The association among renal insufficiency, pharmacotherapy, and outcomes in 6,427 patients with heart failure and coronary artery disease.
OBJECTIVE
This study was designed to examine the use of cardiovascular medications and outcomes in patients with heart failure (HF) and renal dysfunction.


BACKGROUND
Renal insufficiency is associated with poorer outcomes in patients with HF, but the mechanisms are uncertain. In particular, the degree of therapeutic nihilism in these patients, and whether it is appropriate, is unclear.


METHODS
This was a prospective cohort study with a one-year follow-up.


RESULTS
In 6,427 patients with cardiologist-diagnosed HF and angiographically proven coronary artery disease (mean age 69 years; 65% men; one-year mortality, 10%), 39% had creatinine clearances <60 ml/min. Patients with renal insufficiency were less likely to be prescribed angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, statins, or aspirin (all p < 0.001). However, users of aspirin (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.57 to 0.85), statins (OR 0.79, 95% CI 0.64 to 0.97), and beta-blockers (OR 0.75, 95% CI 0.62 to 0.90) were less likely to die in the subsequent 12 months than nonusers, irrespective of renal function (all OR adjusted for covariates including atherosclerotic burden and ejection fraction). Although ACE inhibitor users with creatinine clearances > or =60 ml/min had lower 12-month mortality (OR 0.72, 95% CI 0.48 to 0.99), ACE inhibitor users with clearances <60 ml/min did not (OR 1.21, 95% CI 0.97 to 1.51).


CONCLUSIONS
Renal insufficiency is common in patients with HF and coronary artery disease, and these patients have more advanced coronary atherosclerosis. Patients with renal insufficiency are less likely to be prescribed efficacious therapies, but have better outcomes if they receive these medications.
Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada T6G 2R7.
Justin
J
Ezekowitz
Finlay A
FA
McAlister
Karin H
KH
Humphries
Colleen M
CM
Norris
Marcello
M
Tonelli
William A
WA
Ghali
Merril L
ML
Knudtson
D000319:Adrenergic beta-Antagonists / Q000009:adverse effects / Q000627:therapeutic use; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000009:adverse effects / Q000627:therapeutic use; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use; D002317:Cardiovascular Agents / Q000009:adverse effects / Q000627:therapeutic use*; D002423:Cause of Death; D015331:Cohort Studies; D015897:Comorbidity; D003324:Coronary Artery Disease / Q000188:drug therapy* / Q000401:mortality; D003404:Creatinine / Q000097:blood; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000009:adverse effects / Q000627:therapeutic use; D007676:Kidney Failure, Chronic / Q000188:drug therapy* / Q000401:mortality; D016013:Likelihood Functions; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D016017:Odds Ratio; D016019:Survival Analysis; D018487:Ventricular Dysfunction, Left / Q000188:drug therapy / Q000401:mortality
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D002317:Cardiovascular Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D003404:Creatinine; D001241:Aspirin