Angiotensin II antagonism is associated with reduced risk for gastrointestinal bleeding caused by arteriovenous malformations in patients with left ventricular assist devices.
BACKGROUND
Angiogenesis is implicated in formation of gastrointestinal arteriovenous malformations (AVMs). Angiotensin II signaling is involved in angiogenesis through the vascular endothelial growth factor (VEGF) and angiopoietin-2 pathways. We hypothesized that angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) therapy would be associated with a reduced risk of all-cause gastrointestinal bleeding (GIB) and AVM-associated GIB in patients with left ventricular assist devices (LVADs).


METHODS
We reviewed records of all adult patients receiving a continuous-flow LVAD (HeartMate II or HeartWare HVAD) at Johns Hopkins Hospital between January 2004 and December 2014. Of 192 patients, 131 were included for final analyses. Logistic regression analysis adjusting for demographic, cardiovascular, and laboratory variables was used to assess the association of ACEI or ARB therapy with GIB.


RESULTS
Of 131 patients, 100 received ACEI or ARB therapy during LVAD support. Of the 31 patients who did not receive ACEI or ARB, 15 experienced GIB (48%), with 9 caused by AVMs (29%). Of 100 patients who received ACEI or ARB therapy, 24 experienced GIB (24%), with 9 caused by AVMs (9%). Logistic regression hazards model demonstrated that ACEI or ARB therapy was independently associated with a reduced risk for all-cause GIB (odds ratio 0.29, 95% confidence interval 0.12-0.72) and AVM-related GIB (odds ratio 0.23, 95% confidence interval 0.07-0.71).


CONCLUSIONS
Angiotensin II antagonism is associated with a reduced risk of AVM-related GIB in patients with LVADs. This association is independent of age, sex, blood pressure, renal function, international normalized ratio, LVAD type, and cardiomyopathy etiology.
Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina. Electronic address: houstobr@musc.edu.
Brian A
BA
Houston
Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland.
Andrea L C
AL
Schneider
Department of Critical Care Medicine, National Institutes of Health, Bethesda, Maryland.
Joban
J
Vaishnav
Division of Gastroenterology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
David M
DM
Cromwell
Department of Critical Care Medicine, National Institutes of Health, Bethesda, Maryland.
P Elliott
PE
Miller
Department of Critical Care Medicine, National Institutes of Health, Bethesda, Maryland.
Kamil F
KF
Faridi
Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
Ashish
A
Shah
Department of Cardiothoracic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.
Chris
C
Sciortino
Department of Cardiothoracic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.
Glenn
G
Whitman
Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
Ryan J
RJ
Tedford
Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
Gerin R
GR
Stevens
Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
Daniel P
DP
Judge
Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
Stuart D
SD
Russell
Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
Rosanne
R
Rouf
D000328:Adult; D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D001165:Arteriovenous Malformations / Q000150:complications*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology / Q000517:prevention & control*; D006333:Heart Failure / Q000628:therapy*; D006353:Heart-Assist Devices; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies
D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors
ACE inhibitor; ARB; Arteriovenous malformations; GI bleed; LVAD