Angiotensin Receptor Neprilysin Inhibitor Use and Blood Pressure Lowering in Patients With Heart Failure With Reduced Ejection Fraction Across the Spectrum of Kidney Function: An Analysis of the Veterans Administrative Health System

Abstract

A substantial proportion of patients with HF and kidney disease have poorly controlled blood pressures. This study aimed to evaluate patterns of blood pressure after initiation of angiotensin receptor neprilysin inhibitor (ARNI) or angiotensin-converting enzyme inhibitor (ACEI) /angiotensin receptor blocker (ARB) across the spectrum of kidney function. Between 2016 and 2020, we evaluated 26,091 patients admitted to a Veterans Affairs hospital for an acute heart failure exacerbation with reduced ejection fraction. We assessed patterns of systolic and diastolic blood pressure among those started on ARNI or ACEI/ARB over 6 months, overall and across estimated glomerular filtration rate. To account for differential treatment factors, we applied 1:1 propensity score matching using 15 known baseline covariates. There were 13,781 individuals treated with an ACEI or ARB, and 2,589 individuals with an ARNI prescription. After propensity score matching, 839 patients were matched in each of the ARNI and ACEI/ARB groups. Mean baseline eGFR was 63.8 (standard deviation 21.6) and 10% had stage 4 or 5 CKD. Patients in the ARNI group experienced greater SBP reduction at month 3 (-5.2 mmHg vs. -2.2 mmHg, ARNI vs. ACEI/ARB; p<0.001), and month 6 (-4.7 mmHg vs. -1.85 mmHg, ARNI vs. ACEI/ARB; p < 0.001). These differences in SBP by 6 months did not vary by eGFR above and below 60 ml/min/1.73m2 or continuously across a wide range of eGFR (Pinteraction>0.10 for both). The use of ARNI was associated with significant BP reduction as compared with the ACEI/ARB group overall and across the eGFR spectrum, including in advanced CKD.