Angiotensin Receptor Blockers

Post-MI Studies. The VALIANT trial evaluated the clinical effectiveness of ACE inhibitors and ARBs in patients with a recent MI (0.5-14 days), an LVEF <=40% and clinical or radiographic signs of HF.16 The addition of valsartan to captopril did not result in a significant improvement in total mortality or cardiovascular mortality compared to captopril alone, and there were more drug-related adverse events in the valsartan-captopril group.

The Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan (OPTIMAAL) was designed to prove that losartan would be superior or not inferior to captopril in decreasing all-cause mortality in patients with MI complicated by reduced LVEF.17 There was a trend toward decreased all-cause mortality in the captopril group compared with losartan, and fewer captopril-treated patients experienced sudden death or a resuscitated cardiac arrest.17 The addition of losartan to captopril did not result in a significant improvement in total mortality or cardiovascular mortality compared with captopril alone, and there were more drug-related adverse events in the losartan-captopril group.

The results of VALIANT cannot be directly compared with those of Val-HeFT and CHARM, because VALIANT was conducted in patients with recent MI and both an ACE inhibitor and ARB were added, rather than adding the ARB to a stable patient on chronic ACE inhibitor therapy. These data suggest that an ARB may be beneficial when added to an ACE inhibitor and beta blocker in patients with chronic HF, but not in those with HF because of a recent MI. See Recommendations 7.21 and 7.22 and accompanying background for more information on the optimal use of multi-drug therapy.