Renin-angiotensin inhibition in systolic heart failure and chronic kidney disease

Abstract

Background: The role of renin-angiotensin inhibition in older patients with systolic heart failure with chronic kidney disease remains unclear.

Methods: Of the 1665 patients (aged≥65 years) with systolic heart failure (ejection fraction<45%) and chronic kidney disease (estimated glomerular filtration rate<60 mL/min/1.73 m(2)), 1046 received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Propensity scores for the receipt of these drugs, estimated for each of the 1665 patients, were used to assemble a matched cohort of 444 pairs of patients receiving and not receiving these drugs who were balanced on 56 baseline characteristics.

Results: During more than 8 years of follow-up, all-cause mortality occurred in 75% and 79% of matched patients with chronic kidney disease receiving and not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, respectively (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.74-0.996; P=.045). There was no significant association with heart failure hospitalization (HR, 0.86; 95% CI, 0.72-1.03; P=.094). Similar mortality reduction (HR, 0.83; 95% CI, 0.70-1.00; P=.046) occurred in a subgroup of matched patients with estimated glomerular filtration rate less than 45 mL/min/1.73 m(2). Among 171 pairs of propensity-matched patients without chronic kidney disease, the use of these drugs was associated with a significant reduction in all-cause mortality (HR, 0.72; 95% CI, 0.55-0.94; P=.015) and heart failure hospitalization (HR, 0.71; 95% CI, 0.52-0.95; P=.023).

Conclusion: Discharge prescription of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a significant modest reduction in all-cause mortality in older patients with systolic heart failure with chronic kidney disease, including those with more advanced chronic kidney disease.

Figure 1

Absolute standardized differences comparing 56 baseline characteristics between older systolic heart failure patients with chronic kidney disease receiving and not receiving discharge prescription of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, before and after propensity score matching

Figure 2

Kaplan-Meier plots for all-cause mortality in a propensity-matched cohort of older systolic heart failure patients with chronic kidney disease receiving and not receiving discharge prescription of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (CI=confidence interval)

Figure 3

Association of discharge prescription of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers with all-cause mortality in subgroups of propensity-matched older systolic heart failure patients with chronic kidney disease