Candesartan in heart failure--assessment of reduction in mortality and morbidity (CHARM): rationale and design. Charm-Programme Investigators

Benefits and safety of candesartan treatment in heart failure are independent of age: insights from the Candesartan in Heart failure--Assessment of Reduction in Mortality and morbidity programme

AIMS

Ageing may affect drug efficacy and safety in patients with heart failure (HF). The Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) programme offered an opportunity to study the relationship between increasing age and the efficacy and safety of treatment in an uniquely broad spectrum of patients with symptomatic HF and either reduced or preserved left ventricular ejection fraction.

METHODS AND RESULTS

A total of 7599 patients in NYHA Class II-IV HF were randomized to candesartan (target dose 32 mg once daily, mean dose 24 mg) or placebo, including 3169 patients age >70 years. Mean follow-up was 37.7 months. The proportional hazards model was used to estimate the treatment effect on efficacy and safety within five age groups: <50 years (n = 605) (8% of all study patients), 50-59 years (n = 1474) (19%), 60-69 years (n = 2351) (31%), 70-79 years (n = 2474) (33%), and > or =80 years (n = 695) (9%). The risk of cardiovascular (CV) death or HF hospitalization (primary outcome) increased from 24% in the lowest age group to 46% in the highest age group (and mortality from 13 to 42%). The relative reduction in risk of the primary outcome with candesartan (15% in the overall study population) was similar irrespective of age. Consequently, the absolute benefit was greater with advancing age (3.8 patients avoided a primary outcome per 100 patients treated in the lowest age group compared with 6.8 in the highest). Adverse events leading to drug discontinuation were more frequent in the candesartan group: placebo/candesartan risk (%), lowest compared with highest age category: hyperkalemia (0.0/1.6 vs. 0.6/2.7), increased serum creatinine (1.0/3.9 vs. 6.1/5.4) and hypotension (1.7/2.0 vs. 2.8/5.7).

CONCLUSION

Older patients were at a greater absolute risk of adverse CV mortality and morbidity outcomes but derived a similar relative risk reduction and, therefore, a greater absolute benefit from treatment with candesartan, despite receiving a somewhat lower mean daily dose of candesartan. Adverse effects were more common with candesartan than with placebo, although the relative risk of adverse effects was similar across age groups. The benefit to risk ratio for candesartan was thus favourable across all age groups.

Weight loss and mortality risk in patients with chronic heart failure in the candesartan in heart failure: assessment of reduction in mortality and morbidity (CHARM) programme

AIMS

The curiosity that leanness is associated with poor survival in patients with chronic heart failure (CHF) needs further insight by investigating the impact of weight loss on prognosis in a large sample of patients across a broad spectrum of both reduced and preserved left ventricular (LV) systolic function.

METHODS AND RESULTS

We investigated the change in weight over 6 months in 6933 patients in the Candesartan in Heart failure: Reduction in Mortality and morbidity (CHARM) programme, and its association with subsequent mortality (1435 deaths) over a median 32.9 months follow-up using Cox proportional hazard models to account for the impact of body mass index and other risk predictors. We then used time-updated Cox models to relate each patient's ongoing data on annual weight change to their mortality hazard. The percentage weight loss over 6 months had a highly significant monotonically increasing association with excess mortality, both for cardiovascular and for other causes of death. Patients with 5% or greater weight loss in 6 months had over a 50% increase in hazard compared with those with stable weight. Weight loss carried a particularly high risk in patients who were already lean at study entry. Findings were similar in the presence of dependent oedema, preserved or reduced LV ejection fraction, and treatment with candesartan, although weight loss was significantly less common on candesartan. The time-updated analyses revealed an even stronger link between weight loss and short-term risk of dying, i.e. risk increased more than four-fold for patients whose last recorded annual weight loss exceeded 10%. Weight gain had a more modestly increased short-term mortality risk. Weight loss accelerates in the year prior to death.

CONCLUSIONS

Weight loss and leanness are important predictors of poor prognosis in CHF. Being lean and losing weight is particularly bad. The detection of weight change, and particularly weight loss, should be considered as an adverse sign prompting further evaluation.

Candesartan in heart failure: assessment of reduction in mortality and morbidity (CHARM) and resource utilization and costs in Italy

Chronic heart failure (HF) is a major cause of morbidity and mortality particularly in the elderly and a growing healthcare burden in Italy. The objective was to assess the cost-effectiveness of candesartan cilexetil, an angiotensin II type 1 receptor blocker (ARB) for the treatment of HF. A pre-specified economic evaluation was conducted on resource utilization (cardiovascular drug treatment, cardiovascular and non-cardiovascular hospital admission, cardiovascular procedures/operations) prospectively collected alongside the CHARM program, a series of parallel randomized clinical trials comparing candesartan with placebo (standard therapy) in patients with NYHA Class II-IV HF: CHARM-Alternative (LVEF < or =40% patients not receiving ACE inhibitors because of previous intolerance); CHARM-Added (LVEF < or =40% patients currently receiving ACE inhibitors); or CHARM-Preserved (LVEF > or =40% patients). The primary outcome for the component trials was the composite of cardiovascular death or worsening hospital admission for HF and of the overall program all-cause mortality. Adjunctive treatment with candesartan in CHARM-Alternative and CHARM-Added led to clinical benefits and to either cost-savings or a small additional cost, depending on the trial. The less certain clinical benefit in CHARM-Preserved was obtained at modest extra cost. The incremental cost-effectiveness ratios (ICERs) were estimated to range from euro713 per life year gained for CHARM-Alternative to dominant for CHARM-Added and the pooled reduced LVEF trials.

Candesartan: from left ventricular hypertrophy to heart failure, a global approach

Cardiovascular disease is a continuum, starting with risk factors resulting from physiological changes and extending to vascular pathology associated with adverse clinical outcomes. The overactivation of the renin-angiotensin-aldosterone system has been related to the development and worsening of risk factors associated with cardiovascular diseases such as hypertension and heart failure. Treatment at each stage along the continuum may prevent, or at least delay, the next one, and so it is crucial to initiate therapy as early as possible in such patients so as to provide optimal care. Candesartan, a long-acting angiotensin receptor antagonist, has been shown to be an effective, and well-tolerated therapy, in both the early and late phases of cardiovascular disease (prehypertension, hypertension, left ventricular hypertrophy and heart failure). This article reviews the data supporting the use of candesartan in cardiovascular medicine, with a focus on left ventricular hypertrophy and ultimately heart failure. Particular emphasis is given to the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM) program, which has shown a positive impact of candesartan in patients with chronic heart failure in terms of reducing the incidence of cardiovascular deaths and chronic heart failure hospitalizations.

Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure

BACKGROUND

Patients with chronic heart failure (HF) are at increased risk of both fatal and nonfatal major adverse cardiovascular events. We used data from the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) trials to assess the influence of nonfatal hospitalizations for HF on subsequent mortality rates in a broad spectrum of HF patients.

