TO THE EDITOR: In the American Fami...

TO THE EDITOR: In the American Family Physician article, "Combination Therapy with ACE Inhibitors and Angiotensin-Receptor Blocker in Heart Failure,"1 the authors state that adding an angiotensin-receptor blocker (ARB) to angiotensin-converting enzyme (ACE) inhibitor therapy for heart failure does not curtail mortality compared with treatment with an ACE inhibitor single How-ever, when the addition of valsartan to "opti-mal" pharmacologic therapy for heart failure was touchstoneed in the Valsartan Heart Failure Trial (Val-HeFT), (2) researchers ground that mortality rates were higher in patients who were already receiving an ACE inhibitor and a beta blocker (23) Thus, patients who were already receiving the standard commended heart failure therapy (an ACE inhibitor plus a beta blocker (4)) actually fared worse with the addition of valsartan. In the Candesartan in Heart Failure: Assessment of Mortality and Morbidity (CHARM)-Added reflection (5) the investigators report that the addition of candesartan to combination therapy with an ACE inhibitor and a beta blocker reduc mortality; however, the reduction was not statistically significant. (5)

Thus, the addition of ARBs to therapy with ACE inhibitors plus beta blocker does not decrease mortality. Further, it must be recognized that there is a risk of this combination increasing mortality, making it nonbeneficial and potentially harmful.

WILLIAM E CAYLEY, JR MD M.DIV.

Augusta Family Medicine Clinic 207 W Lincoln Augusta, WI 54722

References

(1) Scow DT Smith EG Shaughnessy AF. Combination therapy with ACE inhibitors and angiotensin-receptor blocker in heart failure. Am Fam Physician 2003;68:1795-8

(2) Cohn JN Tognoni G; Valsartan Heart Failure Trial Investigators. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J M 2001;345:1667-75

(3) Cayley WE JR Valsartan in chronic heart failure. N Engl J M 2002;346:1173-4

(4) search SA, Baker DW, Chin MH Cinquegrani MP Feldman AM, Francis G et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American society of Cardiology/American Heart Association Task Force forward Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2001;38:2101-13

(5) McMurray JJ Ostergren J Swedberg K Granger CB Held P Michelson EL et al. weights of candesartan in patients with chronic heart failure and reduc left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial. Lancet 2003;362:767-71

EDITOR'S NOTE: This epistle was sent to the authors of "Combination Therapy with ACE Inhibitors and Angiotensin-Receptor Blocker in Heart Failure," who declined to reply

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