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Aliskiren, Enalapril, or Aliskiren and Enalapril in Heart Failure
John J V McMurray1, Henry Krum1, William T Abraham1
1From the British Heart Foundation Cardiovascular Research Centre (J.J.V.M.) and the Robertson Centre for Biostatistics (N.G.), University of Glasgow, Glasgow, United Kingdom; Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia (H.K.); the Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, Ohio State University, Columbus (W.T.A.); Stavanger University Hospital, Stavanger, and the Institute of Internal Medicine, University of Bergen, Bergen - both in Norway (K.D.); Rigshospitalet Copenhagen University Hospital, Copenhagen (L.V.K.); the Cardiovascular Division, Brigham and Women's Hospital, Boston (A.S.D., S.D.S.); Novartis Pharma, Basel, Switzerland (M.A.A., Y.C., Q.S., G.T.); and the University of California, San Francisco, San Francisco (B.M.M.).
Insights
Adding aliskiren to enalapril for chronic heart failure did not improve outcomes and increased adverse events. Aliskiren monotherapy was not found to be noninferior to enalapril in these patients.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Chronic heart failure (CHF) management often involves angiotensin-converting-enzyme (ACE) inhibitors.
- The role of renin inhibitors, like aliskiren, in CHF is not well-established.
- This study investigates aliskiren's efficacy and safety in CHF patients with reduced ejection fraction.
Purpose of the Study:
- To compare the efficacy and safety of enalapril versus aliskiren, and their combination, in patients with CHF and reduced ejection fraction.
- To determine if aliskiren is superior or noninferior to enalapril.
- To assess the superiority of combination therapy over enalapril alone.
Main Methods:
- A double-blind, randomized trial involving patients with CHF and reduced ejection fraction.
- Three treatment groups: enalapril alone, aliskiren alone, and combination therapy (enalapril + aliskiren).
- Primary composite outcome: cardiovascular death or heart failure hospitalization.
Main Results:
- Combination therapy showed no significant benefit over enalapril alone (HR 0.93; 95% CI, 0.85-1.03).
- Aliskiren monotherapy was not noninferior to enalapril (HR 0.99; 95% CI, 0.90-1.10).
- Combination therapy increased risks of hypotension, elevated creatinine, and elevated potassium levels compared to enalapril.
Conclusions:
- Adding aliskiren to enalapril in CHF patients offers no additional benefit and increases adverse events.
- Aliskiren monotherapy did not demonstrate noninferiority to enalapril for CHF treatment.
- Current evidence does not support the use of aliskiren in combination with ACE inhibitors for CHF.
Background:
Among patients with chronic heart failure, angiotensin-converting-enzyme (ACE) inhibitors reduce mortality and hospitalization, but the role of a renin inhibitor in such patients is unknown. We compared the ACE inhibitor enalapril with the renin inhibitor aliskiren (to test superiority or at least noninferiority) and with the combination of the two treatments (to test superiority) in patients with heart failure and a reduced ejection fraction.
Methods:
After a single-blind run-in period, we assigned patients, in a double-blind fashion, to one of three groups: 2336 patients were assigned to receive enalapril at a dose of 5 or 10 mg twice daily, 2340 to receive aliskiren at a dose of 300 mg once daily, and 2340 to receive both treatments (combination therapy). The primary composite outcome was death from cardiovascular causes or hospitalization for heart failure.
Results:
After a median follow-up of 36.6 months, the primary outcome occurred in 770 patients (32.9%) in the combination-therapy group and in 808 (34.6%) in the enalapril group (hazard ratio, 0.93; 95% confidence interval [CI], 0.85 to 1.03). The primary outcome occurred in 791 patients (33.8%) in the aliskiren group (hazard ratio vs. enalapril, 0.99; 95% CI, 0.90 to 1.10); the prespecified test for noninferiority was not met. There was a higher risk of hypotensive symptoms in the combination-therapy group than in the enalapril group (13.8% vs. 11.0%, P=0.005), as well as higher risks of an elevated serum creatinine level (4.1% vs. 2.7%, P=0.009) and an elevated potassium level (17.1% vs. 12.5%, P<0.001).
Conclusions:
In patients with chronic heart failure, the addition of aliskiren to enalapril led to more adverse events without an increase in benefit. Noninferiority was not shown for aliskiren as compared with enalapril. (Funded by Novartis; ATMOSPHERE ClinicalTrials.gov number, NCT00853658.).
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