ReviewEfficacy of ACE inhibitors in chronic heart failure with preserved ejection fraction — A meta analysis of 7 prospective clinical studies
Introduction
Heart failure with preserved left ventricular ejection fraction (HFPEF) has emerged as a major cause of morbidity and mortality worldwide. Epidemiological data revealed that the prevalence of HFPEF varied from 13%–74% in heart failure patients [1], [2], [3], [4] and that the mortality of HFPEF was the same as that of heart failure with reduced ejection fraction (HFREF) [5], [6]. Angiotensin-converting enzyme inhibitors (ACE inhibitors) constitute first-line treatment for patients with HFREF with proven effects of reducing mortality and morbidity; however, the effects of ACE inhibitors on HFPEF remain controversial. The aim of this meta-analysis was to assess the efficacy of ACE inhibitors in HFPEF patients, based on the results of the most recently published prospective studies.
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Search strategy
We used PubMed, EMBASE, BIOSIS, the Cochrane Library (Issue 3, 2009) and OVID databases to search for all electronically registered clinical trials by means of the following keywords: angiotensin-converting enzyme inhibitor, captopril, enalapril, benazepril, perindopril, alacepril, zofenopril, cilazapril, quinapril, ramipril, spirapril, imidapril, delapril, lisinopril, fosinopril, trandolapril, heart failure with preserved ejection fraction, heart failure with normal left ventricular ejection
Literature search and study selection
After screening the titles and abstracts of all studies identified by the search strategy, 354 potentially relevant articles were selected and retrieved for more detailed information. Further screening for eligibility was performed by two independent reviewers using the inclusion and exclusion criteria (Fig. 1). Finally, 7 studies were included, all of which were published in English.
Overall study characteristics
The seven selected studies comprised a total of 2554 patients (mean age 75.1 years, female 58%, mean LVEF > 57.1%),
Discussion
The present study demonstrated that ACE inhibitors as monotherapy or first-line therapy resulted in a significant reduction in all-cause mortality in HFPEF. In addition, ACE inhibitors reduced heart failure related rehospitalization in a HEPEF subgroup aged > 75 or treatment over a period of 21 months. However, neither death due to worsening of heart failure nor all-cause rehospitalization was affected by ACE inhibitors.
There was no definite cut-off value for preserved ejection fraction. The
Acknowledgments
The study was supported by the Eleventh Five-Year Science and Technology Support Program of China (2006BAI01A04). The authors are grateful to Dr. Kai Hu from Wuerzburg University in Germany for assistance with the preparation of this manuscript. The authors of this manuscript have certified that they comply with the principles of ethical publishing in the International Journal of Cardiology [40].
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These authors contributed equally to this work.