Abstract
Introduction: While there are data demonstrating poor outcomes associated with discontinuation of renin-angiotensin system inhibitors (RASI) after hospitalization for heart failure with reduced ejection fraction (HFrEF), less is known about the prevalence and outcomes of RASI dose reduction. Objective: To determine the proportion of older US adults with HFrEF who had RASI down-titration after hospitalization and identify characteristics associated with RASI down-titration. Methods: This study included US Medicare beneficiaries age > 65 years with fee-for-service coverage hospitalized with HFrEF in 2007-2017 who filled a prescription for a RASI in the 90 days prior to hospitalization. We compared dosages of RASI prescription fills prior to and up to 1 year after hospitalization. Diagnoses of conditions that can reduce RASI tolerance (hypotension, acute kidney injury, hyperkalemia, angioedema, syncope, fall-related injuries) were identified during the hospitalization. We used modified Poisson models to calculate prevalence ratios and 95% CIs. Results: Among 35,047 Medicare beneficiaries hospitalized with HFrEF, the average age was 78.5 (SD 8.0) years, 82.3% were white, and 50.8% were women. After hospitalization, 61.9% filled a prescription for the same or higher dose, 15.6% filled a lower dose, and 22.6% did not fill a prescription for a RASI. Among the beneficiaries who filled a prescription for a RASI after hospitalization, hypotension, acute kidney injury, and hyperkalemia were associated with a higher prevalence of RASI down-titration (Table). Conclusion: Down-titration of RASIs is common among older adults with HFrEF following hospitalization and is more frequent among individuals with hypotension, acute kidney injury, or hyperkalemia during hospitalization. Down-titration may reduce risks of adverse events during periods of reduced medication tolerance after hospitalization, but could also lead to sustained suboptimal treatment.
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