A 3-month double-blind cross-over study of the effect of benazepril and hydrochlorothiazide on functional class in symptomatic mild heart failure

WITHDRAWN: Diuretics for heart failure

This protocol was withdrawn in April 2016 as the author team was unable to progress to the final review stage. An editorial decision was taken not to pursue this title.

The editorial group responsible for this previously published document have withdrawn it from publication.

Diuretics for heart failure

BACKGROUND

Chronic heart failure is a major cause of morbidity and mortality worldwide. Diuretics are regarded as the first-line treatment for patients with congestive heart failure since they provide symptomatic relief. The effects of diuretics on disease progression and survival remain unclear.

OBJECTIVES

To assess the harms and benefits of diuretics for chronic heart failure

SEARCH METHODS

Updated searches were run in the Cochrane Central Register of Controlled Trials in The Cochrane Library (CENTRAL Issue 1 of 4, 2011), MEDLINE (1966 to 22 February 2011), EMBASE (1980 to 2011 Week 07) and HERDIN database (1990 to February 2011). We hand searched pertinent journals and reference lists of papers were inspected. We also contacted manufacturers and researchers in the field. No language restrictions were applied.

SELECTION CRITERIA

Double-blinded randomised controlled trials of diuretic therapy comparing one diuretic with placebo, or one diuretic with another active agent (e.g. ACE inhibitors, digoxin) in patients with chronic heart failure.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted the data and assessed the eligibility and methodological quality of each trial. Extracted data were analysed by determining the odds ratio for dichotomous data, and difference in means for continuous data, of the treated group compared with controls. The likelihood of heterogeneity of the study population was assessed by the Chi-square test. If there was no evidence of statistical heterogeneity and pooling of results was clinically appropriate, a combined estimate was obtained using the fixed-effects model.

MAIN RESULTS

This update has not identified any new studies for inclusion. The review includes 14 trials (525 participants), 7 were placebo-controlled, and 7 compared diuretics against other agents such as ACE inhibitors or digoxin. We analysed the data for mortality and for worsening heart failure. Mortality data were available in 3 of the placebo-controlled trials (202 participants). Mortality was lower for participants treated with diuretics than for placebo, odds ratio (OR) for death 0.24, 95% confidence interval (CI) 0.07 to 0.83; P = 0.02. Admission for worsening heart failure was reduced in those taking diuretics in two trials (169 participants), OR 0.07 (95% CI 0.01 to 0.52; P = 0.01). In four trials comparing diuretics to active control (91 participants), diuretics improved exercise capacity in participants with CHF, difference in means WMD 0.72 , 95% CI 0.40 to 1.04; P < 0.0001.

AUTHORS' CONCLUSIONS

The available data from several small trials show that in patients with chronic heart failure, conventional diuretics appear to reduce the risk of death and worsening heart failure compared to placebo. Compared to active control, diuretics appear to improve exercise capacity.

Antihypertensive and organ-protective effects of benazepril

Benazepril is a nonsulfhydryl ACE inhibitor with favorable pharmacodynamic and pharmacokinetic properties, well-established antihypertensive effects and a good tolerability profile. Recent clinical studies have demonstrated that patients treated with benazepril alone or in combination with hydrochlorothiazide or amlodipine may achieve beneficial renal outcomes that extend beyond blood pressure control. Furthermore, the recent Avoiding Cardiovascular Events Through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial showed decreased cardiovascular morbidity and mortality with benazepril when administered as a cotreatment. An additional novel therapeutic area for benazepril is atrial fibrillation. Differences between combination therapies have implications for which patients may be best suited to particular interventions, and further studies are required to fully ascertain this potential.

Loop diuretic therapy in heart failure: the need for solid evidence on a fluid issue

BACKGROUND

Heart failure (HF) is a common condition associated with substantial cost, morbidity, and mortality. Because results of clinical trials in the acute decompensated heart failure (ADHF) setting have been mostly neutral, loop diuretics remain the mainstay of treatment.

HYPOTHESIS

Loop diuretic use may be associated with unfavorable outcomes.

METHODS

A MEDLINE literature search was performed to identify articles relating to heart failure and loop diuretics. The current evidence on the risks and benefits of loop diuretics for the treatment of ADHF is reviewed.

