title: Associations between aldosterone antagonist therapy and risks of mortality and readmission among patients with heart failure and reduced ejection fraction.
abstract: BACKGROUND
  Aldosterone antagonist therapy for heart failure and reduced ejection fraction has been highly efficacious in randomized trials. However, questions remain regarding the effectiveness and safety of the therapy in clinical practice.
  
  
  OBJECTIVE
  To examine the clinical effectiveness of newly initiated aldosterone antagonist therapy among older patients hospitalized with heart failure and reduced ejection fraction.
  
  
  METHODS
  Using clinical registry data linked to Medicare claims from 2005 through 2010, we examined outcomes of eligible patients hospitalized with heart failure and reduced ejection fraction. We used Cox proportional hazards models and inverse-weighted estimates of the probability of treatment to adjust for treatment selection bias.
  
  
  METHODS
  All-cause mortality, cardiovascular readmission, and heart failure readmission at 3 years, and hyperkalemia readmission at 30 days and 1 year.
  
  
  RESULTS
  Among 5887 patients who met the inclusion criteria, the mean age was 77.6 years; of those 1070 (18.2%) started aldosterone antagonist therapy at discharge. Cumulative incidence rates among treated and untreated patients were 49.9% vs 51.2% (P = .62) for mortality; 63.8% vs 63.9% (P = .65) for cardiovascular readmission; and 38.7% vs 44.9% (P < .001) for heart failure readmission at 3 years; and 2.9% vs 1.2% (P < .001) for hyperkalemia readmission within 30 days and 8.9% vs 6.3% (P = .002) within 1 year. After inverse weighting for the probability of treatment, there were no significant differences in mortality (hazard ratio [HR], 1.04; 95% CI, 0.96-1.14; P = .32) and cardiovascular readmission (HR, 1.00; 95% CI, 0.91-1.09; P = .94). Heart failure readmission was lower among treated patients at 3 years (HR, 0.87; 95% CI, 0.77-0.98; P = .02). Readmission associated with hyperkalemia was higher with aldosterone antagonist therapy at 30 days (HR, 2.54; 95% CI, 1.51-4.29; P < .001) and 1 year (HR, 1.50; 95% CI, 1.23-1.84; P < .001).
  
  
  CONCLUSIONS
  Initiation of aldosterone antagonist therapy at hospital discharge was not independently associated with improved mortality or cardiovascular readmission but was associated with improved heart failure readmission among eligible older patients with heart failure and reduced ejection fraction. There was a significant increase in the risk of readmission with hyperkalemia, predominantly within 30 days after discharge.
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina 27715, USA. adrian.hernandez@duke.edu
authors.forename: Adrian F
authors.initials: AF
authors.lastname: Hernandez
authors.forename: Xiaojuan
authors.initials: X
authors.lastname: Mi
authors.forename: Bradley G
authors.initials: BG
authors.lastname: Hammill
authors.forename: Stephen C
authors.initials: SC
authors.lastname: Hammill
authors.forename: Paul A
authors.initials: PA
authors.lastname: Heidenreich
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Masoudi
authors.forename: Laura G
authors.initials: LG
authors.lastname: Qualls
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.forename: Lesley H
authors.initials: LH
authors.lastname: Curtis
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D003625:Data Collection; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality* / Q000503:physiopathology; D006801:Humans; D006947:Hyperkalemia / Q000139:chemically induced; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D000451:Mineralocorticoid Receptor Antagonists / Q000009:adverse effects / Q000627:therapeutic use*; D010351:Patient Discharge; D010359:Patient Readmission; D012042:Registries / Q000706:statistics & numerical data; D012306:Risk; D013318:Stroke Volume / Q000187:drug effects*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D000451:Mineralocorticoid Receptor Antagonists