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Angiotensin-converting enzyme inhibitors and outcomes in heart failure and preserved ejection fraction
Marjan Mujib1, Kanan Patel, Gregg C Fonarow
1New York Medical College, Valhalla, NY, USA.
Insights
Initiating angiotensin-converting enzyme (ACE) inhibitors in older heart failure patients with preserved ejection fraction modestly reduced the combined risk of death or hospitalization. However, it did not significantly impact individual mortality or hospitalization rates.
Area of Science:
- Cardiology
- Geriatrics
- Pharmacology
Background:
- The efficacy of angiotensin-converting enzyme (ACE) inhibitors in patients diagnosed with heart failure and preserved ejection fraction (HFpEF) remains incompletely understood.
- Older adults are disproportionately affected by HFpEF, necessitating clear treatment guidelines.
Purpose of the Study:
- To investigate the association between initiating ACE inhibitor therapy and clinical outcomes in hospitalized elderly patients with HFpEF.
- To evaluate the impact of ACE inhibitors on composite endpoints versus individual components of mortality and heart failure hospitalizations.
Main Methods:
- A cohort of 10,570 elderly patients with HFpEF was identified from a large healthcare program database.
- Propensity score matching was employed to create a balanced cohort of 1337 patients initiating ACE inhibitors versus those who did not, excluding patients on angiotensin receptor blockers or with contraindications.
- Outcomes were assessed over a median follow-up of 2.4 years.
Main Results:
- The study included 1337 matched pairs of patients with a mean age of 81 years and mean ejection fraction of 55%.
- Initiation of ACE inhibitor therapy was linked to a statistically significant reduction in the composite endpoint of all-cause mortality or heart failure hospitalization (HR, 0.91; P = .028).
- No significant association was found between ACE inhibitor initiation and individual endpoints of all-cause mortality (HR, 0.96; P = .373) or heart failure hospitalization (HR, 0.93; P = .257).
Conclusions:
- In older, hospitalized patients with HFpEF, initiating ACE inhibitors upon discharge was associated with a modest benefit in reducing the combined risk of death or HF hospitalization.
- The study did not find a significant effect of ACE inhibitors on individual mortality or hospitalization events in this population.
- Further research may be needed to clarify the specific benefits and optimal use of ACE inhibitors in HFpEF management.
Background:
The role of angiotensin-converting enzyme (ACE) inhibitors in patients with heart failure and preserved ejection fraction remains unclear.
Methods:
Of the 10,570 patients aged ≥65 years with heart failure and preserved ejection fraction (≥40%) in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (2003-2004) linked to Medicare (through December 2008), 7304 were not receiving angiotensin receptor blockers and had no contraindications to ACE inhibitors. After excluding 3115 patients with pre-admission ACE inhibitor use, the remaining 4189 were eligible for new discharge prescriptions for ACE inhibitors, and 1706 received them. Propensity scores for the receipt of ACE inhibitors, calculated for each of the 4189 patients, were used to assemble a cohort of 1337 pairs of patients, balanced on 114 baseline characteristics.
Results:
Matched patients had a mean age of 81 years and mean ejection fraction of 55%, 64% were women, and 9% were African American. Initiation of ACE inhibitor therapy was associated with a lower risk of the primary composite end point of all-cause mortality or heart failure hospitalization during 2.4 years of median follow-up (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84-0.99; P = .028), but not with individual end points of all-cause mortality (HR, 0.96; 95% CI, 0.88-1.05; P = .373) or heart failure hospitalization (HR, 0.93; 95% CI, 0.83-1.05; P = .257).
Conclusion:
In hospitalized older patients with heart failure and preserved ejection fraction not receiving angiotensin receptor blockers, discharge initiation of ACE inhibitor therapy was associated with a modest improvement in the composite end point of total mortality or heart failure hospitalization but had no association with individual end point components.
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