Initiation, continuation, or withdrawal of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and outcomes in patients hospitalized with heart failure with reduced ejection fraction

Lauren G. Gilstrap; Gregg C. Fonarow; Akshay S. Desai; Li Liang; Roland Matsouaka; Adam D. DeVore; Eric E. Smith; Paul Heidenreich; Adrian F. Hernandez; Clyde W. Yancy; Deepak L. Bhatt

doi:10.1161/JAHA.116.004675

Initiation, continuation, or withdrawal of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and outcomes in patients hospitalized with heart failure with reduced ejection fraction

Lauren G. Gilstrap, Gregg C. Fonarow, Akshay S. Desai, Li Liang, Roland Matsouaka, Adam D. DeVore, Eric E. Smith, Paul Heidenreich, Adrian F. Hernandez, Clyde W. Yancy, Deepak L. Bhatt^*

^*Corresponding author for this work

Medicine, Cardiology Division

Research output: Contribution to journal › Article › peer-review

109 Scopus citations

Abstract

Background-Guidelines recommend continuation or initiation of guideline-directed medical therapy, including angiotensinconverting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB), in hospitalized patients with heart failure with reduced ejection fraction. Methods and Results-Using the Get With The Guidelines-Heart Failure Registry, we linked clinical data from 16 052 heart failure with reduced ejection fraction (ejection fraction ≤40%) patients with Medicare claims data. We divided ACEi/ARB-eligible patients into 4 categories based on admission and discharge ACEi/ARB use: continued (reference group), started, discontinued, or not started on therapy. A multivariable Cox proportional hazard model was used to determine the association between ACEi/ARB category and outcomes. Most, 90.5%, were discharged on ACEi/ARB (59.6% continued and 30.9% newly started). Of those discharged without ACEi/ARB, 1.9% were discontinued, and 7.5% were eligible but not started. Thirty-day mortality was 3.5% for patients continued and 4.1% for patients started on ACEi/ARB. In contrast, 30-day mortality was 8.8% for patients discontinued (adjusted hazard ratio [HR_adj] 1.92; 95% CI 1.32-2.81; P < 0.001) and 7.5% for patients not started (HR_adj 1.50; 95% CI 1.12-2.00; P=0.006). The 30-day readmission rate was lowest among patients continued or started on therapy. One-year mortality was 28.2% for patients continued and 29.7% for patients started on ACEi/ARB compared to 41.6% for patients discontinued (HR_adj 1.35; 95% CI 1.13-1.61; P < 0.001) and 41.7% (HR_adj 1.28; 95% CI 1.14-1.43; P < 0.001) for patients not started on therapy. Conclusions-Compared with continuation, withdrawal of ACEi/ARB during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission, even after adjustment for severity of illness.

Original language	English (US)
Article number	e004675
Journal	Journal of the American Heart Association
Volume	6
Issue number	2
DOIs	https://doi.org/10.1161/JAHA.116.004675
State	Published - 2017

Keywords

Angiotensin II receptor blockers
Angiotensin-converting enzyme inhibitors
Heart failure
Outcomes research
Quality of care

ASJC Scopus subject areas

Cardiology and Cardiovascular Medicine

Access to Document

10.1161/JAHA.116.004675

Cite this

Gilstrap, L. G., Fonarow, G. C., Desai, A. S., Liang, L., Matsouaka, R., DeVore, A. D., Smith, E. E., Heidenreich, P., Hernandez, A. F., Yancy, C. W., & Bhatt, D. L. (2017). Initiation, continuation, or withdrawal of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and outcomes in patients hospitalized with heart failure with reduced ejection fraction. Journal of the American Heart Association, 6(2), Article e004675. https://doi.org/10.1161/JAHA.116.004675