METHODS AND RESULTS

In the present study, 7599 patients with New York Heart Association class II to IV HF and reduced or preserved left ventricular ejection fraction were randomized to placebo or candesartan. We assessed the risk of death after discharge from a first hospitalization for HF using time-updated Cox proportional-hazards models on 7572 patients for whom discharge data were available. Of 7572 patients, 1455 (19%) had at least 1 HF hospitalization, and 586 of 1819 deaths occurred after discharge from an HF hospitalization. The mortality rate was increased after HF hospitalizations, even after adjustment for baseline predictors of death (hazard ratio, 3.15; 95% confidence interval, 2.83 to 3.50). Longer duration of HF hospitalization enhanced the risk of dying, as did repeat HF hospitalizations. Moreover, risk of death was highest within a month of discharge and then declined progressively over time, particularly for death resulting from HF progression and for sudden cardiac death. We observed a similar pattern of risk associated with all-cause hospitalization, although the magnitude was less than that with HF hospitalization.

CONCLUSIONS

In patients with chronic HF, the risk of death is greatest in the early period after discharge after a hospitalization for HF and is directly related to the duration and frequency of HF hospitalizations. These findings suggest a role for increased surveillance in the early postdischarge period of greatest vulnerability after an HF admission.

Body Mass Index and Prognosis in Patients With Chronic Heart Failure

BACKGROUND

In individuals without known cardiovascular disease, elevated body mass index (BMI) (weight/height2) is associated with an increased risk of death. However, in patients with certain specific chronic diseases, including heart failure, low BMI has been associated with increased mortality.

METHODS AND RESULTS

We examined the influence of BMI on prognosis using Cox proportional hazards models in 7599 patients (mean age, 65 years; 35% women) with symptomatic heart failure (New York Heart Association class II to IV) and a broad spectrum of left ventricular ejection fractions (mean, 39%) in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program. During a median follow-up of 37.7 months, 1831 patients died. After adjustment for potential confounders, compared with patients with BMI between 30 and 34.9, patients in lower BMI categories had a graded increase in the risk of death. The hazard ratios (95% confidence intervals) were 1.22 (1.06 to 1.41), 1.46 (1.24 to 1.71), and 1.69 (1.43 to 2.01) among those with BMI of 25 to 29.9, 22.5 to 24.9, and < 22.5, respectively. The increase in risk of death among patients with BMI > or = 35 was not statistically significant (hazard ratio, 1.17; 95% confidence interval, 0.95 to 1.43). The association between BMI and mortality was not altered by age, smoking status, or left ventricular ejection fraction (P for interaction >0.20). However, lower BMI was associated with a greater risk of all-cause death in patients without edema but not in patients with edema (P for interaction <0.0001). Lower BMI was associated with a greater risk of cardiovascular death and noncardiovascular death. Baseline BMI did not influence the risk of hospitalization for worsening heart failure or due to all causes.

CONCLUSIONS

In patients with symptomatic heart failure and either reduced or preserved left ventricular systolic function, underweight or low BMI was associated with increased mortality, primarily in patients without evidence of fluid overload (edema).

Sex Differences in Clinical Characteristics and Prognosis in a Broad Spectrum of Patients With Heart Failure

Background— We wished to test previous hypotheses that sex-related differences in mortality and morbidity may be due to differences in the cause of heart failure or in left ventricular ejection fraction (LVEF) by comparing fatal and nonfatal outcomes in women and men with heart failure and a broad spectrum of left ventricular ejection fraction.

Methods and Results— We compared outcomes in 2400 women and 5199 men randomized in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program using multivariable regression analyses. A total of 1188 women (50%) had a low LVEF (≤0.40), and 1212 had a preserved LVEF (>0.40). Among the men, 3388 (65%) had a low LVEF, and 1811 had a preserved LVEF. A total of 1216 women (51%) and 3465 men (67%) had an ischemic cause of their heart failure. All-cause mortality was 21.5% in women and 25.3% in men (adjusted hazard ratio [HR], 0.77; 95% CI, 0.69 to 0.86; P <0.001). Fewer women (30.4%) than men (33.3%) experienced cardiovascular death or heart failure hospitalization (adjusted HR, 0.83; 95% CI, 0.76 to 0.91; P <0.001). The risks of sudden death (HR, 0.70; 95% CI, 0.58 to 0.85) and death due to worsening heart failure (HR, 0.72; 95% CI, 0.58 to 0.89) were reduced to a comparable extent. The adjusted risk of cardiovascular hospitalization was also lower in women (HR, 0.88; 95% CI, 0.82 to 0.95), mainly because of a reduced risk of heart failure hospitalization (HR, 0.87; 95% CI, 0.78 to 0.97). Women had a lower risk of death irrespective of cause of heart failure or LVEF.

Conclusions— Among patients with heart failure, women have lower risks of most fatal and nonfatal outcomes that are not explained, as previously suggested, by LVEF or origin of the heart failure.

The CHARM program: study design leads to findings of clinical and public health importance

In large-scale randomized trials and their meta-analyses, beta-adrenergic blockers and angiotensin-converting enzyme inhibitors provide statistically significant and clinically important additive mortality and morbidity benefits in the treatment of heart failure. The CHARM trials were designed to test whether the angiotensin-receptor blocker candesartan would provide statistically significant and clinically important additive mortality and morbidity benefits to patients with heart failure as an alternative or in addition to angiotensin-converting enzyme inhibitors. CHARM demonstrated that an angiotensin-receptor blocker at a proven dose is an effective and safe therapy as an alternative or in addition to angiotensin-converting enzyme inhibitors in patients with heart failure, 55% of whom were receiving beta-adrenergic blockers. These benefits include reductions in cardiovascular mortality rate as well as in hospitalization for heart failure. Such patients have a 50% mortality rate at 5 years, and heart failure is the leading cause of hospitalization for patients 65 years of age and older.

Angiotensin II Receptor Blockers: The Importance of Dose in Cardiovascular and Renal Risk Reduction

Numerous clinical studies have established that angiotensin II receptor blockers are effective as antihypertensive therapy and are well tolerated. Studies demonstrate that adding an angiotensin II receptor blocker to existing antihypertensive regimens reduces cardiovascular and renal risk, which may, in part, be a result of blocking the effects of angiotensin II. Though the antihypertensive dose response of these agents is well documented, the dose response for optimal target organ protection has not yet been clarified. A review of recent studies of angiotensin II receptor blockers in hypertension, acute myocardial infarction, heart failure, and nephropathy provide some data on specific drugs, doses, and risk reduction. Taken as a whole, these studies suggest the highest doses tested, which are at the upper limit of the antihypertensive range, provide greater risk reduction than lower doses. What is unknown is whether even higher doses or full-dose angiotensin II receptor blockers plus full-dose angiotensin-converting enzyme inhibitors might provide even greater risk reduction. Data from ongoing trials will provide additional insight.

Prevalence and prognostic impact of bundle branch block in patients with heart failure: evidence from the CHARM programme

BACKGROUND

Bundle branch block (BBB) is a powerful independent predictor of cardiovascular mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). The prognostic implications in HF with preserved systolic function (HF-PSF) are less well understood.

METHODS

The Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme randomised 7599 patients with symptomatic HF to receive candesartan or placebo. The primary outcome comprised cardiovascular death or HF hospitalisation. The relative risk conveyed by BBB relative to a normal electrocardiogram was examined.

RESULTS

The prevalence of BBB was significantly lower in patients with preserved compared with reduced systolic function (CHARM-Preserved 14.4%, Alternative 29.6%, Added 30.5%), p<0.0001. Overall, the adjusted hazard ratio for the primary outcome was 1.48 (95% confidence interval 1.22-1.78), p<0.0001, reflecting increased risk in patients with reduced LVEF (1.72 [1.28-2.31], p=0.0003). The apparently more modest risk among patients with HF-PSF was significant in unadjusted (1.80 [1.37-2.37], p<0.0001) but not adjusted analysis (1.16 [0.88-1.54], p=0.2897). However, no formal statistical difference was observed between the two cohorts, and interpretation is limited by the unknown prevalence of left and right BBB morphologies in each. Comparing BBB presence with absence yielded qualitatively similar results.

