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Editor's Correspondence | Health Care Reform

Network Meta-analysis of Heart Failure Prevention by Antihypertensive Drugs

William J. Elliott, MD, PhD; Sanjib Basu, PhD; Peter M. Meyer, PhD
Arch Intern Med. 2011;171(5):472-473. doi:10.1001/archinternmed.2011.44.
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We agree with the conclusions of the “network meta-analysis” of heart failure prevention by antihypertensive drugs, which used a Bayesian technique and 26 clinical trials.1 We have reported similar results supporting the superiority of a diuretic using both the network meta-analytic technique of Lumley,2 and a Bayesian technique, which included data from all 47 or 53 of the then published hypertension clinical trials.3,4 We noted the great preponderance of evidence favoring chlorthalidone, which accounts for more than 90% of their heart failure cases. Although a network meta-analysis in 2004 suggested no significant difference between chlorthalidone vs another diuretic as initial therapy to prevent heart failure,5 data from all 61 hypertension trials involving 355 225 subjects (from the first Veterans Administration trial6 to the very recent Valsartan Amlodipine Randomized Trial7), using the therapeutic categories of Sciarretta et al1 suggests a major difference in precision among diuretics (Figure). “Other diuretics” has the smallest number of heart failure cases of any treatment, nearly 4-times smaller than that for chlorthalidone. The P value for chlorthalidone is nearly 5 orders of magnitude smaller than that of “other diuretics.” Our results were robust to many sensitivity analyses, such as when combining “conventional therapy” and “β-blocker,” including only studies that randomized subjects to initial therapy, omitting data from studies done in nonhypertensive patients, and omitting data from the Antihypertensive and Lipid-Lowering to prevent Heart Attack Trial (ALLHAT). We add to the conclusions of Sciaretta et al1 that the clinical trial evidence is strongest, by far, for chlorthalidone as the most effective antihypertensive agent to prevent heart failure.

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Figure.

Odds ratios (95% confidence intervals [CIs]) for incident heart failure associated with different types of antihypertensive drugs in clinical trials, determined by the network meta-analytic technique of Lumley.2 ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; CT, conventional therapy (diuretic and/or β-blocker); ω, incoherence.

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