Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers
Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers
Background: Patients with coexistent heart failure and chronic kidney disease (CKD) have a poor prognosis, possibly related to the underuse of standard medical therapies-angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB).
Methods: We performed a retrospective analysis of the Minnesota Heart Survey, identifying patients hospitalized in 2000 in the Minneapolis-St Paul metropolitan area with heart failure. The main outcome measure was the association of ACE-I and ARB use on 30-day and 1-year mortality, stratified by glomerular filtration rate (GFR).
Results: Compared to patients with heart failure with preserved renal function (GFR ≥90 mL/min), patients with severely impaired renal function (GFR <15 mL/min) were far less likely to receive ACE-I or ARB during hospitalization (52.0% vs 69.5%, P < .0001) or at discharge (50.5% vs 65.1%, P < .0001). Worsening renal function was associated with increased mortality, both at 30 days and at 1 year. The inhospital use of either an ACE-I or ARB was associated with significantly reduced 30-day mortality (OR 0.45, 95% CI 0.28-0.59) after adjusting for multiple risk factors. Similarly, the discharge prescription of either an ACE-I or ARB was associated with a significant reduction in adjusted 1-year mortality (OR 0.72, 95% CI 0.58-0.91). However, among patients on dialysis, there was no benefit of ACE-I or ARB on either 30-day or 1-year mortality.
Conclusions: Angiotensin-converting enzyme inhibitors and ARB are underused in patients with heart failure with chronic kidney disease. Given the reduction in 30-day and 1-year mortality, these medications should be considered in most patients with heart failure, independent of underlying renal function. Among patients on hemodialysis, further investigation is warranted.
Congestive heart failure (CHF) is an increasingly prevalent condition in the United States and now affects 2.2% of the population. There is strong evidence indicating that the use of angiotensin-converting enzyme inhibitors (ACE-I) among patients hospitalized with CHF results in decreased mortality. There are also data confirming angiotensin receptor blockers (ARB) can provide a similar reduction in mortality compared to ACE-I. The data from these trials form the basis for the American College of Cardiology/American Heart Association guidelines for the management of patients with chronic heart failure. Contemporary data suggest the use of ACE-I and ARB remains suboptimal even in patients who have no contraindications to either therapy.
Renal dysfunction is an independent predictor of morbidity and mortality in the setting of CHF. The role of ACE-I and ARB in this group of patients is less well established for 2 major reasons. First, randomized clinical trials have typically excluded patients with severely impaired renal dysfunction. Second, physicians have been reluctant to initiate either medication in patients with renal impairment because of the fear of precipitating acute renal failure or hyperkalemia. Consequently, there is a knowledge gap regarding the potential benefits and risks of ACE-I in patients with CHF and associated chronic kidney disease (CKD).
The population-based Minnesota Heart Survey (MHS) is uniquely suited to address the inhospital and discharge use of CHF medical therapies. We hypothesized (1) ACE-I and ARB are underused in patients with CHF and coexistent CKD; (2) the inhospital use of ACE-I and ARB in patients with CHF and severe renal insufficiency is associated with a significant reduction in 30-day mortality; and (3) the discharge prescription of ACE-I and ARB in patients with CHF and severe renal insufficiency is associated with a significant reduction in 1-year mortality.
Background: Patients with coexistent heart failure and chronic kidney disease (CKD) have a poor prognosis, possibly related to the underuse of standard medical therapies-angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB).
Methods: We performed a retrospective analysis of the Minnesota Heart Survey, identifying patients hospitalized in 2000 in the Minneapolis-St Paul metropolitan area with heart failure. The main outcome measure was the association of ACE-I and ARB use on 30-day and 1-year mortality, stratified by glomerular filtration rate (GFR).
Results: Compared to patients with heart failure with preserved renal function (GFR ≥90 mL/min), patients with severely impaired renal function (GFR <15 mL/min) were far less likely to receive ACE-I or ARB during hospitalization (52.0% vs 69.5%, P < .0001) or at discharge (50.5% vs 65.1%, P < .0001). Worsening renal function was associated with increased mortality, both at 30 days and at 1 year. The inhospital use of either an ACE-I or ARB was associated with significantly reduced 30-day mortality (OR 0.45, 95% CI 0.28-0.59) after adjusting for multiple risk factors. Similarly, the discharge prescription of either an ACE-I or ARB was associated with a significant reduction in adjusted 1-year mortality (OR 0.72, 95% CI 0.58-0.91). However, among patients on dialysis, there was no benefit of ACE-I or ARB on either 30-day or 1-year mortality.
Conclusions: Angiotensin-converting enzyme inhibitors and ARB are underused in patients with heart failure with chronic kidney disease. Given the reduction in 30-day and 1-year mortality, these medications should be considered in most patients with heart failure, independent of underlying renal function. Among patients on hemodialysis, further investigation is warranted.
Congestive heart failure (CHF) is an increasingly prevalent condition in the United States and now affects 2.2% of the population. There is strong evidence indicating that the use of angiotensin-converting enzyme inhibitors (ACE-I) among patients hospitalized with CHF results in decreased mortality. There are also data confirming angiotensin receptor blockers (ARB) can provide a similar reduction in mortality compared to ACE-I. The data from these trials form the basis for the American College of Cardiology/American Heart Association guidelines for the management of patients with chronic heart failure. Contemporary data suggest the use of ACE-I and ARB remains suboptimal even in patients who have no contraindications to either therapy.
Renal dysfunction is an independent predictor of morbidity and mortality in the setting of CHF. The role of ACE-I and ARB in this group of patients is less well established for 2 major reasons. First, randomized clinical trials have typically excluded patients with severely impaired renal dysfunction. Second, physicians have been reluctant to initiate either medication in patients with renal impairment because of the fear of precipitating acute renal failure or hyperkalemia. Consequently, there is a knowledge gap regarding the potential benefits and risks of ACE-I in patients with CHF and associated chronic kidney disease (CKD).
The population-based Minnesota Heart Survey (MHS) is uniquely suited to address the inhospital and discharge use of CHF medical therapies. We hypothesized (1) ACE-I and ARB are underused in patients with CHF and coexistent CKD; (2) the inhospital use of ACE-I and ARB in patients with CHF and severe renal insufficiency is associated with a significant reduction in 30-day mortality; and (3) the discharge prescription of ACE-I and ARB in patients with CHF and severe renal insufficiency is associated with a significant reduction in 1-year mortality.
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