CONCLUSION

The simple clinical finding of BBB is a powerful independent predictor of worse clinical outcomes in patients with HF and reduced LVEF. It is less frequent, with a more modest predictive effect, in patients with preserved systolic function.

Pharmacological treatment of chronic heart failure

Heart failure (HF) is associated with a high morbidity and mortality in the Western World. Our knowledge of the epidemiology, pathophysiology, and therapy has improved dramatically during the last 20 years. Pharmacological treatment, as it stands today, is a combination of preventive and symptomatic strategies. The mainstay life-saving drugs are angiotensin-converting enzyme inhibitors and beta-blockers. Additional benefits are obtained when angiotensin-receptor blockers or aldosterone antagonists are added. Digitalis and/or diuretics are useful for symptom reduction. In addition, combination therapy with hydralazine and isosorbide dinitrate is recommended in African Americans.

Role of angiotensin II in cardiovascular disease therapeutic implications of more than a century of research

More than a century of research on the reninangiotensin system (RAS) has uncovered the widespread involvement of angiotensin II (Ang II) in the pathophysiology of cardiovascular diseases. A number of outcomes-based mega trials utilising hard clinical endpoints have revealed beneficial effects of angiotensin receptor antagonists (AIIAs/ARBs) in patients with hypertension, heart failure, diabetic nephropathy, and post-myocardial infarction (MI). The results of these studies not only emphasise the importance of Ang II in the pathophysiology of these diseases but have provided the basis for an evidence-based approach for the use of AIIAs in clinical practice. It is hoped that the next 100 years of research into the RAS will uncover hitherto unimaginable therapeutic opportunities.

Variable Impact of Combining Fatal and Nonfatal End Points in Heart Failure Trials

Randomized clinical trials (RCTs) are a cornerstone of evidence-based medicine. Their design, implementation, and interpretation are sometimes subject to flaws and errors. To achieve statistical significance and economically feasible RCTs, the use of composite end points in heart failure (HF) trials has become more common. We analyzed the incremental value of combining HF hospitalizations with all-cause mortality in trials of chronic HF that enrolled >1000 placebo patients and had a mean follow-up >9 months. We tested the assumption that, compared with mortality, combining HF hospitalization with all-cause death would yield a consistently predictable increase in event rate across HF RCTs. Average placebo arm duration of follow-up was determined, and standardized placebo event rates per 100 patient-years were estimated. Twelve major HF RCTs were included in this analysis. There was a substantial relative increase in the event rate ranging from 64% to 134% when a composite end point was used. This increase was not related to disease severity as described by annual mortality rate. The relative contribution of combining HF hospitalization with all-cause mortality was, however, influenced by the duration of the trial. Combining HF hospitalization with all-cause mortality increases the overall event rate in HF clinical trials; the relative increase varies widely and is unrelated to disease severity. Longer-duration trials have a more predictable increase in events than short RCTs. Trial duration must be considered when composite end points are used during the design and interpretation of HF RCTs.

Candesartan for the management of heart failure: more than an alternative

Candesartan is a long-acting angiotensin receptor antagonist that is well absorbed from the gastrointestinal tract, with insurmountable receptor binding abilities. Recent studies have shown candesartan to be an effective therapy for heart failure patients, producing a significant reduction in mortality and morbidity. Importantly, studies have demonstrated that candesartan is effective in heart failure patients who are intolerant to angiotensin-converting enzyme inhibitors, in patients already receiving angiotensin-converting enzyme inhibitors and for heart failure patients with preserved systolic function. The primary end point in the latter group failed to achieve statistical significance due to the small number of events. This paper will review the data supporting the use of candesartan to treat all heart failure patients, regardless of their ejection fraction.

Prevalence and prognostic implications of electrocardiographic left ventricular hypertrophy in heart failure: evidence from the CHARM programme

BACKGROUND

Electrocardiographic left ventricular hypertrophy (ECG LVH) is a powerful independent predictor of cardiovascular morbidity and mortality in hypertension.

OBJECTIVE

To determine the contemporary prevalence and prognostic implications of ECG LVH in a broad spectrum of patients with heart failure with and without reduced left ventricular ejection fraction (LVEF). METHODS AND OUTCOME: The Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme randomised 7599 patients with symptomatic heart failure to receive candesartan or placebo. The primary outcome comprised cardiovascular death or hospital admission for worsening heart failure. The relative risk (RR) conveyed by ECG LVH compared with a normal ECG was examined in a Cox model, adjusting for as many as 31 covariates of prognostic importance.

RESULTS

The prevalence of ECG LVH was similar in all three CHARM trials (Alternative, 15.4%; Added, 17.1%; Preserved, 14.7%; Overall, 15.7%) despite a more frequent history of hypertension in CHARM-Preserved. ECG LVH was an independent predictor of worse prognosis in CHARM-Overall. RR for the primary outcome was 1.27 (95% confidence interval (CI) 1.04 to 1.55, p = 0.018). The risk of secondary end points was also increased: cardiovascular death, 1.50 (95% CI 1.13 to 1.99, p = 0.005); hospitalisation due to heart failure, 1.19 (95% CI 0.94 to 1.50, p = 0.148); and composite major cardiovascular events, 1.35 (95% CI 1.12 to 1.62, p = 0.002).

CONCLUSION

ECG LVH is similarly prevalent in patients with symptomatic heart failure regardless of LVEF. The simple clinical finding of ECG LVH was an independent predictor of a worse clinical outcome in a broad spectrum of patients with heart failure receiving extensive contemporary treatment. Candesartan had similar benefits in patients with and without ECG LVH.

Candesartan

Candesartan cilexetil is the prodrug of candesartan, an angiotensin II receptor antagonist. Candesartan binds selectively and non-competitively to the angiotensin II receptor type 1, thus preventing the actions of angiotensin II. Clinical trials have demonstrated its efficacy at a dose range of 2 to 32 mg once daily in hypertension of all grades, heart failure, in reducing urinary albumin excretion in diabetes mellitus and in coexisting hypertension and renal failure. Pharmacokinetic properties of candesartan cilexetil in elderly patients are not significantly different from those in younger individuals. Hepatic impairment does not change pharmacokinetics of candesartan cilexetil at doses up to 12 mg/day. No dose adjustment is necessary in patients with mild or moderate renal impairment. Tolerability of candesartan cilexetil is not much different from that of placebo. All adverse events are usually of mild to moderate severity and not dose-related. The most common adverse events were headache, upper respiratory tract infection, back pain, and dizziness. The incidence of these adverse effects, as well as of cough, was similar in patients treated with candesartan cilexetil or placebo. The incidence of adverse events in long-term trials was not different from that in short-term trials. Tolerability of candesartan cilexetil does not differ with either age or gender.

