The quality of evidence is downgraded by study limitations (unclear allocation concealment).
A Cochrane review[Abstract] 1 included 24 studies with a total of 25 051 subjects with symptomatic heart failure (HF). Twenty-two studies randomised 17 900 patients with LVEF HASH(0x2fd5bc8)40% and 2 studies randomised 7 151 patients with LVEF >40%.
LVEF HASH(0x2fd5bc8)40% (mean study duration 2.2 years): Angiotensin receptor blockers (ARBs) did not reduce total morbidity as measured by total hospitalisations (RR 0.94, 95% CI 0.88 to 1.01; 2 studies, n=2 298) compared with placebo. ARBs reduced the risk of hospital admissions for HF (RR 0.71, 95% CI 0.61 to 0.82; 3 studies, n=2 590; NNT=13) but increased the risk of hospital admissions for other causes (RR 1.12, 95% CI 1.00 to 1.25; 2 studies, n=2 298) compared to placebo. All data for these otcomes were from candesartan studies. The observed reduction in total mortality between ARBs and placebo was of borderline statistical significance (RR 0.87, 95% CI 0.76 to 1.00; 9 studies, n=4 643).
Total mortality (RR 1.05, 95% CI 0.91 to 1.22; 8 studies, n=5 201), total hospitalisations (RR 1.00, 95% CI 0.92 to 1.08; 4 studies, n=4 310), myocardial infarction (RR 1.0, 95% CI 0.62 to 1.63; 2 studies, n=3 874), and stroke (RR 1.63, 95% CI 0.77 to 3.44; 1 study, n=3 152) did not differ between ARBs and ACE inhibitors (ACEIs) but withdrawals due to adverse effects were lower with ARBs (RR 0.63, 95% CI 0.52 to 0.76; 6 studies, n=3 511). Combinations of ARBs plus ACEIs increased the risk of withdrawals due to adverse effects (RR 1.34, 95% CI 1.19 to 1.51; 4 studies, n=7 703) but did not reduce total mortality or total hospital admissions versus ACEI alone.
LVEF >40% (2 studies, n=7151; mean study duration 3.7 years): ARBs did not reduce total mortality (RR 1.02, 95% CI 0.93 to 1.12) or total morbidity as measured by total hospitalisations (RR 1.00, 95% CI 0.97 to 1.05) compared with placebo.
According to the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2, ARBs are recommended for symptomatic patients with heart failure with reduced ejection fraction unable to tolerate ACEI or angiotensin receptor-neprilysin inhibitor (ARNI),
ACE inhibitor should be the first choice in heart failure patients and ARBs remain recommended as an alternative in patients intolerant of an ACE inhibitor.
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