Abstract 12458: Mineralocorticoid Receptor Antagonist Use in Patients With Heart Failure and Co-Morbid Diabetes or Chronic Kidney Disease

Abstract

Introduction: The risk of hyperkalemia or acute renal insufficiency (ARI) may limit the use of mineralocorticoid receptor antagonists (MRAs) in heart failure (HF) patients, especially in those with diabetes mellitus (DM) or chronic kidney disease (CKD). Hypothesis: Despite risks, MRAs may be beneficial in these patients. Methods: Using the GWTG-HF registry linked to Medicare claims, we analyzed patients hospitalized from 2005-2013 with a history of DM or CKD and not on a MRA at admission. Patients were stratified by MRA use at discharge. We used proportional hazards models, weighted by inverse treatment probability, for associations between MRA use and 30-day, 1- and 3-year mortality, all-cause readmissions, and readmission for HF, hyperkalemia, or ARI. We performed interaction analyses for differential effects on 3-year outcomes for reduced and preserved ejection fraction (HFrEF and HFpEF). Results: Of 16,848 patients, 12.3% received a MRA at discharge. Higher creatinine was associated with lower odds of MRA use (OR 0.66, 95% CI 0.61, 0.71) but higher potassium was not (OR 1.00, 95% CI 0.90, 1.11). There was no difference in risk of mortality between groups (Table). MRA use was associated with increased short- and long-term risk of hyperkalemia and ARI, but decreased risk of 1- and 3- year all-cause rehospitalization. In the interaction analysis, HFpEF patients on MRA had increased rehospitalization for hyperkalemia (HR 1.44, 95% CI 1.17, 1.78) and ARI (HR 1.29, 95% CI 1.15, 1.44), but HFrEF patients did not (hyperkalemia HR 1.04, 95% CI 0.86, 1.25; ARI HR 0.94, 95% CI 0.82, 1.07). There were no significant interactions by EF group for mortality, or all-cause or HF readmission. Conclusions: Among patients with HF and DM or CKD, MRA use was associated with less all-cause hospitalizations despite increased risk of hyperkalemia and ARI. The increased risk of adverse events was confined to patients with HFpEF. MRAs may be safe in a highly selected group of HF patients with DM or CKD.