Cardiac remodeling and angiotensin II-forming enzyme activity of the left ventricle in hamsters with chronic pressure overload induced by ascending aortic stenosis

Cardiac remodeling and angiotensin II-forming enzyme activity of the left ventricle on chronic pressure overload were studied in male Syrian hamsters, whose chymase activity is similar to that of dogs. Pressure overload was achieved by banding at the ascending aorta (aortic stenosis). Echocardiography, histological analysis, and analysis of cardiac angiotensin-converting enzyme and chymase-like activities were performed. At 10 weeks after banding, concentric hypertrophy of the left ventricle was evident. At 20 weeks after banding, the ventricular weight-to-body ratio, cardiac fibrosis, and cardiac chymase-like activity were significantly increased, while cardiac angiotensin-converting enzyme activity was significantly decreased. This suggests that cardiac chymase, compared with cardiac angiotensin-converting enzyme, was activated against the chronic pressure overload and was responsible for the cardiac remodeling through the formation of angiotensin II. Considering the utility of the rodents, the interspecies similarity of the Ang II-forming pathway, and the effect of chymase in the hamsters, the present model is considered useful for studies evaluating the effect of Ang II and chymase in the canine heart with chronic pressure overload.

Atrial fibrillation and risk of clinical events in chronic heart failure with and without left ventricular systolic dysfunction: results from the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) program

OBJECTIVES

We assessed the risk of adverse cardiovascular (CV) outcomes associated with atrial fibrillation (AF) in the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) program, which enrolled patients with chronic heart failure (CHF) and a broad range of ejection fractions (EFs).

BACKGROUND

Atrial fibrillation is associated with an increased risk of adverse CV outcomes in patients with CHF and reduced EF. The risk of AF in patients with CHF and preserved left ventricular ejection fraction (PEF) is unknown.

METHODS

A total of 7,599 patients with symptomatic CHF were randomized to candesartan or placebo. Patients were divided by baseline EF (< or =40% or >40%) in low or preserved EF groups. Major outcomes were cardiovascular death or hospitalization for worsening heart failure, and all-cause mortality. Median follow-up was 37.7 months.

RESULTS

A total of 670 (17%) patients in the low EF group and 478 (19%) in the PEF group had AF at baseline. Atrial fibrillation predicted a high risk of cardiovascular morbidity and mortality regardless of baseline EF. Patients with AF and low EF had the highest absolute risk for adverse CV outcomes. However, AF was associated with greater relative increased risk of the major outcomes in patients with PEF than in patients with low EF: hazard ratio 1.72 (95% confidence interval [CI] 1.45 to 2.06) versus 1.29 (95% CI 1.14 to 1.46), respectively. The same was true for the risk of all-cause mortality. Candesartan was associated with similar treatment effects regardless of baseline rhythm.

CONCLUSIONS

Atrial fibrillation is associated with an increased risk of CV outcomes in patients with CHF and either reduced EF or PEF. Candesartan improved outcomes similarly regardless of baseline rhythm.

Evaluation of enalapril+losartan treatment with cardiopulmonary exercise test in patients with left ventricular dysfunction

The aim of this study was to evaluate the effects of the combination of enalapril and losartan in patients with left ventricular systolic dysfunction by means of cardiopulmonary exercise test (CPET). Patients with left-ventricular systolic dysfunction and ejection fractions of 40% or less were included to the study. All patients were under the treatment of enalapril 20 mg once daily. The study group consisted of 20 patients (18 men, 2 women; mean age +/- standard deviation: 62.4 +/-6.5 years) and the comparison group consisted of 10 (8 men, 2 women; mean age 59.3 +/-11.9 years). The dose of 50 mg of losartan once daily was given additionally to the study patients. Breath-by-breath CPET was performed before administration of losartan and then 6-8 weeks later in the study group and 2 times with an interval of 6-8 weeks in the control group without any change in the treatment protocol. In the study group the average exercise times were 361 +/-192 and 454 +/-205 seconds (p = 0.001) before and after the study. Peak oxygen consumption ( VO2) values were 1,209 +/-366 and 1,284 +/-398 mL/minute before and after the study (p = 0.01). Anaerobic threshold VO2 values were 785 +/-187 and 855 +/-217 mL/minute before and after the study, respectively (p = 0.01). Peak heart rates (HR) were 141 +/-28 and 143 +/-22/minute (p = 0.35); peak VO2/HR values were 9.02 +/-3.1 and 9.3 +/-3 mL/minute (p = 0.4) before and after the study, respectively. On the other hand, in the control group, average exercise times were 556 +/-250 and 528 +/-251 seconds (p = 0.8); peak VO2 values were 1,502 +/-537 and 1,450 +/-501 mL/minute (p = 0.2); and anaerobic threshold VO2 values were 1,005 +/-338 and 975 +/-319 mL/min (p = 0.7), before and after the study respectively. At the highest comparable exercise stage for both tests in the study group the expired volume/oxygen consumption ( VE/ VO2) ratio declined from 35.1 +/-6.2 to 32.4 +/-5.6 (p = 0.007). VE values declined from 37.5 +/-10.9 to 33.9 +/-10.1 L (p = 0.02); heart rate declined from 140 +/-27 to 132 +/-21/minute (p = 0.02). No significant change was observed in the mentioned values for the control group. Addition of losartan to the standard therapy in patients with left ventricular systolic dysfunction improved exercise capacity and caused lower heart rate and ventilation requirements for the same exercise level.

Proposed New Score to Rate the Strength of Evidence and Its Application to Large-Scale Clinical Trials of Angiotensin-Receptor Blockers

BACKGROUND

Many large-scale clinical studies appear to be interpreted with bias and with hindsight. To select the best treatment, accurate evaluation of randomized controlled trials (RCTs) and fair comparison of the results using the concept of evidence-based medicine are critical. A scoring system has been developed to rate the scientific strength of evidence and thereby provide guidance for best clinical practice and for large-scale RCTs of angiotensin-receptor blockers (ARBs).

METHOD AND RESULTS

Positive evidence scores (ESs) were given based on whether specified study endpoints were proven and whether treatments tested made significant progress over current usual therapy. Retrospective ad hoc analyses data were not counted, in order to simplify the system and to avoid hindsight interpretations, even in cases that were medically significant. In fact, in more than half of the large-scale trials with ARBs examined, ad-hoc analyses had been retroactively performed. When such post-hoc analyses were not used, the ESs were positive with candesartan and valsartan for treatment of heart failure, irbesartan and losartan for nephropathy and losartan for hypertension. Applying the ES system, losartan was judged to be an ARB with the strongest evidence covering a wide range of clinical relevance.

CONCLUSION

ES is useful for quantifying and comparing the strength of evidence obtained in large-scale RCTs of ARBs. Several problems related to rating the evidence obtained from clinical trials were recognized in this study.

Predictors of mortality and morbidity in patients with chronic heart failure

AIMS

We aimed to develop prognostic models for patients with chronic heart failure (CHF).

METHODS AND RESULTS

We evaluated data from 7599 patients in the CHARM programme with CHF with and without left ventricular systolic dysfunction. Multi-variable Cox regression models were developed using baseline candidate variables to predict all-cause mortality (n=1831 deaths) and the composite of cardiovascular (CV) death and heart failure (HF) hospitalization (n=2460 patients with events). Final models included 21 predictor variables for CV death/HF hospitalization and for death. The three most powerful predictors were older age (beginning >60 years), diabetes, and lower left ventricular ejection fraction (EF) (beginning <45%). Other independent predictors that increased risk included higher NYHA class, cardiomegaly, prior HF hospitalization, male sex, lower body mass index, and lower diastolic blood pressure. The model accurately stratified actual 2-year mortality from 2.5 to 44% for the lowest to highest deciles of predicted risk.

