Blood Pressure-Lowering Treatment and the Prevention of Heart Failure: Differences and Similarities of Antihypertensive Drug Classes

Benefit of blood pressure (BP)-lowering treatment on various outcomes was evaluated by meta-analyses restricted to randomized controlled trials (RCTs) measuring all major outcomes. The question whether BP-lowering and each class of antihypertensive agents prevent “new-onset” heart failure was explored by additional meta-analyses limited to RCTs excluding baseline heart failure from randomization. Thirty-five BP-lowering RCTs measured all outcomes, and heart failure [RR 0.63 (0.52–0.75)] and stroke [RR 0.58 (0.49–0.68)] were the outcomes most effectively prevented. Heart failure and stroke reductions were significantly related to systolic BP, diastolic BP, and pulse pressure reductions. In 18 BP-lowering RCTs excluding baseline heart failure from recruitment, heart failure reduction (“new-onset” heart failure) [RR 0.58 (0.44–0.75)] was very similar to that observed in the entire set of RCTs. In meta-analyses of head-to-head comparisons of different antihypertensive classes, calcium antagonists were inferior in preventing “new-onset” heart failure [RR 1.16 (1.01–1.33)]. However, this inferiority disappeared when meta-analysis was limited to RCTs allowing concomitant use of diuretics, beta-blockers, or renin-angiotensin system blockers, also in the calcium antagonist group [RR 0.96 (0.81–1.12)]. BP-lowering treatment effectively prevents “new-onset” heart failure. It is suggested that BP lowering by calcium antagonists is effective as BP lowering by other drugs in preventing “new-onset” heart failure, unless the trial design creates an unbalance against calcium antagonists.