Initiation, Continuation, or Withdrawal of Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Outcomes in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

Lauren G Gilstrap; Gregg C Fonarow; Akshay S Desai; Li Liang; Roland Matsouaka; Adam D DeVore; Eric E Smith; Paul Heidenreich; Adrian F Hernandez; Clyde W Yancy; Deepak L Bhatt

doi:10.1161/JAHA.116.004675

Initiation, Continuation, or Withdrawal of Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Outcomes in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

J Am Heart Assoc. 2017 Feb 11;6(2):e004675. doi: 10.1161/JAHA.116.004675.

Authors

Affiliations

¹ Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA.
² Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA.
³ Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
⁴ Department of Clinical Neurosciences, University of Calgary, Alberta, Canada.
⁵ Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
⁶ Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
⁷ Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA dlbhattmd@post.harvard.edu.

Abstract

Background: Guidelines recommend continuation or initiation of guideline-directed medical therapy, including angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB), in hospitalized patients with heart failure with reduced ejection fraction.

Methods and results: Using the Get With The Guidelines-Heart Failure Registry, we linked clinical data from 16 052 heart failure with reduced ejection fraction (ejection fraction ≤40%) patients with Medicare claims data. We divided ACEi/ARB-eligible patients into 4 categories based on admission and discharge ACEi/ARB use: continued (reference group), started, discontinued, or not started on therapy. A multivariable Cox proportional hazard model was used to determine the association between ACEi/ARB category and outcomes. Most, 90.5%, were discharged on ACEi/ARB (59.6% continued and 30.9% newly started). Of those discharged without ACEi/ARB, 1.9% were discontinued, and 7.5% were eligible but not started. Thirty-day mortality was 3.5% for patients continued and 4.1% for patients started on ACEi/ARB. In contrast, 30-day mortality was 8.8% for patients discontinued (adjusted hazard ratio [HR_adj] 1.92; 95% CI 1.32-2.81; P<0.001) and 7.5% for patients not started (HR_adj 1.50; 95% CI 1.12-2.00; P=0.006). The 30-day readmission rate was lowest among patients continued or started on therapy. One-year mortality was 28.2% for patients continued and 29.7% for patients started on ACEi/ARB compared to 41.6% for patients discontinued (HR_adj 1.35; 95% CI 1.13-1.61; P<0.001) and 41.7% (HR_adj 1.28; 95% CI 1.14-1.43; P<0.001) for patients not started on therapy.

Conclusions: Compared with continuation, withdrawal of ACEi/ARB during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission, even after adjustment for severity of illness.

Keywords: angiotensin II receptor blockers; angiotensin‐converting enzyme inhibitors; heart failure; outcomes research; quality of care.

Publication types

Multicenter Study

MeSH terms

Aged
Angiotensin Receptor Antagonists / therapeutic use*
Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
Female
Follow-Up Studies
Guideline Adherence*
Heart Failure / drug therapy*
Heart Failure / epidemiology
Heart Failure / physiopathology
Hospitalization
Humans
Male
Morbidity / trends
Outcome Assessment, Health Care / methods*
Patient Readmission / trends
Quality of Health Care*
Registries
Retrospective Studies
Stroke Volume / physiology*
Survival Rate / trends
United States / epidemiology
Withholding Treatment

Substances

Angiotensin Receptor Antagonists
Angiotensin-Converting Enzyme Inhibitors