CONCLUSION

In a large contemporary CHF population, including patients with preserved and decreased left ventricular systolic function, routine clinical variables can discriminate risk regardless of EF. Diabetes was found to be a surprisingly strong independent predictor. These models can stratify risk and help define how patient characteristics relate to clinical course.

The Irbesartan in Heart Failure With Preserved Systolic Function (I-PRESERVE) Trial: Rationale and Design

BACKGROUND

Although 40% to 50% of patients with chronic heart failure (HF) have relatively preserved systolic function (PSF), few trials have been conducted in this population and treatment guidelines do not include evidence-based recommendations.

METHODS AND RESULTS

The Irbesartan in Heart Failure with Preserved Systolic Function (I-PRESERVE) is enrolling 4100 subjects with HF-PSF to evaluate whether 300 mg irbesartan is superior to placebo in reducing mortality and prespecified categories of cardiovascular hospitalizations. The principal inclusion criteria are age > or =60 years, heart failure symptoms, an ejection fraction > or =45%, and either hospitalization for heart failure within 6 months or corroborative evidence of heart failure or the substrate for diastolic heart failure. Additional secondary end points include cardiovascular mortality, cause-specific mortality and morbidity, change in New York Heart Association functional class, quality of life, and N-terminal pro-BNP measurements. Follow-up will continue until 1440 patients experience a primary end point. Substudies will evaluate changes in echocardiographic measurements and serum collagen markers.

CONCLUSION

I-PRESERVE is the largest trial in this understudied area and will provide crucial information on the characteristics and course of the syndrome, as well as the efficacy of the angiotensin receptor blocker irbesartan.

Treating Hypertension With Cardioprotective Therapies

Hypertension is both a disease and risk factor for cardiovascular disease (CVD) and each 20/10 mm Hg rise in blood pressure (BP) doubles the risk for CVD. Although BP reduction through lifestyle modification and/or antihypertensive therapy has been shown to dramatically reduce the risk for CVD, recent evidence has shown that many patients with hypertension do not have adequate BP control. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) provides comprehensive guidelines on the diagnosis, classification, and management of hypertension and related CV conditions. The JNC 7 guidelines recommend that most patients receive first-line therapy with thiazide diuretics, but the majority of patients will require 2 or more antihypertensive agents to achieve adequate BP control. The selection of additional antihypertensive therapies should be based on the presence of concomitant CV and metabolic conditions as well as patient-specific factors such as race. An important role exists for angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and beta-blockers, particularly in patients with comorbid CV or metabolic conditions. Clinical evidence suggests that these agents may offer benefits beyond simple BP lowering. Furthermore, synergies among antihypertensive classes may improve BP control and combination therapy may also permit the use of smaller doses of each medication and reduce the risk of dose-related adverse effects.

High glucose levels abolish antiatherosclerotic benefits of ACE inhibition in alloxan-induced diabetes in rabbits

Renin-angiotensin system activation is recognized to play an important role in atherosclerosis. This study aimed to verify the antiatherosclerotic effects of ACE inhibition on an experimental model of diabetes and hypercholesterolemia. Diabetes was induced in New Zealand male rabbits with a single dose of alloxan (100 mg/kg, i.v.), and, according to plasma glucose levels obtained after 1 week, the animals were divided into 2 groups (> or =250 mg/dL or <250 mg/dL). Each group was randomly assigned to receive or not quinapril (30 mg/d) added to a 0.5% cholesterol-enriched diet. Animals with high glucose levels at 1 week and that remained high after 12 weeks presented higher triglyceride levels (P < 0.02 versus basal). Those initially hyperglycemic but presenting <250 mg/dL glucose at the end of study formed an additional group. Plasma ACE activity was lower in quinapril-treated animals (P < 0.01 versus untreated groups). However, aorta intima/media ratio and intima area were lower only in the subgroups of quinapril-treated animals with low glucose levels (P < 0.05). Our results support the hypothesis that high plasma glucose may abolish the antiatherosclerotic effect of ACE inhibitors.

Angiotensin Receptor Blockers versus ACE Inhibitors: Prevention of Death and Myocardial Infarction in High-Risk Populations

OBJECTIVE:

To determine, through a review of the medical literature, whether there is adequate evidence to support the use of angiotensin receptor blockers (ARBs) in place of angiotensin-converting enzyme (ACE) inhibitors in high-risk populations, focusing on the prevention of death and myocardial infarction (MI).

DATA SOURCES:

Original investigations, reviews, and meta-analyses were identified from the biomedical literature via a MEDLINE search (1966–August 2004). Published articles were also cross-referenced for pertinent citations, and recent meeting abstracts were searched for relevant data.

STUDY SELECTION AND DATA EXTRACTION:

All articles identified during the search were evaluated. Preference was given to prospective, randomized, controlled trials that evaluated major cardiovascular endpoints and compared ARBs with ACE inhibitors, active controls, or placebo.

DATA SYNTHESIS:

The renin—angiotensin system plays a pivotal role in the continuum of cardiovascular disease and represents a major therapeutic target in the treatment of patients at risk for vascular events. While ACE inhibitors have been definitively shown to prevent death and MI, studies with ARBs in similar populations have not reduced these endpoints. In clinical trials that enrolled patients with heart failure, post-MI, diabetes, and hypertension, ARBs did not prevent MI or prolong survival compared with ACE inhibitors, other antihypertensives, or placebo.

CONCLUSIONS:

ACE inhibitors and ARBs should not be considered interchangeable, even among patients with a documented history of ACE inhibitor intolerance. ARBs can be considered a second-line alternative in such patients with the realization that they have not been shown to prevent MI or prolong survival.

Eliciting and using expert opinions about influence of patient characteristics on treatment effects: a Bayesian analysis of the CHARM trials

When randomized trial results are available for several different groups of patients, neither applying the overall results to each type of patient nor using group-specific results is entirely satisfactory. Instead, we estimate group-specific treatment effects using a Bayesian approach with informative priors for the treatment x group interactions. We describe how we elicited these prior beliefs about the effects of a new drug for the treatment of heart failure in three different patient groups. Using results from three trials, one in each patient group, the posterior mean treatment effects are very similar to the trial-specific maximum likelihood estimates, showing that in this case each trial effectively stands by itself. Our methods can also be applied to subgroup analyses in a single clinical trial, where subgroup-specific posterior means are likely to lie between the subgroup-specific maximum likelihood estimates and the pooled maximum likelihood estimates.

Mortality and Morbidity Reduction With Candesartan in Patients With Chronic Heart Failure and Left Ventricular Systolic Dysfunction

Background— Patients with symptomatic chronic heart failure (CHF) and reduced left ventricular ejection fraction (LVEF) have a high risk of death and hospitalization for CHF deterioration despite therapies with angiotensin-converting enzyme (ACE) inhibitors, β-blockers, and even an aldosterone antagonist. To determine whether the angiotensin-receptor blocker (ARB) candesartan decreases cardiovascular mortality, morbidity, and all-cause mortality in patients with CHF and depressed LVEF, a prespecified analysis of the combined Candesartan in Heart Failure Assessment of Reduction in Mortality and morbidity (CHARM) low LVEF trials was performed. CHARM is a randomized, double-blind, placebo-controlled, multicenter, international trial program.

