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Published on: May 19, 2020
Impact of RAS inhibitors on 2-year mortality and disease progression in chronic mitral regurgitation
Chenyang Li1, Yunqing Ye1, Can Wang1
1Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing, 100037, China.
Background:
Chronic mitral regurgitation (MR) is associated with adverse clinical outcomes, and the role of renin-angiotensin system inhibitors (RASI) in patients with MR remains uncertain. This study evaluated the association between RASI use patterns and 2-year all-cause mortality and disease progression in patients with primary MR (PMR) and secondary MR (SMR).
Methods:
This registry-based study included 3,297 patients with moderate-to-severe chronic MR from the China Valvular Heart Disease registry, including 955 with PMR and 2,342 with SMR. RASI use was assessed at baseline and during follow-up, and patients were categorized as always users, never users, or inconsistent users. The primary endpoint was 2-year all-cause mortality. The secondary endpoint was change in MR severity. Associations between RASI use and outcomes were assessed using multivariable Cox regression, propensity-score matching, and time-varying Cox analyses.
Results:
Consistent RASI use was associated with lower 2-year all-cause mortality in both PMR and SMR. In multivariable Cox regression, never users had higher mortality risk than always users in both cohorts (PMR: HR 5.40, 95% CI 1.58-18.47, P = 0.007; SMR: HR 5.09, 95% CI 2.85-9.09, P < 0.001). Inconsistent users also had higher mortality risk than always users (PMR: HR 7.56, 95% CI 2.25-25.37, P = 0.001; SMR: HR 3.29, 95% CI 1.85-5.84, P < 0.001). Propensity-score-matched analyses showed broadly consistent results. Time-varying Cox analyses demonstrated directionally consistent associations in the overall cohort and SMR during selected follow-up intervals, whereas in PMR the interval-specific estimates were less stable and did not reach statistical significance. Consistent RASI use was also associated with improvement in MR severity, particularly in SMR and in patients without guideline-based indications for valvular intervention.
Conclusions:
In patients with moderate-to-severe chronic MR, consistent RASI use was associated with lower 2-year all-cause mortality and improvement in MR severity. These findings suggest that RASI therapy may have a role in optimized medical management for selected patients with chronic MR, particularly those with SMR or impaired/borderline LV function. Further prospective studies are needed to confirm whether RASI directly improves survival or delays MR progression.
Trial Registration:
This study utilized data from the China Valvular Heart Disease (China-VHD) registry (NCT03484806).
Insights
Consistent use of renin-angiotensin system inhibitors (RASI) is linked to reduced mortality and improved severity in chronic mitral regurgitation (MR) patients. This suggests RASI therapy may benefit selected patients with MR.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Chronic mitral regurgitation (MR) is linked to poor outcomes.
- The role of renin-angiotensin system inhibitors (RASI) in MR management is unclear.
- This study investigates RASI use patterns in primary MR (PMR) and secondary MR (SMR).
Purpose of the Study:
- To evaluate the association between RASI use patterns and 2-year mortality in chronic MR.
- To assess the impact of RASI use on MR disease progression.
- To compare outcomes in primary MR versus secondary MR patients.
Main Methods:
- Registry-based study of 3,297 patients with moderate-to-severe chronic MR from the China Valvular Heart Disease registry.
- Categorization of RASI use: always, never, or inconsistent users.
- Statistical analyses included multivariable Cox regression, propensity-score matching, and time-varying Cox analyses.
Main Results:
- Consistent RASI use was associated with significantly lower 2-year all-cause mortality in both PMR and SMR cohorts.
- Never and inconsistent RASI users exhibited higher mortality risks compared to always users.
- Consistent RASI use correlated with improved MR severity, especially in SMR patients.
Conclusions:
- Consistent RASI use is associated with reduced mortality and improved MR severity in chronic MR patients.
- RASI therapy may be beneficial for selected chronic MR patients, particularly those with SMR.
- Further prospective studies are warranted to confirm RASI's direct impact on survival and MR progression.
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