The following is the summary of “Network Meta-Analysis Comparing Angiotensin Receptor-Neprilysin Inhibitors, Angiotensin Receptor Blockers, and Angiotensin-Converting Enzyme Inhibitors in Heart Failure With Reduced Ejection Fraction” published in the January 2023 issue of Cardiovascular Disease by Park, et al.

Despite the publishing of new trials that failed to establish clinical advantages, the superiority of angiotensin receptor-neprilysin inhibitors (ARNIs) over ACE-Is and angiotensin receptor blockers (ARBs) still needs to be re-evaluated. Therefore, researchers conducted a modernized network meta-analysis contrasting the benefits and risks of ARNI, ACE-I, ARB, and placebo in patients with heart failure and a lower ejection fraction. Randomized clinical trials of ARNI, ARB, ACE-I, and placebo were included for treating heart failure with a decreased ejection fraction. By combining frequentist and Bayesian methods, researchers could extract predetermined efficacy endpoints and generate network estimates, p scores, and the surface under the cumulative ranking curve scores. 

There were a total of 47,407 participants across 28 randomized controlled trials. Compared to ARB, ARNI was related to a higher risk of hypotension (RR 1.46, 95% CI 1.02 to 2.10) but a lower risk of all-cause mortality (RR 0.81, 95% CI 0.68 to 0.96) or cardiac death (relative risk (RR) 0.79, 95% CI 0.64 to 0.99) or major adverse cardiac events (MACEs; RR 0.83, 95% CI 0.72 to 0.97). 

P values and the surface under the cumulative ranking curve scores showed that ARNI was superior to ARB and ACE-I in all-cause mortality, cardiac death, MACE, and hospitalization for heart failure. However, ARNI was associated with a higher risk of hypotension (RR 1.69, 95% CI 1.27 to 2.24). In conclusion, compared to ARB and ACE-I, ARNI was linked with better clinical results, except a slightly increased risk of hypotension.

Source: sciencedirect.com/science/article/abs/pii/S0002914922011213