Antihypertensive treatment and development of heart failure in hypertension: a Bayesian network meta-analysis of studies in patients with hypertension and high cardiovascular risk

Arch Intern Med. 2011 Mar 14;171(5):384-94. doi: 10.1001/archinternmed.2010.427. Epub 2010 Nov 8.


Background: It is still debated whether there are differences among the various antihypertensive strategies in heart failure prevention. We performed a network meta-analysis of recent trials in hypertension aimed at investigating this issue.

Methods: Randomized, controlled trials published from 1997 through 2009 in peer-reviewed journals indexed in the PubMed and EMBASE databases were selected. Selected trials included patients with hypertension or a high-risk population with a predominance of patients with hypertension.

Results: A total of 223,313 patients were enrolled in the selected studies. Network meta-analysis showed that diuretics (odds ratio [OR], 0.59; 95% credibility interval [CrI], 0.47-0.73), angiotensin-converting enzyme (ACE) inhibitors (OR, 0.71; 95% CrI, 0.59-0.85) and angiotensin II receptor blockers (ARBs) (OR, 0.76; 95% CrI, 0.62-0.90) represented the most efficient classes of drugs to reduce the heart failure onset compared with placebo. On the one hand, a diuretic-based therapy represented the best treatment because it was significantly more efficient than that based on ACE inhibitors (OR, 0.83; 95% CrI, 0.69-0.99) and ARBs (OR, 0.78; 95% CrI, 0.63-0.97). On the other hand, diuretics (OR, 0.71; 95% CrI, 0.60-0.86), ARBs (OR, 0.91; 95% CrI, 0.78-1.07), and ACE inhibitors (OR, 0.86; 95% CrI, 0.75-1.00) were superior to calcium channel blockers, which were among the least effective first-line agents in heart failure prevention, together with β-blockers and α-blockers.

Conclusions: Diuretics represented the most effective class of drugs in preventing heart failure, followed by renin-angiotensin system inhibitors. Thus, our findings support the use of these agents as first-line antihypertensive strategy to prevent heart failure in patients with hypertension at risk to develop heart failure. Calcium channel blockers and β-blockers were found to be less effective in heart failure prevention.

Publication types

  • Meta-Analysis
  • Review

MeSH terms

  • Adrenergic alpha-Antagonists / therapeutic use
  • Adrenergic beta-Antagonists / therapeutic use
  • Angiotensin Receptor Antagonists / therapeutic use
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Antihypertensive Agents / therapeutic use*
  • Bayes Theorem*
  • Calcium Channel Blockers / therapeutic use
  • Diuretics / therapeutic use
  • Female
  • Heart Failure / etiology
  • Heart Failure / prevention & control*
  • Humans
  • Hypertension / complications
  • Hypertension / drug therapy*
  • Male
  • Randomized Controlled Trials as Topic
  • Risk


  • Adrenergic alpha-Antagonists
  • Adrenergic beta-Antagonists
  • Angiotensin Receptor Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Antihypertensive Agents
  • Calcium Channel Blockers
  • Diuretics