Methods and Results— New York Heart Association (NYHA) class II through IV CHF patients with an LVEF of ≤40% were randomized to candesartan or placebo in 2 complementary parallel trials (CHARM-Alternative, for patients who cannot tolerate ACE inhibitors, and CHARM-Added, for patients who were receiving ACE inhibitors). Mortality and morbidity were determined in 4576 low LVEF patients (2289 candesartan and 2287 placebo), titrated as tolerated to a target dose of 32 mg once daily, and observed for 2 to 4 years (median, 40 months). The primary outcome (time to first event by intention to treat) was cardiovascular death or CHF hospitalization for each trial, with all-cause mortality a secondary end point in the pooled analysis of the low LVEF trials. Of the patients in the candesartan group, 817 (35.7%) experienced cardiovascular death or a CHF hospitalization as compared with 944 (41.3%) in the placebo group (HR 0.82; 95% CI 0.74 to 0.90; P <0.001) with reduced risk for both cardiovascular deaths (521 [22.8%] versus 599 [26.2%]; HR 0.84 [95% CI 0.75 to 0.95]; P =0.005) and CHF hospitalizations (516 [22.5%] versus 642 [28.1%]; HR 0.76 [95% CI 0.68 to 0.85]; P <0.001). It is important to note that all-cause mortality also was significantly reduced by candesartan (642 [28.0%] versus 708 [31.0%]; HR 0.88 [95% CI 0.79 to 0.98]; P =0.018). No significant heterogeneity for the beneficial effects of candesartan was found across prespecified and subsequently identified subgroups including treatment with ACE inhibitors, β-blockers, an aldosterone antagonist, or their combinations. The study drug was discontinued because of adverse effects by 23.1% of patients in the candesartan group and 18.8% in the placebo group; the reasons included increased creatinine (7.1% versus 3.5%), hypotension (4.2% versus 2.1%), and hyperkalemia (2.8% versus 0.5%), respectivelyt (all P <0.001).

Conclusion— Candesartan significantly reduces all-cause mortality, cardiovascular death, and heart failure hospitalizations in patients with CHF and LVEF ≤40% when added to standard therapies including ACE inhibitors, β-blockers, and an aldosterone antagonist. Routine monitoring of blood pressure, serum creatinine, and serum potassium is warranted.

Angiotensin II Receptor Blockers in Older Patients

Older patients with hypertension are often inadequately treated due to misconceptions regarding reasonable goal blood pressures or concerns about treatment side effects. Adequately treating hypertension can yield impressive benefits in terms of improved morbidity and enhanced quality of life in persons of any age. Antagonists of the renin-angiotensin-aldosterone system are especially effective in older persons, many of whom have concomitant conditions such as diabetes mellitus, renal dysfunction, and other cardiovascular risk factors. Treatment with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers has been shown to improve many of the complications of hypertension, including left ventricular hypertrophy and renal disease. Results of recent key studies such as Losartan Intervention For Endpoint Reduction in Hypertension (LIFE), Valsartan in Heart Failure Trial (Val-HeFT), Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM), and Valsartan in Acute Myocardial Infarction (VALIANT) add to the evidence that angiotensin II receptor blockers are well suited for the treatment of hypertension in older patients. These trials also indicate that they are appropriate therapy for heart failure patients and for patients who have experienced acute myocardial infarction, particularly those who are unable to tolerate an angiotensin-converting enzyme inhibitor.

A phase II, double-blind, randomized, placebo-controlled, dose comparative study of the efficacy, tolerability, and safety of MCC-135 in subjects with chronic heart failure, NYHA class II/III (MCC-135-GO1 study): rationale and design

BACKGROUND

Chronic heart failure (CHF) can be caused either by a predominant abnormality in systolic function (systolic heart failure) or a predominant abnormality in diastolic function (diastolic heart failure). Randomized clinical trials have identified a number of pharmaceutical agents that can reduce morbidity and mortality in patients with systolic heart failure. Despite significant therapeutic advances, systolic heart failure continues to result in high rates of morbidity and mortality. In contrast to systolic heart failure, no randomized clinical trials have been performed in patients with diastolic heart failure. Common to the mechanisms causing both systolic and diastolic heart failure are abnormalities in calcium homeostasis. Mitsubishi Pharma Corporation has developed a compound (MCC-135, INN; caldaret) whose mechanism of action is proposed to be modulation of calcium homeostasis at the sarcoplasmic reticulum and cellular membrane. The purpose of this study was to test the safety, tolerability, and efficacy of MCC-135 in patients with mild to moderate heart failure.

METHODS

This was a phase II, multicenter, randomized, double-blind study of parallel group design comparing 3 oral dose regimens of MCC-135 (5 mg, 25 mg, 50 mg, twice daily) with a placebo control. The treatment period was 24 weeks. A total of 511 patients were recruited from 69 centers in the United States and Europe. One hundred and twenty-five patients were recruited in each of the 4 treatment groups. Patients in each treatment group were divided into 2 cohorts: those with an ejection fraction < or = 40%, and those with an ejection fraction >40% as determined by core laboratory analysis of echocardiographic studies.

CONCLUSION

Patient recruitment was completed in September 2002. Patient follow-up was completed by February 2003; the results will be available for release in 2004.

Hospitalization for heart failure in the presence of a normal left ventricular ejection fraction

OBJECTIVES

We conducted a prospective multicenter registry in a large metropolitan area to define the clinical characteristics, hospital course, treatment, and factors precipitating decompensation in patients hospitalized for heart failure with a normal ejection fraction (HFNEF).

BACKGROUND

The clinical profile of patients hospitalized for HFNEF has been characterized by retrospective analyses of hospital records and state data banks, with few prospective single-center studies.

METHODS

Patients hospitalized for heart failure (HF) at 24 medical centers in the New York metropolitan area and found to have a left ventricular (LV) ejection fraction of > or 50% within seven days of admission were included in this registry. Patient demographics, signs and symptoms of HF, coexisting and exacerbating cardiovascular and medical conditions, treatment, laboratory tests, procedures, and hospital outcomes data were collected. Analysis by gender and race was prespecified.

RESULTS

Of 619 patients, 73% were women, who were on average four years older than men (72.8 +/- 14.1 years vs. 68.6 +/- 13.8 years, p < 0.001). Black non-Hispanic patients comprised 30% of the study population. They were eight years younger than other patients (66.0 +/- 14.2 years vs. 74 +/- 13.5 years p < 0.001). Co-morbid conditions and their prevalence were: hypertension, 78%; increased LV mass, 82%; diabetes, 46%; and obesity, 46%. Before clinical decompensation that precipitated hospitalization, 86% of patients had chronic symptoms compatible with New York Heart Association functional classes II to IV. Factors precipitating clinical decompensation were identified in 53% of patients. In-hospital mortality was 4.2%.

CONCLUSIONS

Patients hospitalized for HFNEF are most often chronically incapacitated elderly women with a history of hypertension and increased LV mass. Reasons for clinical decompensation are identified in only one-half of patients.

Efficacy and safety of oral candesartan cilexetil in patients with congestive heart failure

BACKGROUND

Candesartan cilexetil is a new angiotensin II receptor blocker with a high affinity for the angiotensin II-subtype 1 receptor.

AIMS

This 6-month study examined the safety and efficacy of candesartan cilexetil, 8 mg once daily, to prevent the progression of congestive heart failure (CHF).

