Evidence for heart failure therapies

ACE inhibitors improve symptoms in CCF (CONSENSUS) and reduce mortality even in asymptomatic patients with low ejection fraction (SOLVD). Angiotensin receptor blockers also appear to share these benefits (CHARM, ValHEFT), though any benefit when added to ACEi is controversial (CHARM, ValHEFT).

Aldosterone antagonists do confer extra benefit when added to ACEi/ARBs in NYHA 3 (RALES) and NYHA 2 CCF (EMPHASIS-HF).

Beta-blockers also improve mortality and reduce hospitalisations (CIBIS-II) with some evidence of superiority between agents (COMET). If blockers such as Ivabradine is an alternative rate-controlling agent that appears beneficial in some patients (BEAUTIFUL, SHIFT).

Neither routine anticoagulation with warfarin (WARCEF) nor treatment with digoxin (DIG) appear beneficial on mortality

Insertion of cardiac resynchronisation devices (CRT) adds further benefit (MADIT-CRT) above the benefits of inserting an implantable cardiac defibrillatory (ICD) (SCD-HeFT).

Statins do not add benefit in CCF in patients with no other indication (CORONA) and ultrafiltration appears inferior to stepped medical therapy in patients with acute cardio-renal syndrome

Surgical revascularisation may be beneficial in some patients (STITCH) but the high crossover in this trial makes interpretation very difficult.

Topic Therapy group Therapy Trial
Heart failure ACE inhibitors Enalapril CONSENSUS, SOLVD
ARBs Candesartan CHARM
Diastolic dysfunction CHARM, I-PRESERVE
Valsartan ValHeFT
Aldosterone antagonists Eplerenone (NYHA 2+) EMPHASIS-HF
Spironolactone (NYHA 3+) RALES
Anticoagulation Warfarin WARCEF
Beta-blockers Bisoprolol CIBIS-II
Carvedilol COMET
Glycosides Digoxin DIG
If channel blockers Ivabradine BEAUTIFUL, SHIFT
Statins Rosuvastatin CORONA
Ultrafiltration Cardiorenal syndrome CARRESS-HF