Relative efficacy of vasodilator therapy in chronic congestive heart failure. Implications of randomized trials
C. D. Mulrow, J. P. Mulrow, W. D. Linn, C. Aguilar and G. Ramirez
Division of General Internal Medicine, University of Texas Health Science Center, San Antonio.
We examined existing evidence concerning the relative efficacy of various
vasodilator agents in chronic congestive heart failure. Only randomized
placebo-controlled trials with clinical end points and treatment durations
of four weeks or more were selected from an exhaustive search of the
English-language medical literature. Twenty-eight trials involving 1976
patients were found. Treatment durations of the trials varied from one
month to two years. Patients with symptomatic heart failure despite
digitalis and diuretic therapy were studied; most were middle-aged men and
approximately half had coronary artery disease. Results of the trials were
appraised by three independent observers, and mortality and functional
status outcomes were pooled in a meta-analysis. All vasodilator agents
except hydralazine hydrochloride were associated with improvements in
functional status. Angiotensin converting-enzyme inhibitors were the only
agents associated with both decreased mortality (odds ratio, 0.51; 95%
confidence interval, 0.34 to 0.75) and improved functional status (odds
ratio, 4.53; 95% confidence interval, 3.46 to 5.92). The optimal timing for
initiation of these agents was not established.
