La combinación de un inhibidor de la enzima de conversión de la angiotensina (IECA) y un bloqueador beta es el tratamiento clave de primera línea para pacientes con insuficiencia cardiaca crónica (ICC) y disfunción sistólica del ventrículo izquierdo (DSVI), así como para pacientes con insuficiencia cardiaca, DSVI o ambos tras un infarto agudo de miocardio (IAM). La adición de un antagonista de los receptores de la angiotensina (ARA-II) a un IECA proporciona mayor beneficio en la ICC en clase funcional II-IV de la New York Heart Association (NYHA). En el caso del IAM, no se ha observado ningún beneficio por añadir un ARA-II. La adición de un antagonista de la aldosterona (AA) reduce la mortalidad en la ICC de clase funcional III y IV de la NYHA y también en pacientes con DSVI y síntomas de insuficiencia cardiaca o diabetes mellitus tras un IAM. Por tanto, la controversia surge solamente al considerar la elección de un tercer agente para pacientes con ICC sistólica que estén en clase funcional III de la NYHA, donde está justificada la adición de un ARA-II o de un AA. Desafortunadamente, ningún ensayo ha comparado un ARA-II con un AA en esta situación y no hay ninguno previsto actualmente, aunque si hay un ensayo con un AA en pacientes con ICC sistólica en clase funcional II de la NYHA. Tenemos la posibilidad de elegir, pero hay que añadir uno u otro agente. A menudo la elección del fármaco vendrá dada por la tolerabilidad del paciente.
Palabras clave
Antagonista del receptor de la angiotensina
Antagonista de la aldosterona
Insuficiencia cardiaca
Infarto de miocardio
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