Heart Failure with Preserved Ejection Fraction: Treatments Compared

Studies among patients with HF and preserved ejection fraction "have been generally disappointing"
Studies among patients with HF and preserved ejection fraction "have been generally disappointing"

Findings from a systematic review and meta-analysis on the efficacy of various treatments in patients with heart failure and preserved ejection fraction were published in the journal Heart.

Many treatment advances have been seen in the treatment of heart failure with reduced ejection fraction (HFrEF) but randomized controlled studies among patients with heart failure and preserved ejection fraction "have been generally disappointing with no convincing demonstration of mortality or morbidity reduction," explained lead author Sean Lee Zheng. 

His team systematically searched various databases for randomized controlled trials evaluating pharmacologic therapies in heart failure patients with left ventricular ejection fraction (LVEF) ≥40% between January 1996 to May 2016. The primary outcome was all-cause mortality; secondary outcomes included cardiovascular mortality, heart failure hospitalization, exercise capacity, quality of life and biomarkers. 

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A total of 25 randomized controlled trials involving 18,101 patients were included for the analysis. Zheng and his team found beta-blockers were the only pharmacologic agents to show a reduction in all-cause mortality vs. placebo (relative risk [RR] 0.78, 95% CI: 0.65–0.94; P=0.008). 

No effect was seen with ACE inhibitors (RR 1.10, 95% CI: 0.85–1.43; P=0.46), aldosterone receptor blockers ([ARB], RR 1.02, 95% CI: 0.93–1.12; P=0.71), mineralocorticoid receptor antagonists (RR 0.92, 95% CI: 0.79–1.08; P=0.32), and other pharmacologic classes when compared to placebo. Moreover, pooled effects of other drug types showed no difference (RR 0.95, 95% CI: 0.78–1.15; P=0.58). 

Regarding cardiovascular mortality, the study authors observed similar results. Beta-blockers reduced cardiovascular mortality vs. controls (RR 0.75, 95% CI: 0.60–0.94; P=0.01) but ACE inhibitors (RR 0.94, 95%CI: 0.62–1.43; P=0.77) and ARB (RR 1.02, 95% CI: 0.90–1.14; P=0.79) had no effect. 

"No single drug class reduced heart failure hospitalization compared with placebo," noted Zheng. A pooled analysis of drugs blocking the renin-angiotensin-aldosterone system (RAAS) did demonstrate a reduction in the risk for heart failure hospitalization (RR  0.90, 95% CI: 0.82–0.98; P=0.01). 

Forheart failure patients with left ventricular ejection fraction (LVEF) ≥40%, beta-blocker therapy was associated with a decrease in all-cause and cardiovascular mortality compared to other drug classes, however "the effect of treatments on functional and quality of life outcomes was limited." More randomized, controlled trials are needed to confirm the efficacy of beta-blockers in this patient population. 

For more information visit heart.bmj.com.