METHODS

This randomised, double-blind, placebo-controlled study enrolled 305 patients with CHF who were not receiving ACE inhibitor therapy. The composite primary efficacy endpoint was progression of CHF or addition or dose escalation of CHF medications. The secondary endpoints were incidence of cardiovascular events and changes in left ventricular function.

RESULTS

The study was prematurely terminated after the second interim safety analysis. The incidence of confirmed progression of CHF was significantly lower in the candesartan group (7.4%) than in the placebo group (22.2%), with a risk reduction of 66.7% and a risk difference of -14.8% (95% CI: -22.8 to -6.8%, P<0.001). Cardiovascular events were also significantly lower during treatment with candesartan than with placebo (10.8% vs. 22.9%) with a risk reduction of 52.8% and a risk difference of -12.1% (95% CI: -20.6 to -3.6%, P<0.01). The actively treated group had a significant improvement in hemodynamics. Candesartan cilexetil was well tolerated.

CONCLUSION

Candesartan cilexetil, 8 mg/day, significantly reduced the progression of CHF when compared with placebo.

AII antagonists in hypertension, heart failure, and diabetic nephropathy: focus on losartan

The goal of antihypertensive therapy is to prevent cardiovascular complications of hypertension, such as heart failure, stroke, end stage renal disease, and death, not just to normalize blood pressure. Recently, several clinical trials investigated the beneficial effects of angiotensin II antagonists (AIIAs) in patients with hypertension, heart failure or diabetic nephropathy utilizing proven clinical outcomes (e.g., all-cause mortality) rather than surrogate outcomes (e.g., blood pressure or proteinuria). The AIIAs may offer therapeutic advantages with respect to particular outcomes in certain types of patients. Evidence is also emerging that losartan may possess beneficial pharmacological properties such as effects on uric acid, platelets, sexual dysfunction, and cognitive function, that may set it apart from other members of the AIIA class. However, further studies are needed to delineate fully these potential pharmacological differences among the AIIAs and their possible clinical relevance. This paper reviews recent AIIA outcomes studies in patients with hypertension, heart failure, or diabetic nephropathy and also examines data suggesting that molecular differences exist within the AIIA class, differences that may assist in explaining the outcomes achieved in these recent trials.

Clinical trials update from the European Society of Cardiology: CHARM, BASEL, EUROPA and ESTEEM

This article contains a series of reports on recent research developments in the field of heart failure. Reports of key presentations made at the European Society of Cardiology meeting, held in Vienna, Austria, between 30 August and 3 September 2003 are reported. In the CHARM study, candesartan reduced cardiovascular deaths and hospital admissions for heart failure, both in patients who were already taking an ACE-inhibitor and in those who were ACE intolerant. However, results in patients with preserved left ventricular function were less conclusive. The BASEL study supports the use of B-type natriuretic peptide testing to confirm the diagnosis of heart failure in patients presenting with acute dyspnoea. In EUROPA, the largest ever study of secondary prevention of coronary artery disease, long-term treatment with perindopril reduced the incidence of cardiovascular death, myocardial infarction (MI) and cardiac arrest. The ESTEEM study showed that the oral thrombin inhibitor ximelagatran plus aspirin was more effective than aspirin alone in the prophylaxis of major cardiovascular events following MI.

Update on therapy for heart failure

The success of angiotensin-converting enzyme (ACE) inhibitors in reducing morbidity and mortality in patients with heart failure has led to investigations of other inhibitors of the renin-angiotensin-aldosterone system. Although ACE inhibitors remain first-line drugs in the treatment of heart failure and left ventricular dysfunction, clinical evidence suggests that a newer class of agents--angiotensin II receptor blockers--may provide additional benefit by blocking the adverse effects of angiotensin II more completely. An improved adverse-effect profile also makes angiotensin II receptor blockers appropriate in patients who cannot tolerate ACE inhibitors. Clinical trials have demonstrated the beneficial effects of angiotensin II receptor blockers on the combined endpoints of morbidity and mortality in patients with heart failure. Aldosterone antagonism with spironolactone has additive benefits in patients receiving an ACE inhibitor. The most recent treatment guidelines for heart failure recommend the use of angiotensin II receptor blockers and spironolactone in selected patients.

Demographics, Treatment Regimens and the Use of Angiotensin-Receptor Blockers in Heart Failure: Findings from the Valsartan Heart Failure Trial

Heart failure is the only major cardiovascular disease with an incidence and prevalence that continue to increase in the developed world. Early identification and correct treatment of the condition are of paramount importance. In recent years, there has been growing interest in identifying the differences between patients in terms of their risk of heart failure and response to treatment. Differences between men and women, different age groups, patients with varying aetiologies or co-morbidities and differences between ethnic groups are only some of the factors that have been identified. This review surveys the available data on differences in responses to treatment, and discusses the use of angiotensin-receptor blockers in heart failure in light of the recent Valsartan Heart Failure Trial (Val-HeFT).

Conclusion: Heart failure is a complex syndrome, a fact that is reflected in the wide spectrum of patient characteristics and breadth of treatments available to physicians. Recommendations will keep evolving as we learn more about the changing aetiology and manifestations of the disease, and as new data become available on old and emerging treatments. The recent addition of ARBs (or at least valsartan) to the list of drugs of benefit in HF is a welcome development. Perhaps the most important message from Val-HeFT is that valsartan significantly reduced the risk of a first morbid event, irrespective of most underlying physiological and demographic parameters. This implies that valsartan will be beneficial in most patients, whether they are old or young, male or female and whatever the aetiology of their HF. As polypharmacy will continue to be the therapy of choice in HF and as no wonder-drug seems to be on the horizon to make the concept obsolete, further blocking the RAS by adding a well-tolerated agent would seem a very welcome expansion of our current treatment options.

Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial

BACKGROUND

Half of patients with chronic heart failure (CHF) have preserved left-ventricular ejection fraction (LVEF), but few treatments have specifically been assessed in such patients. In previous studies of patients with CHF and low LVEF or vascular disease and preserved LVEF, inhibition of the renin-angiotensin system is beneficial. We investigated the effect of addition of an angiotensin-receptor blocker to current treatments.

METHODS

Between March, 1999, and July, 2000, we randomly assigned 3023 patients candesartan (n=1514, target dose 32 mg once daily) or matching placebo (n=1509). Patients had New York Heart Association functional class II-IV CHF and LVEF higher than 40%. The primary outcome was cardiovascular death or admission to hospital for CHF. Analysis was done by intention to treat.

FINDINGS

Median follow-up was 36.6 months. 333 (22%) patients in the candesartan and 366 (24%) in the placebo group experienced the primary outcome (unadjusted hazard ratio 0.89 [95% CI 0.77-1.03], p=0.118; covariate adjusted 0.86 [0.74-1.0], p=0.051). Cardiovascular death did not differ between groups (170 vs 170), but fewer patients in the candesartan group than in the placebo group were admitted to hospital for CHF once (230 vs 279, p=0.017) or multiple times. Composite outcomes that included non-fatal myocardial infarction and non-fatal stroke showed similar results to the primary composite (388 vs 429; unadjusted 0.88 [0.77-1.01], p=0.078; covariate adjusted 0.86 [0.75-0.99], p=0.037).

INTERPRETATION

Candesartan has a moderate impact in preventing admissions for CHF among patients who have heart failure and LVEF higher than 40%.

Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial

BACKGROUND

Angiotensin-converting-enzyme (ACE) inhibitors improve outcome of patients with chronic heart failure (CHF). A substantial proportion of patients, however, experience no benefit from ACE inhibitors because of previous intolerance. We aimed to find out whether candesartan, an angiotensin-receptor blocker, could improve outcome in such patients not taking an ACE inhibitor.

METHODS

Between March, 1999, and March, 2001, we enrolled 2028 patients with symptomatic heart failure and left-ventricular ejection fraction 40% or less who were not receiving ACE inhibitors because of previous intolerance. Patients were randomly assigned candesartan (target dose 32 mg once daily) or matching placebo. The primary outcome of the study was the composite of cardiovascular death or hospital admission for CHF. Analysis was by intention to treat.

FINDINGS

The most common manifestation of ACE-inhibitor intolerance was cough (72%), followed by symptomatic hypotension (13%) and renal dysfunction (12%). During a median follow-up of 33.7 months, 334 (33%) of 1013 patients in the candesartan group and 406 (40%) of 1015 in the placebo group had cardiovascular death or hospital admission for CHF (unadjusted hazard ratio 0.77 [95% CI 0.67-0.89], p=0.0004; covariate adjusted 0.70 [0.60-0.81], p<0.0001). Each component of the primary outcome was reduced, as was the total number of hospital admissions for CHF. Study-drug discontinuation rates were similar in the candesartan (30%) and placebo (29%) groups.

INTERPRETATION

Candesartan was generally well tolerated and reduced cardiovascular mortality and morbidity in patients with symptomatic chronic heart failure and intolerance to ACE inhibitors.

Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial

BACKGROUND

Angiotensin II type 1 receptor blockers have favourable effects on haemodynamic measurements, neurohumoral activity, and left-ventricular remodelling when added to angiotensin-converting-enzyme (ACE) inhibitors in patients with chronic heart failure (CHF). We aimed to find out whether these drugs improve clinical outcome.

METHODS

Between March, 1999, and November, 1999, we enrolled 2548 patients with New York Heart Association functional class II-IV CHF and left-ventricular ejection fraction 40% or lower, and who were being treated with ACE inhibitors. We randomly assigned patients candesartan (n=1276, target dose 32 mg once daily) or placebo (n=1272). At baseline, 55% of patients were also treated with beta blockers and 17% with spironolactone. The primary outcome of the study was the composite of cardiovascular death or hospital admission for CHF. Analysis was done by intention to treat.

FINDINGS

The median follow-up was 41 months. 483 (38%) patients in the candesartan group and 538 (42%) in the placebo group experienced the primary outcome (unadjusted hazard ratio 0.85 [95% CI 0.75-0.96], p=0.011; covariate adjusted p=0.010). Candesartan reduced each of the components of the primary outcome significantly, as well as the total number of hospital admissions for CHF. The benefits of candesartan were similar in all predefined subgroups, including patients receiving baseline beta blocker treatment.

INTERPRETATION

The addition of candesartan to ACE inhibitor and other treatment leads to a further clinically important reduction in relevant cardiovascular events in patients with CHF and reduced left-ventricular ejection fraction.

Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme

BACKGROUND

Patients with chronic heart failure (CHF) are at high risk of cardiovascular death and recurrent hospital admissions. We aimed to find out whether the use of an angiotensin-receptor blocker could reduce mortality and morbidity.

METHODS

In parallel, randomised, double-blind, controlled, clinical trials we compared candesartan with placebo in three distinct populations. We studied patients with left-ventricular ejection fraction (LVEF) 40% or less who were not receiving angiotensin-converting-enzyme inhibitors because of previous intolerance or who were currently receiving angiotensin-converting-enzyme inhibitors, and patients with LVEF higher than 40%. Overall, 7601 patients (7599 with data) were randomly assigned candesartan (n=3803, titrated to 32 mg once daily) or matching placebo (n=3796), and followed up for at least 2 years. The primary outcome of the overall programme was all-cause mortality, and for all the component trials was cardiovascular death or hospital admission for CHF. Analysis was by intention to treat.

FINDINGS

Median follow-up was 37.7 months. 886 (23%) patients in the candesartan and 945 (25%) in the placebo group died (unadjusted hazard ratio 0.91 [95% CI 0.83-1.00], p=0.055; covariate adjusted 0.90 [0.82-0.99], p=0.032), with fewer cardiovascular deaths (691 [18%] vs 769 [20%], unadjusted 0.88 [0.79-0.97], p=0.012; covariate adjusted 0.87 [0.78-0.96], p=0.006) and hospital admissions for CHF (757 [20%] vs 918 [24%], p<0.0001) in the candesartan group. There was no significant heterogeneity for candesartan results across the component trials. More patients discontinued candesartan than placebo because of concerns about renal function, hypotension, and hyperkalaemia.

INTERPRETATION

Candesartan was generally well tolerated and significantly reduced cardiovascular deaths and hospital admissions for heart failure. Ejection fraction or treatment at baseline did not alter these effects.

Demographics and concomitant disorders in heart failure

Chronic heart failure is an increasingly common cause of premature death and poor quality of life. Community-based epidemiological studies have provided much-needed information on the demography of chronic heart failure, providing insight into its influence on public health. In most patients, chronic heart failure is accompanied by a range of concomitant disorders that both contribute to the cause of the disease and have a key role in its progression and response to treatment. Information on the most common comorbidities in chronic heart failure--ischaemic heart disease, hypertension, and diabetes mellitus--is presented for prespecified subgroups in the reports of many large-scale, multicentre trials; despite their limitations, these subanalyses provide guidance in therapeutic decision-making. Similarly, because chronic heart failure is commonly an endpoint in intervention trials of both hypertension and diabetes, such studies afford important information on the prevention of chronic heart failure in these common diseases.

The renin-angiotensin-aldosterone system: cardiorenal effects and implications for renal and cardiovascular disease states

The renin-angiotensin-aldosterone system (RAAS) plays an integral role in maintaining vascular tone, optimal salt and water homeostasis, and cardiac function in humans. However, it has been recognized in recent years that pathologic consequences may also result from overactivity of the RAAS. Clinical disease states such as renal artery stenosis, hypertension, diabetic and nondiabetic nephropathies, left ventricular hypertrophy, coronary atherosclerosis, myocardial infarction, and congestive heart failure (CHF) are examples. Part of the adverse cardiorenal effects of the RAAS may be related to the prominent role that this system plays in the activation of the sympathetic nervous system, the dysregulation of endothelial function and progression of atherosclerosis, as well as inhibition of the fibrinolytic system. Also, direct profibrotic actions of angiotensin II and aldosterone in the kidney and heart promote end organ injury. Current basic science and clinical research supports the use of inhibitors of the RAAS, including angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone antagonists in treating hypertension, improving diabetic nephropathy and other forms of chronic kidney disease, preventing or ameliorating CHF, and optimizing prognosis after myocardial infarction.

Treatment of hypertension for patients with diastolic dysfunction

Diastolic dysfunction is a poorly understood pathophysiological entity; its importance is magnified by the increasing prevalence of diastolic heart failure. Forty-six million people in the US are experiencing heart failure and 550000 new cases are diagnosed annually. A large percentage of these patients with heart failure have a normal or nearly normal left-ventricular ejection fraction. Isolated diastolic dysfunction may be associated with an increased mortality. One of the major causes of diastolic dysfunction is hypertension. Advances in diagnosis and treatment strategies may improve the clinical outcome for patients with diastolic dysfunction.