@article{405fa77273974f6ebe99879a23da471f,

title = "Initiation, continuation, or withdrawal of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and outcomes in patients hospitalized with heart failure with reduced ejection fraction",

abstract = "Background-Guidelines recommend continuation or initiation of guideline-directed medical therapy, including angiotensinconverting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB), in hospitalized patients with heart failure with reduced ejection fraction. Methods and Results-Using the Get With The Guidelines-Heart Failure Registry, we linked clinical data from 16 052 heart failure with reduced ejection fraction (ejection fraction ≤40%) patients with Medicare claims data. We divided ACEi/ARB-eligible patients into 4 categories based on admission and discharge ACEi/ARB use: continued (reference group), started, discontinued, or not started on therapy. A multivariable Cox proportional hazard model was used to determine the association between ACEi/ARB category and outcomes. Most, 90.5%, were discharged on ACEi/ARB (59.6% continued and 30.9% newly started). Of those discharged without ACEi/ARB, 1.9% were discontinued, and 7.5% were eligible but not started. Thirty-day mortality was 3.5% for patients continued and 4.1% for patients started on ACEi/ARB. In contrast, 30-day mortality was 8.8% for patients discontinued (adjusted hazard ratio [HRadj] 1.92; 95% CI 1.32-2.81; P < 0.001) and 7.5% for patients not started (HRadj 1.50; 95% CI 1.12-2.00; P=0.006). The 30-day readmission rate was lowest among patients continued or started on therapy. One-year mortality was 28.2% for patients continued and 29.7% for patients started on ACEi/ARB compared to 41.6% for patients discontinued (HRadj 1.35; 95% CI 1.13-1.61; P < 0.001) and 41.7% (HRadj 1.28; 95% CI 1.14-1.43; P < 0.001) for patients not started on therapy. Conclusions-Compared with continuation, withdrawal of ACEi/ARB during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission, even after adjustment for severity of illness.",

keywords = "Angiotensin II receptor blockers, Angiotensin-converting enzyme inhibitors, Heart failure, Outcomes research, Quality of care",

author = "Gilstrap, {Lauren G.} and Fonarow, {Gregg C.} and Desai, {Akshay S.} and Li Liang and Roland Matsouaka and DeVore, {Adam D.} and Smith, {Eric E.} and Paul Heidenreich and Hernandez, {Adrian F.} and Yancy, {Clyde W.} and Bhatt, {Deepak L.}",

note = "Publisher Copyright: {\textcopyright} 2017 The Authors.",

year = "2017",

doi = "10.1161/JAHA.116.004675",

language = "English (US)",

volume = "6",

journal = "Journal of the American Heart Association",

issn = "2047-9980",

publisher = "Wiley-Blackwell",

number = "2",

}

Gilstrap, LG, Fonarow, GC, Desai, AS, Liang, L, Matsouaka, R, DeVore, AD, Smith, EE, Heidenreich, P, Hernandez, AF, Yancy, CW & Bhatt, DL 2017, 'Initiation, continuation, or withdrawal of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and outcomes in patients hospitalized with heart failure with reduced ejection fraction', Journal of the American Heart Association, vol. 6, no. 2, e004675. https://doi.org/10.1161/JAHA.116.004675

Initiation, continuation, or withdrawal of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and outcomes in patients hospitalized with heart failure with reduced ejection fraction. / Gilstrap, Lauren G.; Fonarow, Gregg C.; Desai, Akshay S. et al.
In: Journal of the American Heart Association, Vol. 6, No. 2, e004675, 2017.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - Initiation, continuation, or withdrawal of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and outcomes in patients hospitalized with heart failure with reduced ejection fraction

AU - Gilstrap, Lauren G.

AU - Fonarow, Gregg C.

AU - Desai, Akshay S.

AU - Liang, Li

AU - Matsouaka, Roland

AU - DeVore, Adam D.

AU - Smith, Eric E.

AU - Heidenreich, Paul

AU - Hernandez, Adrian F.

AU - Yancy, Clyde W.

AU - Bhatt, Deepak L.

