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The following is a summary of “Prevention of Heart Failure in Hypertension – the Role of Coronary Heart Disease Events Treated with Versus without Revascularization: the ALLHAT Study,” published in the September 2024 issue of Cardiology by Chen et al.

In modern clinical practice, less than half of new-onset patients with heart failure (HF) underwent ischemic evaluation, and only a minority underwent revascularization.

Researchers conducted a retrospective study to assess the proportion of the effect of hypertension (antihypertensive treatment) on incident HF to be eliminated by preventing coronary heart disease (CHD) events treated with or without revascularization, considering possible treatment-mediator interaction.

They used causal mediation analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) that included 42,418 participants (age 66.9±7.7; 35.6% Black, 53.2% men). A new CHD event (myocardial infarction or angina) that occurred after randomization but before the incident HF outcome was the mediator. Incident symptomatic congestive HF (CHF) and hospitalized/fatal HF (HHF) were the primary and secondary outcomes. Logistic regression (for mediator) and Cox proportional hazards regression (for outcome) were adjusted for demographics, cardiovascular disease history, and risk factors.

The results showed that during a median 4.5-year follow-up, 2,785 patients developed CHF, including 2,216 HHF events. Participants who developed CHD events had twice the higher incidence rate of CHF than CHD-free (28.5 vs 13.9 events/ 1,000 person-years). The proportion of reference interaction indicating direct harm due to the CHD event for lisinopril (234% for CHF; 355% for HHF) and amlodipine (244% for CHF; 468% for HHF) was more significant than for chlorthalidone (143% for CHF; 269% for HHF). In patients with revascularized CHD events, chlorthalidone and amlodipine eliminated 21-24%, and lisinopril – 45% of HHF. Antihypertensive treatment was not able to eliminate harm from CHD events treated without revascularization.

They concluded that the antihypertensive drugs (chlorthalidone, lisinopril, amlodipine) prevent HF not principally by preventing CHD events but via other pathways; HF was moderated but not mediated by CHD events. Revascularization of CHD events was paramount for HF prevention.

Source: ajconline.org/article/S0002-9149(24)00648-9/abstract