RESULTS

Loop diuretics are associated with symptomatic improvements in congestion, urine output, and body weight, but have shown no long-term mortality benefit. Loop diuretics, especially at high doses, are associated with worsened renal function and other poor outcomes.

CONCLUSIONS

Loop diuretics still prove useful in HF treatment, but risk-benefit analysis of these agents in the treatment of ADHF requires a well-designed prospective study.

Diuretics for heart failure

BACKGROUND

Chronic heart failure is a major cause of morbidity and mortality world-wide. Diuretics are regarded as the first-line treatment for patients with congestive heart failure since they provide symptomatic relief. The effects of diuretics on disease progression and survival remain unclear.

OBJECTIVES

To assess the harms and benefits of diuretics for chronic heart failure

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (Issue 2 2004), MEDLINE 1966-2004, EMBASE 1980-2004 and HERDIN database. We hand searched pertinent journals and reference lists of papers were inspected. We also contacted manufacturers and researchers in the field.

SELECTION CRITERIA

Only double-blinded randomised controlled trials of diuretic therapy comparing one diuretic with placebo, or one diuretic with another active agent (e.g. ACE inhibitors, digoxin) in patients with chronic heart failure were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently abstracted the data and assessed the eligibility and methodological quality of each trial. Extracted data were entered into the Review Manager 4.2 computer software, and analysed by determining the odds ratio for dichotomous data, and difference in means for continuous data, of the treated group compared with controls. The likelihood of heterogeneity of the study population was assessed by the Chi-square test. If there was no evidence of statistical heterogeneity and pooling of results was clinically appropriate, a combined estimate was obtained using the fixed-effects model.

MAIN RESULTS

We included 14 trials (525 participants), 7 were placebo-controlled, and 7 compared diuretics against other agents such as ACE inhibitors or digoxin. We analysed the data for mortality and for worsening heart failure. Mortality data were available in 3 of the placebo-controlled trials (202 participants). Mortality was lower for participants treated with diuretics than for placebo, odds ratio (OR) for death 0.24, 95% confidence interval (CI) 0.07 to 0.83; P = 0.02. Admission for worsening heart failure was reduced in those taking diuretics in two trials (169 participants), OR 0.07 (95% CI 0.01 to 0.52; P = 0.01). In four trials comparing diuretics to active control (91 participants), diuretics improved exercise capacity in participants with CHF, difference in means WMD 0.72 , 95% CI 0.40 to 1.04; P < 0.0001.

AUTHORS' CONCLUSIONS

The available data from several small trials show that in patients with chronic heart failure, conventional diuretics appear to reduce the risk of death and worsening heart failure compared to placebo. Compared to active control, diuretics appear to improve exercise capacity.

Postmarketing surveillance study of benazepril in chinese patients with hypertension: An open-label, experimental, epidemiologic study

BACKGROUND

Benazepril hydrochloride is an angiotensin-converting enzyme inhibitor. Previous clinical trials show that antihypertensive treatment with benazepril provides effective blood pressure (BP) control and is generally well tolerated by patients with hypertension. However, the long-term antihypertensive effects and tolerability of benazepril remain to be established in Chinese patients with hypertension.

OBJECTIVE

The aim of this study was to investigate the long-term efficacy and tolerability of benazepril in Chinese patients with essential hypertension.

METHODS

This 36-month, community-based, open-label, postmarketing surveillance study was conducted in the Nanshi District (Shanghai, China). Chinese patients with essential hypertension were to receive 1 or more benazepril tablets PO QD in the morning for 36 months. Data for BP and pulse pressure (PP) were collected at baseline (month 0) and throughout the surveillance period. The rate of patients achieving BP targets (systolic BP [SBP]/diastolic BP [DBP], <140/<90 mm Hg) was determined, as was the rate of decrease in BP. Subanalyses by sex and age group also were conducted.

RESULTS

A total of 1831 patients (1090 men, 741 women; mean [SD] age, 55.8 [10.1] years [range, 35-88 years]) entered the study. After the 36-month treatment period, 75.7% of patients receiving benazepril as prescribed (1289 patients) had achieved the SBP target, 87.4% achieved the DBP target, and 71.5% achieved both targets. After 36 months of treatment, the mean (SD) decreases in SBP, DBP, and PP were 15.1 (0.4) mm Hg, 11.0 (0.3) mm Hg, and 4.2 (0.4) mm Hg, respectively, among compliers. In general, the rate of BP decrease slowed over time. No serious adverse drug reactions (ADRs) were detected during the 36-month follow-up period. All ADRs except cough (19.9%) occurred at a relatively low incidence rate (<3.0%). The cumulative incidence of benazepril related cough was statistically significantly higher in women than in men (23.6% vs 18.8%, respectively; P = 0.007). Of the 1831 patients studied, 1360 patients (74.3%) persisted in taking benazepril and were considered optimally compliant at 36-month follow-up.

CONCLUSION

In this study of Chinese patients with hypertension, benazepril was associated with prolonged, stable efficacy in lowering BP and relatively low incidence of ADRs.

Current evidence supporting the role of diuretics in heart failure: a meta analysis of randomised controlled trials

OBJECTIVE

To summarise the current evidence from randomised controlled trials for diuretics in patients with congestive heart failure (CHF).

DATA SOURCES

English-language randomised controlled trials and review papers referenced in Medline, Embase between 1966 and 1999. General literature review of pertinent journals was carried out and reference lists of papers were inspected.

REVIEW METHOD

STUDY DESIGN

Meta-analysis of randomised controlled trials of diuretic therapy in patients with CHF.

STUDY SELECTION

Studies were included if they were randomised comparisons of loop or thiazide diuretics and control, or one diuretic and another active agent (e.g. ACE inhibitors, ibopamine and digoxin).

DATA ABSTRACTION

Using a standardised protocol, two reviewers independently abstracted the data and assessed the methodological quality of each paper.

DATA SYNTHESIS

The odds ratio (OR) of treated group compared with control was estimated for each end-point outcome and plotted against each other using the fixed-effects model. THE MAIN OUTCOME MEASURES: The primary outcomes of our analysis were effects of diuretics on mortality and morbidity.

RESULTS

Eighteen trials met our criteria and were eligible for analysis, involving 928 patients. Eight trials were placebo-controlled. We analysed the data for mortality and for worsening heart failure. A further ten trials compared diuretics against other agents such as ACE inhibitors, ibopamine, and digoxin. Mortality data were available in three of the placebo-controlled trials (n=221); the mortality rate was lower for patients treated with diuretics than for control [the odds ratio for death, 0.25; 95% confidence intervals (CI), 0.07-0.84; P=0.03]. Admissions for worsening heart failure in the four small trials (n=448) showed an odds ratio of 0.31 (95% CI 0.15-0.62; P=0.001). In six studies of diuretics compared to active control, diuretics significantly improved exercise capacity in patients with CHF [OR: 0.37; CI: 0.10-0.64, P=0.007].

CONCLUSION

Compared to active control, diuretics appear to reduce the risk of worsening disease and improve exercise capacity. The available data from small studies show that in CHF conventional diuretics reduce the risk of death and worsening heart failure compared to placebo.

[Evidence based medical treatment of heart failure]

INTRODUCTION AND OBJECTIVES

Recommendations for the treatment of heart failure were carried out by a systematic review of the available evidence of the different pharmacologic treatments.

MATERIAL AND METHODS

The review focused on the treatment of chronic and systolic heart failure. All the studies published in english about the pharmacologic treatment of heart failure where identified. The evidence of every pharmacologic treatment was classified according to: a) efficacy variables (reduction of mortality and hospitalizations, improvement of functional class, ejection fraction and exercise tolerance), and b) the level of quality of the evidence according to an evaluation scale. The evidence was also reviewed for the comparisons and the combinations of the pharmacologic treatments, as well as for the toxicity and costs of treatments.

RESULTS

The recommendations were defined according to the NYHA functional class and were classified in the A, B and C categories according to the level of quality of the available evidence. The evidence on mortality was considered the most important. First line drugs, the alternatives and other possible treatments were take into account.

CONCLUSIONS

There is enough evidence based on information about some variables such as reduction of mortality or hospitalizations to carry out treatment recommendations in all stages of heart failure. This point out the interest ant the priority of used them in the evaluation and improvement of the results of heart failure.