The Supplemental Benefit of an Angiotensin Receptor Blocker in Hypertensive Patients with Stable Heart Failure Using Olmesartan (SUPPORT) Trial

We examined whether an additive treatment with an angiotensin receptor blocker, olmesartan, reduces the mortality and morbidity in hypertensive patients with chronic heart failure (CHF) treated with standard therapy. In this prospectively, randomized, open-label, blinded endpoint study, a total of 1,147 hypertensive patients with symptomatic CHF (mean age 66 years, 75% male) were randomized to the addition of olmesartan (n=578) to baseline therapy versus control (n=569). The primary endpoint was a composite of all-cause death, acute myocardial infarction, stroke and hospitalization for worsening heart failure. During a median follow-up of 4.4 years, the primary endpoint occurred in 192 patients (33.2%) in the olmesartan group and in 166 patients (29.2%) in the control group (hazard ratio (HR) 1.18; 95% confidence interval (95% CI), 0.96-1.46, P=0.112), while renal dysfunction developed more frequently in the olmesartan group (HR 1.64; 95% CI, 1.19-2.26, P=0.003). Subgroup analysis revealed that addition of olmesartan to combination of ACE inhibitors and beta-blockers was associated with increased incidence of the primary endpoint (HR 1.47; 95% CI, 1.11-1.95, P=0.006). However, in patients with preserved ejection fraction (HFpEF), addition of olmesartan to beta-blockers reduced incidence of all-cause death (HR 0.32; 95% CI 0.12-0.90, P=0.03). The triple combination therapy with olmesartan, ACE inhibitors and beta-blockers was associated with increased cardiac events. In HFpEF, however, combination with olmesartan with beta-blockers might be beneficial.