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ARBs vs. ACE Inhibitors After Myocardial Infarction with LV Dysfunction

All-cause mortality and secondary cardiovascular outcomes were similar in the monotherapy and combined-therapy groups.

Because angiotensin-receptor blockers (ARBs) inhibit angiotensin II activity more completely than do angiotensin-converting-enzyme inhibitors, it's reasonable to wonder whether ARBs are better than ACE inhibitors for some indications. Researchers compared these 2 drug classes in this international, randomized, double-blind study of nearly 15,000 patients who had myocardial infarction (within 10 days before enrollment) and left ventricular systolic dysfunction (mean ejection fraction, 35%). The maker of the ARB valsartan (Diovan) supported the study.

Patients received valsartan (up to 160 mg twice daily), captopril (up to 50 mg 3 times daily), or both drugs. After a median follow-up of 25 months, no significant differences were noted between groups in all-cause mortality or in secondary endpoints that included various combinations of fatal and nonfatal cardiovascular outcomes. Patients who received combined therapy had a significantly lower rate of hospitalization for heart failure or MI than did other patients (17% vs. about 19% in each monotherapy group), but this analysis was post-hoc. Adverse events that resulted in dose reductions or drug discontinuation were more common with combined therapy than with monotherapy (48% vs. 43%).

Comment: Basing their conclusions on these results and the proven record of ACE inhibitors, editorialists state that ACE inhibitors should remain the first-line treatment for patients who are at high risk after MI. However, ARBs appear to be as effective as ACE inhibitors, as long as comparable dosages are used. Combined therapy could be valuable for some patients, but more research is needed to delineate that subgroup.

— Allan S. Brett, MD

Published in Journal Watch General Medicine December 12, 2003

Citation(s):

Pfeffer MA et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med 2003 Nov 13; 349:1893-906.

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Mann DL and Deswal A. Angiotensin-receptor blockade in acute myocardial infarction -- A matter of dose. N Engl J Med 2003 Nov 13; 349:1963-5.

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• Medline abstract (Free)