ACEi/ARB therapy at discharge associated with lower mortality and readmission rates in HFrEF
Initiation, Continuation, or Withdrawal of Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Outcomes in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction
Literature - Gilstrap LG, Fonarow GC, Desai AS, et al. - J Am Heart Assoc. 2017;6:e004675Background
Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) improve symptoms, reduce hospitalisations, and improve survival in heart failure (HF) patients with reduced ejection fraction (HFrEF), and are recommended by guidelines at discharge for the prevention of symptomatic HF in these patients [1-5]. However, the impact of continuing or discontinuing ACEi/ARB after hospitalisation for acute decompensated heart failure (ADHF) has not been thoroughly evaluated.
In this study, the relationship between the continuation or withdrawal of ACEi/ARB therapy and outcomes was assessed, in 16 052 HFrEF patients hospitalised for ADHF. Data of the Get With The Guidelines Heart Failure (GWTG-HF) registry linked with Medicare inpatient data were used for these analyses.
Main results
- 90.5% of patients were discharged on ACEi/ARB, of whom 59.6% continued and 30.9% newly started ACEi/ARB, 1.9% discontinued ACEi/ARB therapy, and 7.5% were not started.
- Patients who discontinued or did not start ACEi/ARB therapy, had higher rates of renal dysfunction, and lower rates of being provided discharge instructions, smoking cessation counselling, timely follow-up appointments, and ICD counselling.
- The adjusted HR for 30-day mortality in patients who discontinued ACEi/ARB therapy was 1.92 (95% CI: 1.32-2.81; P<0.001) compared to patients who continued therapy. For patients who did not start therapy, the adjusted HR for 30-day mortality was 1.50 (95% CI: 1.12-2.06; P=0.006).
- The adjusted HR for 1-year mortality of patients discontinued from ACEi/ARB therapy was 1.35 (95% CI: 1.13-1.61; P=0.001), and for those not started on ACEi/ARB the adjusted HR was 1.28 (95% CI: 1.14-1.43; P<0.001).
- The adjusted HR for 30-day readmission was 1.40 (95% CI: 1.16-1.71; P<0.001) among those who discontinued compared with patients who continued or started on ACEi/ARB and 1.14 (95% CI: 1.01-1.29; P=0.038) among those who did not start ACEi/ARB.
- At 90 days, after adjustment, there was no difference in readmission rates between the groups.
- The findings regarding the composite endpoint of mortality and readmission were similar to the mortality and readmission rates described above.
Conclusion
In a large cohort of 16 052 HFrEF patients, the continuation or initiation of ACEi/ARB therapy at the time of discharge after admission for ADHF was associated with lower mortality and readmission rates, compared with those who discontinued or did not start therapy. These findings provide further evidence related to guideline recommendations for these patients.
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