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Renin-angiotensin inhibition in diastolic heart failure and chronic kidney disease
Ali Ahmed1, Michael W Rich, Michael Zile
1University of Alabama at Birmingham, Birmingham, AL, USA. aahmed@uab.edu
Insights
Renin-angiotensin inhibition significantly reduced all-cause mortality in older patients with diastolic heart failure and chronic kidney disease. This benefit was observed even in those with advanced kidney disease, suggesting a protective role for these medications.
Area of Science:
- Cardiology
- Nephrology
- Geriatrics
Background:
- The efficacy of renin-angiotensin system inhibitors in elderly individuals with diastolic heart failure and concurrent chronic kidney disease is not well-established.
- Diastolic heart failure and chronic kidney disease are common comorbidities in older populations, presenting complex management challenges.
Purpose of the Study:
- To investigate the impact of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) on mortality and heart failure hospitalizations in older patients with diastolic heart failure and chronic kidney disease.
- To determine if the benefits of ACEIs/ARBs extend to patients with more severe chronic kidney disease.
Main Methods:
- A propensity score-matched analysis was conducted on a cohort of 1340 patients aged 65 years and older.
- Patients had diastolic heart failure (ejection fraction ≥45%) and chronic kidney disease (eGFR <60 mL/min/1.73 m²).
- 421 pairs of patients receiving ACEIs/ARBs were matched with controls not receiving these drugs based on 56 baseline characteristics.
Main Results:
- Over 8 years, ACEI/ARB use was associated with a significant reduction in all-cause mortality (HR, 0.82; P = .021) in matched patients with chronic kidney disease.
- No significant association was found with heart failure hospitalization (HR, 0.98; P = .816).
- A similar mortality reduction was observed in a subgroup with eGFR <45 mL/min/1.73 m² (HR, 0.81; P = .045).
Conclusions:
- Discharge prescriptions for ACEIs or ARBs were linked to a significant decrease in all-cause mortality for older patients with diastolic heart failure and chronic kidney disease.
- The findings suggest a survival benefit of these medications, even in patients with advanced chronic kidney disease.
- These results support the use of ACEIs/ARBs in this vulnerable patient population.
Background:
The role of renin-angiotensin inhibition in older patients with diastolic heart failure and chronic kidney disease remains unclear.
Methods:
Of the 1340 patients (age ≥65 years) with diastolic heart failure (ejection fraction ≥45%) and chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m(2)), 717 received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Propensity scores for the use of these drugs, estimated for each of the 1340 patients, were used to assemble a cohort of 421 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 63% and 69% of matched patients with chronic kidney disease receiving and not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, respectively (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.70-0.97; P = .021). There was no association with heart failure hospitalization (HR, 0.98; 95% CI, 0.82-1.18; P = .816). Similar mortality reduction (HR, 0.81; 95% CI, 0.66-0.995; P = .045) occurred in a subgroup of matched patients with an estimated glomerular filtration rate less than 45 mL/min/1.73 m(2). Among 207 pairs of propensity-matched patients without chronic kidney disease, the use of these drugs was not associated with mortality (HR, 1.03; 95% CI, 0.80-1.33; P = .826) or heart failure hospitalization (HR, 0.99; 95% CI, 0.76-1.30; P = .946).
Conclusions:
A discharge prescription for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a significant reduction in all-cause mortality in older patients with diastolic heart failure and chronic kidney disease, including those with more advanced chronic kidney disease.
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