Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients with congestive heart failure and chronic kidney disease.
BACKGROUND
Patients with coexistent heart failure and chronic kidney disease (CKD) have a poor prognosis, possibly related to the underuse of standard medical therapies--angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB).


METHODS
We performed a retrospective analysis of the Minnesota Heart Survey, identifying patients hospitalized in 2000 in the Minneapolis-St Paul metropolitan area with heart failure. The main outcome measure was the association of ACE-I and ARB use on 30-day and 1-year mortality, stratified by glomerular filtration rate (GFR).


RESULTS
Compared to patients with heart failure with preserved renal function (GFR > or = 90 mL/min), patients with severely impaired renal function (GFR <15 mL/min) were far less likely to receive ACE-I or ARB during hospitalization (52.0% vs 69.5%, P < .0001) or at discharge (50.5% vs 65.1%, P < .0001). Worsening renal function was associated with increased mortality, both at 30 days and at 1 year. The inhospital use of either an ACE-I or ARB was associated with significantly reduced 30-day mortality (OR 0.45, 95% CI 0.28-0.59) after adjusting for multiple risk factors. Similarly, the discharge prescription of either an ACE-I or ARB was associated with a significant reduction in adjusted 1-year mortality (OR 0.72, 95% CI 0.58-0.91). However, among patients on dialysis, there was no benefit of ACE-I or ARB on either 30-day or 1-year mortality.


CONCLUSIONS
Angiotensin-converting enzyme inhibitors and ARB are underused in patients with heart failure with chronic kidney disease. Given the reduction in 30-day and 1-year mortality, these medications should be considered in most patients with heart failure, independent of underlying renal function. Among patients on hemodialysis, further investigation is warranted.
Berger
Alan K
AK
Section of Cardiovascular Medicine, Department of Medicine, University of MN, Minneapolis, MN 55454, USA. berger1217@aol.com
Duval
Sue
S
Manske
Connie
C
Vazquez
Gabriela
G
Barber
Cheryl
C
Miller
Leslie
L
Luepker
Russell V
RV
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D050197:Atherosclerosis / Q000453:epidemiology; D002908:Chronic Disease; D015897:Comorbidity; D004363:Drug Utilization; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000453:epidemiology* / Q000401:mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007674:Kidney Diseases / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D008910:Minnesota / Q000453:epidemiology; D006435:Renal Dialysis / Q000706:statistics & numerical data; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000453:epidemiology
D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors