Antihypertensive Treatment and Development of Heart Failure in Hypertension A Bayesian Network Meta-analysis of Studies in Patients With Hypertension and High Cardiovascular Risk

Background: It is still debated whether there are differences among the various antihypertensive strategies in heart failure prevention. We performed a network meta-analysis of recent trials in hypertension aimed at investigating this issue. Methods: Randomized, controlled trials published from 1997 through 2009 in peer-reviewed journals indexed in the PubMed and EMBASE databases were selected. Selected trials included patients with hypertension or a high-risk population with a predominance of patients with hypertension. Results: A total of 223 313 patients were enrolled in the selected studies. Network meta-analysis showed that diuretics (odds ratio [OR], 0.59; 95% credibility interval [CrI], 0.47-0.73), angiotensin-converting enzyme (ACE) inhibitors (OR, 0.71; 95% CrI, 0.59-0.85) and angiotensin II receptor blockers (ARBs) (OR, 0.76; 95% CrI, 0.62-0.90) represented the most efficient classes of drugs to reduce the heart failure onset compared with placebo. On the one hand, a diuretic-based therapy represented the best treatment because it was significantly more efficient than that based on ACE inhibitors (OR, 0.83; 95% CrI, 0.69-0.99) and ARBs (OR, 0.78; 95% CrI, 0.63-0.97). On the other hand, diuretics (OR, 0.71; 95% CrI, 0.60-0.86), ARBs (OR, 0.91; 95% CrI, 0.78-1.07), and ACE inhibitors (OR, 0.86; 95% CrI, 0.75-1.00) were superior to calcium channel blockers, which were among the least effective first-line agents in heart failure prevention, together with beta-blockers and alpha-blockers. Conclusions: Diuretics represented the most effective class of drugs in preventing heart failure, followed by renin- angiotensin system inhibitors. Thus, our findings support the use of these agents as first-line antihypertensive strategy to prevent heart failure in patients with hypertension at risk to develop heart failure. Calcium channel blockers and beta-blockers were found to be less effective in heart failure prevention.