PY - 2017

Y1 - 2017

N2 - Background-Guidelines recommend continuation or initiation of guideline-directed medical therapy, including angiotensinconverting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB), in hospitalized patients with heart failure with reduced ejection fraction. Methods and Results-Using the Get With The Guidelines-Heart Failure Registry, we linked clinical data from 16 052 heart failure with reduced ejection fraction (ejection fraction ≤40%) patients with Medicare claims data. We divided ACEi/ARB-eligible patients into 4 categories based on admission and discharge ACEi/ARB use: continued (reference group), started, discontinued, or not started on therapy. A multivariable Cox proportional hazard model was used to determine the association between ACEi/ARB category and outcomes. Most, 90.5%, were discharged on ACEi/ARB (59.6% continued and 30.9% newly started). Of those discharged without ACEi/ARB, 1.9% were discontinued, and 7.5% were eligible but not started. Thirty-day mortality was 3.5% for patients continued and 4.1% for patients started on ACEi/ARB. In contrast, 30-day mortality was 8.8% for patients discontinued (adjusted hazard ratio [HRadj] 1.92; 95% CI 1.32-2.81; P < 0.001) and 7.5% for patients not started (HRadj 1.50; 95% CI 1.12-2.00; P=0.006). The 30-day readmission rate was lowest among patients continued or started on therapy. One-year mortality was 28.2% for patients continued and 29.7% for patients started on ACEi/ARB compared to 41.6% for patients discontinued (HRadj 1.35; 95% CI 1.13-1.61; P < 0.001) and 41.7% (HRadj 1.28; 95% CI 1.14-1.43; P < 0.001) for patients not started on therapy. Conclusions-Compared with continuation, withdrawal of ACEi/ARB during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission, even after adjustment for severity of illness.

AB - Background-Guidelines recommend continuation or initiation of guideline-directed medical therapy, including angiotensinconverting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB), in hospitalized patients with heart failure with reduced ejection fraction. Methods and Results-Using the Get With The Guidelines-Heart Failure Registry, we linked clinical data from 16 052 heart failure with reduced ejection fraction (ejection fraction ≤40%) patients with Medicare claims data. We divided ACEi/ARB-eligible patients into 4 categories based on admission and discharge ACEi/ARB use: continued (reference group), started, discontinued, or not started on therapy. A multivariable Cox proportional hazard model was used to determine the association between ACEi/ARB category and outcomes. Most, 90.5%, were discharged on ACEi/ARB (59.6% continued and 30.9% newly started). Of those discharged without ACEi/ARB, 1.9% were discontinued, and 7.5% were eligible but not started. Thirty-day mortality was 3.5% for patients continued and 4.1% for patients started on ACEi/ARB. In contrast, 30-day mortality was 8.8% for patients discontinued (adjusted hazard ratio [HRadj] 1.92; 95% CI 1.32-2.81; P < 0.001) and 7.5% for patients not started (HRadj 1.50; 95% CI 1.12-2.00; P=0.006). The 30-day readmission rate was lowest among patients continued or started on therapy. One-year mortality was 28.2% for patients continued and 29.7% for patients started on ACEi/ARB compared to 41.6% for patients discontinued (HRadj 1.35; 95% CI 1.13-1.61; P < 0.001) and 41.7% (HRadj 1.28; 95% CI 1.14-1.43; P < 0.001) for patients not started on therapy. Conclusions-Compared with continuation, withdrawal of ACEi/ARB during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission, even after adjustment for severity of illness.

KW - Angiotensin II receptor blockers

KW - Angiotensin-converting enzyme inhibitors

KW - Heart failure

KW - Outcomes research

KW - Quality of care

UR - http://www.scopus.com/inward/record.url?scp=85016017429&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85016017429&partnerID=8YFLogxK

U2 - 10.1161/JAHA.116.004675

DO - 10.1161/JAHA.116.004675

M3 - Article

C2 - 28189999

AN - SCOPUS:85016017429

SN - 2047-9980

VL - 6

JO - Journal of the American Heart Association

JF - Journal of the American Heart Association

IS - 2

M1 - e004675

ER -

Initiation, continuation, or withdrawal of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and outcomes in patients hospitalized with heart failure with reduced ejection fraction

Abstract

Keywords

ASJC Scopus subject areas

Access to Document

Other files and links

Fingerprint

Cite this