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: Guidelines recommend continuation or initiation of guideline-directed medical therapy, including angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB), in hospitalized patients with heart failure with reduced ejection fraction.
  
  
  
  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 (HRadj1.50; 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 (HRadj1.35; 95% CI 1.13-1.61;P<0.001) and 41.7% (HRadj1.28; 95% CI 1.14-1.43;P<0.001) for patients not started on therapy.
  
  
  
  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.
authors.affiliation: Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA.
authors.forename: Lauren G
authors.initials: LG
authors.lastname: Gilstrap
authors.affiliation: Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA.
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.affiliation: Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA.
authors.forename: Akshay S
authors.initials: AS
authors.lastname: Desai
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
authors.forename: Li
authors.initials: L
authors.lastname: Liang
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
authors.forename: Roland
authors.initials: R
authors.lastname: Matsouaka
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
authors.forename: Adam D
authors.initials: AD
authors.lastname: DeVore
authors.affiliation: Department of Clinical Neurosciences, University of Calgary, Alberta, Canada.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
authors.affiliation: Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
authors.forename: Paul
authors.initials: P
authors.lastname: Heidenreich
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
authors.forename: Adrian F
authors.initials: AF
authors.lastname: Hernandez
authors.affiliation: Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors.forename: Clyde W
authors.initials: CW
authors.lastname: Yancy
authors.affiliation: Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA dlbhattmd@post.harvard.edu.
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
mesh_terms: D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006333:Heart Failure / Q000188:drug therapy* / Q000453:epidemiology / Q000503:physiopathology; D006760:Hospitalization; D006801:Humans; D008297:Male; D009017:Morbidity / Q000639:trends; D017063:Outcome Assessment, Health Care / Q000379:methods*; D010359:Patient Readmission / Q000639:trends; D011787:Quality of Health Care; D012042:Registries; D012189:Retrospective Studies; D013318:Stroke Volume / Q000502:physiology*; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology; D028761:Withholding Treatment
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors
keywords: angiotensin II receptor blockers; angiotensin‐converting enzyme inhibitors; heart failure; outcomes research; quality of care