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Angiotensin blockade or aldosterone blockade as the third neuroendocrine-blocking drug in mild but symptomatic heart failure patients
  1. A D Struthers
  1. Correspondence to:
    Professor Allan D Struthers
    Division of Medicine & Therapeutics, Ninewells Hospital, Dundee DD1 9SY, UK; a.d.struthers{at}


Recent clinical trials have explored whether angiotensin receptor blockers (ARBs) or aldosterone blockade should be added to standard angiotensin-converting enzyme (ACE) inhibitor/β blocker treatment in heart failure. Both strategies are of some value but it is unclear which strategy should be used first in patients with mild but symptomatic heart failure. The arguments for and against each strategy are discussed. The strongest argument for aldosterone blockade is the consistency in the results of the RALES (Randomized Aldactone Evaluation Study) and EPHESUS (Eplerenone Post-acute Myocardial Infarction Heart Failure Efficacy and Survival Study) studies, but what is lacking is a trial of aldosterone blockade in patients with mild, symptomatic heart failure as such. The strongest argument for ARBs is that the CHARM (Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity) Added trial result was positive in the precise patient population of interest (mild, symptomatic heart failure). The strength of this argument is diminished by the somewhat different results in Val-HeFT (Valsartan Heart Failure Trial). A third possibility is to use neither an ARB nor an aldosterone blocker and arguments can be marshalled for this position also. Clinicians should now assess these various arguments to select what they believe would be best for their patients.

  • ACE, angiotensin-converting enzyme
  • ARB, angiotensin receptor blocker
  • BEST, Beta-blocker Evaluation of Survival Trial
  • CHARM, Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity
  • CONSENSUS II, Cooperative New Scandinavian Enalapril Survival Study II
  • EPHESUS, Eplerenone Post-acute Myocardial Infarction Heart Failure Efficacy and Survival Study
  • MI, myocardial infarction
  • LIFE, Losartan Intervention For Endpoint reduction in hypertension
  • MOSES, Morbidity and mortality after Stroke: Eprosartan compared with nitrendipine in Secondary prevention
  • RALES, Randomized Aldactone Evaluation Study
  • Val-HeFT, Valsartan Heart Failure Trial
  • VALIANT, Valsartan in Acute Myocardial Infarction Trial
  • VALUE, Valsartan Antihypertensive Long-term Use Evaluation

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  • Published Online First 9 December 2005

  • Research funding from the British Heart Foundation and the Chief Scientist Office.

  • Competing interests: The author has received honoraria for speaking from Pfizer (aldosterone blockers) and from Takeda, Astra Zeneca and Novartis (angiotensin receptor blockers), and has a small amount of stock in Astra Zeneca.