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ACE inhibitor dosage at the time of listing predicts survival
1Department of Cardiology, University of Vienna, Austria. etanzl@pop3.kard.akh-wien.ac.at
Insights
Optimizing angiotensin converting enzyme (ACE) inhibitor dosage before heart transplantation (HTx) is crucial. Lower doses are linked to increased mortality risk in HTx candidates, highlighting the need for careful patient monitoring.
Area of Science:
- Cardiology
- Pharmacology
- Transplantation Medicine
Background:
- Optimization of angiotensin converting enzyme (ACE) inhibitor dosage is recommended for heart transplantation (HTx) listing.
- However, the prognostic impact of ACE inhibitor dosage in pre-transplantation cohorts remains under-investigated.
Purpose of the Study:
- To analyze the prognostic impact of high versus low ACE inhibitor doses at the time of listing for elective HTx.
- To evaluate the role of ACE inhibitor dosage alongside established prognostic factors.
Main Methods:
- A retrospective database study reviewed medical records of 237 patients undergoing elective HTx.
- Patients were categorized into "high-dose" (> or =75 mg captopril, > or =20 mg enalapril, > or =20 mg lisinopril, or > or =5 mg ramipril daily) and "low-dose" groups.
Main Results:
- Kaplan-Meier survival analysis revealed a significant difference between groups (P = 0.03), with lower mortality in the high-dose group.
- ACE inhibitor treatment dose was the strongest independent predictor of mortality (P = 0.01).
- Other significant predictors included blood pressure, alanine transaminase, and left ventricular end-diastolic diameter.
Conclusions:
- Heart transplantation candidates receiving below-recommended ACE inhibitor dosages face increased mortality risk.
- These patients warrant closer scrutiny and potentially dose optimization.
- Potential explanations include greater benefit from higher doses, "sicker" patients on lower doses, or more experienced heart failure care in the high-dose group.
Background:
To be listed for heart transplantation (HTx), optimization of the dosage of angiotensin converting enzyme (ACE) -inhibitors is recommended worldwide even though this issue has not been thoroughly investigated in the pre-transplantation cohort.
Objective:
The aim of this database study was to analyze the prognostic impact of a pre-defined high vs a low ACE inhibitor dose range at the time of listing for elective HTx in addition to various previously established prognostic factors.
Methods:
Medical records from 237 patients (84% male, mean age 54 years) admitted between January 1995 and January 1998 from 25 different centers in Austria were reviewed. Forty-seven percent were taking > or =75 mg captopril, > or =20 mg enalapril, > or =20 mg lisinopril or > or =5 mg ramipril daily ("high-dose" group) and 53% received smaller doses ("low-dose" group).
Results:
No significant differences between groups were detected at baseline except that patients with higher ACE inhibitor doses were more likely to take nitrates, beta-blockers and amiodarone, received higher furosemide doses and had higher serum gamma-glutamyl transferase levels. Follow-up was 328 days (248 SD) with 16% deaths in the "high-dose" group vs 288 days (270 SD) with 25% deaths in the "low-dose" group. Kaplan-Meier survival curves demonstrated a significant difference over time between the two treatment groups (P = 0.03). Furthermore, dichotomized ACE inhibitor treatment at the time of listing was the strongest independent single predictor of mortality (P = 0.01) with only blood pressure (P = 0.02), alanine transaminase (P = 0.02) and left ventricular end diastolic diameter (P = 0.02) providing additional prognostic information. To explain these findings several factors have to be considered a) greater benefit with higher ACE inhibitor doses b) sicker patients receiving lower ACE inhibitor doses and c) more experienced heart failure care of the "high-dose" group.
Conclusions:
Heart transplantation candidates who, for whatever reason, receive ACE-inhibitors below the recommended dosages, are at increased mortality risk and thus merit greater scrutiny.