Authors' objectives:

This evidence-based report had two objectives. The first objective was to assess whether angiotensin-converting enzyme inhibitors (ACE inhibitors) and beta-adrenergic blocking agents (beta-blockers) are effective in patients with left ventricular systolic heart failure and whether this effectiveness differs in the following subpopulations: men, women, blacks, whites, diabetics, and nondiabetics. The second objective was to assess the cost-effectiveness of both treatment of and screening for left ventricular systolic dysfunction.

Authors' results and conclusions: We found evidence, with two exceptions, that treatment with ACE inhibitors or beta-blockers reduces all-cause mortality in male, female, black, white, diabetic, and nondiabetic patients. The two exceptions were the use of ACE inhibitors in women and the use of beta-blockers in black patients. Regarding the former, we found clear evidence that treating women with symptomatic heart failure with ACE inhibitors was beneficial. However, the available evidence do not support a beneficial effect in women with asymptomatic left ventricular systolic dysfunction. Regarding black patients, treatment with the beta-blocker bucindolol was associated with a nonstatistically significant increase in all-cause mortality, while treatment with other beta-blockers was associated with a nonstatistically significant reduction in mortality of similar magnitude to the statistically significant reductions observed in white patients. In our cost-effectiveness analyses, we found that treatment of asymptomatic left ventricular dysfunction with ACE inhibitors was very cost-effective under virtually all assumptions, with typical costs per quality-adjusted life-year gained of between $5,000 and $10,000. Additional analysis showed that screening with B-type natriuretic peptide followed by echocardiography in a cohort of asymptomatic 55-year-old individuals was also cost-effective, compared with the costs of other therapies currently considered standard medical care. The number needed to screen in order to gain one year of additional life was 77. These results were only modestly sensitive to cost and were most sensitive to the prevalence of asymptomatic decreased left ventricular ejection fraction. When the prevalence falls below about 1%, a strategy of screening becomes less cost-effective than commonly accepted thresholds for cost-effective care.

Authors' recommendations: ACE inhibitors and beta-blockers reduce mortality in a broad range of patients with left ventricular systolic dysfunction, including men and women, blacks and whites, and diabetics and nondiabetics. However, the value of ACE inhibitors in women with asymptomatic left ventricular systolic dysfunction is uncertain, and additional study is needed. In addition, based on data from a single study, the beta-blocker bucindolol may be associated with increased mortality in blacks, whereas other beta-blockers provide similar benefits in blacks and whites. Treatment of asymptomatic left ventricular dysfunction with ACE inhibitors is very cost- effective. In addition, screening for asymptomatic left ventricular dysfunction with B-type natriuretic peptide followed by echocardiography is cost-effective in populations where the prevalence of this condition is 1% or greater.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.ahrq.gov/downloads/pub/evidence/pdf/heartfailure/heartfail.pdf

Year Published: 2003

URL for published report: http://www.ahrq.gov/clinic/tp/hrtfailtp.htm

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Agency for Healthcare Research and Quality

Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;

Contact Name: martin.erlichman@ahrq.hhs.gov

Contact Email: martin.erlichman@ahrq.hhs.gov

Copyright: Agency for Healthcare Research and Quality (AHRQ)