WHEN CONVENTIONAL THERAPY FOR CCF IS INADEQUATE, SHALL WE ADD ARB, DRI OR AA?

Very often, in patients with severe heart failure, conventional therapy of diuretics, beta blockers, ACE-I, is still inadequate to control symptoms. What then shall we do, what are our choices? Shall we add an ARB ( angiotensin receptor blocker ), an DRI ( Direct Renin inhibitor ) or an AA ( Aldosterone Antagonist )? Which has more risk of side effects? Which gives better symptom relief and also prolong survival?
Well, Dr Bangalore and colleagues ( they are from Dr Messerli's group ), from New York University School of Medicine, did a meta-analysis of all the large RCT done on this subject, searching the electronic data bases till March 2011. They did a detailed search on all large enough size clinical trial on heart failure where ARBs, DRIs, AAs were used as an adjunct in the management of heart failure. Their common end point was MACE ( death, CV death, non fatal MI, HF hospitalisation, CV death + hospitalisation), and their side effects observed included hyperkalemia, hypotension and renal failure. They must all have follow up of at least 3 months.
Altogether, they found 16 large RCT with 31,429 patients that fit their criteria. They found that, when compared to placebo, adding AA was the best. It improved MACE especially cardiac mortality, HF hospitalisation with a lesser increase in hyperkalemia, as opposed to ARBs and DRIs, which both showed no improvement in MACE and had a higher incidence of hyperkalemia ( ARBs ) or hypotension ( DRIs ).

Relative risk (RR) for clinical end points associated with AAs added to ACE inhibitors in systolic HF

End point	RR (95% CrI)
Mortality	0.79 (0.66-0.98)
CV death	0.78 (0.65-0.93)
HF hospitalization	0.74 (0.55-0.94)
CV death or HF hospitalization	0.73 (0.55-0.90)

This has been our experience too. Aldosterone antagonist does improve symptoms and also many of my CCF patients ( some of them with multiple co-morbidities ) are still alive after a decade battling troublesome CCF. I particularly like the newer AA like eplerenone. It is more expensive, but seemed to do the job better than Spironolactone. It is anecdotal but that has been my experience.

HAPPY NEW YEAR 2013.
MAY 2013 BRING A CHANGE IN MALAYSIA. A CHANGE THROUGH THE BALLOT BOX.