Candesartan vs Losartan and Mortality in Patients With Heart Failure—Reply

In Reply: Drs Fruhwald and Pieske suggest that losartan should not be used in HF. Randomized controlled trials have compared losartan, valsartan, and candesartan with placebo or captopril. A meta-analysis suggested benefit of losartan, valsartan, and candesartan in reducing mortality or HF hospitalization in patients with HF.¹ Trials of ARBs in HF differ in inclusion and exclusion criteria, comparators, end points, and designs, and none has compared ARBs against each other. Thus, losartan has not been shown to be superior to other ARBs in the treatment of HF. But neither has any other ARB. The ESC guidelines² state that “an ARB is recommended” and note the noninferiority of losartan in the OPTIMAAL trial.³ The AHA/ACC recommends ARBs and lists candesartan, losartan, and valsartan as ARBs “commonly used.”⁴ Because questions remain and because clinicians consider both original data and guidelines, we performed our study, which confirmed our hypothesis and that of Fruhwald and Pieske that candesartan was associated with a lower mortality risk compared with losartan.