sahlgrenska University Hospital, Ostra/Goteborg, Sweden, said that despite dramatic treatment advances over the last 10 to 15 years, HF remains a "malignant" disease with considerable risk of death in the first year after a first hospitalization.

Patients in CHARM were randomized to placebo or candesartan 4 mg or 8 mg once daily titrated to target of 32 mg/daily. CHARM investigators evaluated primary outcomes of cardiovascular death or CHF hospitalization in component trials and all-cause death in the overall program.