Angiotensin converting enzyme inhibitors and angiotensin receptor blockers in acute heart failure: invasive hemodynamic parameters and clinical outcomes.

Kira Balestrini,Grace Salacup,Ruchika Bhargav,Eduardo Quintero,Janani Rangaswami,Roy O Mathew,Jiahui Jiang,Anum Shahzad,Kevin Bryan Lo,Peter A Mccullough,Hesam Mostafavi Toroghi

doi:10.31083/j.rcm.2021.01.216

Abstract

There are limited data regarding the use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs) in acute heart failure (AHF). The purpose is to determine the patterns of ACEi/ARB use at the time of admission and discharge in relation to invasive hemodynamic data, mortality, and heart failure (HF) readmissions. This is a retrospective single-center study in patients with AHF who underwent right heart catheterization between January 2010 and December 2016. Patients on dialysis, evidence of shock, or incomplete follow up were excluded. Multivariate logistic regression analysis was used to analyze the factors associated with continuation of ACEi/ARB use on discharge and its relation to mortality and HF readmissions. The final sample was 626 patients. Patients on ACEi/ARB on admission were most likely continued on discharge. The most common reasons for stopping ACEi/ARB were worsening renal function (WRF), hypotension, and hyperkalemia. Patients with ACEi/ARB use on admission had a significantly higher systemic vascular resistance (SVR) and mean arterial pressure (MAP), but lower cardiac index (CI). Patients with RA pressures above the median received less ACEi/ARB (P = 0.025) and had significantly higher inpatient mortality (P = 0.048). After multivariate logistic regression, ACEi/ARB use at admission was associated with less inpatient mortality; OR 0.32 95% CI (0.11 to 0.93), and this effect extended to the subgroup of patients with HFpEF. Patients discharged on ACEi/ARB had significantly less 6-month HF readmissions OR 0.69 95% CI (0.48 to 0.98). ACEi/ARB use on admission for AHF was associated with less inpatient mortality including in those with HFpEF.

Highlights

The inhibition of the Renin Angiotensin Aldosterone System (RAAS) plays a key role in reducing morbidity and mortality in patients with heart failure, in those patients with reduced ejection fraction (HFrEF)
right heart catheterization (RHC) was done for worsening heart failure for 66% of patients, 13% for valvular heart disease evaluation, 9% for evaluation of ischemia, 5% for evaluation of pulmonary hypertension and 6% for other reasons such as intracardiac shunt evaluation, pericardial tamponade, transplant evaluation and worsening renal function
We looked at patients above and below the median values of Pulmonary capillary wedge pressure (PCWP) and right atrial pressures (RAP) as these were the hemodynamic parameters that coincide with signs and symptoms of acute heart failure (AHF)

Summary

Introduction

The inhibition of the Renin Angiotensin Aldosterone System (RAAS) plays a key role in reducing morbidity and mortality in patients with heart failure, in those patients with reduced ejection fraction (HFrEF). While there is less certainty on the benefits with RAASi in patients with heart failure with preserved ejection fraction (HFpEF), there may be a potential role in reducing hospitalizations and mortality with careful patient selection [4]. While continuation of RAASi therapy after hospital discharge in patients with HFrEF has been associated with lower mortality and readmission rates in prior observational studies [6], there is still a high rate of discontinuation of ACEi/ARB therapy during AHF due to complications such as worsening kidney function, hypotension, hyperkalemia, and angioedema [5]. We aimed to investigate further the patterns of ACEi/ARB use among patients with AHF, reasons for stopping these agents, hemodynamic changes associated with use, and impact on clinical outcomes of mortality and HF readmissions

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