Almost 5 million individuals in the United States have chronic
heart failure (HF), which is increasing in prevalence.
Angiotensin-converting enzyme (
ACE) inhibitors are standard
therapies for HF, although more than 10% of patients with HF are unable to tolerate these agents. Furthermore,
ACE inhibitors may not provide complete blockade of the renin-angiotensin system (RAS) in the long term. Because
angiotensin II receptor blockers (ARBs) may block the RAS more completely than
ACE inhibitors and are better tolerated, several large-scale ARB trials have been performed exploring their potential role in treating patients with symptomatic HF and
left ventricular systolic dysfunction. The
Losartan Heart Failure Survival Study (ELITE II) demonstrated no significant differences in morbidity and mortality between the ARB
losartan and the
ACE inhibitor captopril among elderly patients with HF. The
Valsartan Heart Failure Trial (Val-HeFT) demonstrated reductions in hospitalizations for HF with the ARB
valsartan when added to standard HF
therapy, with no effect on mortality. Both trials suggested a potential negative interaction between ARB and beta-blocker
therapy. The
Candesartan in
Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) program demonstrated significant reductions in morbidity and mortality with the ARB
candesartan in patients with HF due to systolic dysfunction, with or without
ACE inhibitors and with or without beta blockers. Thus, the addition of ARBs to the treatment regimen of patients with symptomatic HF should be strongly considered.