Angiotensin Receptor Blockers In Patients Research Articles

Association of serum sodium minus chloride level at initiation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and hyperkalemia in patients with CKD: a case control study

Abstract Background Angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) exert a renoprotective effect on patients with chronic kidney disease (CKD). Despite their benefit, one of their side effects is hyperkalemia, and it is one of the most common reasons for discontinuation of these drugs. Hyperchloremic metabolic acidosis is a known risk factor for hyperkalemia in patients with CKD. However, whether it is a risk factor for hyperkalemia after initiating ACE-I or ARB remains unclear. Methods In a previous study, serum sodium minus chloride level ([Na+) − (Cl−]) was identified as useful for diagnosing metabolic acidosis. To estimate the baseline acid–base status, we determined for the cutoff value of [Na+] − [Cl−] that correlates with [HCO3−] below 24 mEq/L in patients with CKD. We then investigated whether this cutoff value was associated with hyperkalemia (serum potassium level ≥ 5.0 mEq/L) after initiating ACE-I or ARB in patients with CKD. Results In the investigation of the cutoff value of [Na+] − [Cl−], 612 patients were examined, and [Na+] − [Cl−] showed a good correlation with [HCO3−] (r = 0.67, p < 0.001). Based on receiver operating curve analysis, we derived a cut-off value of [Na+] − [Cl−] below 33.5 mEq/L. Using this cut off value, the sensitivity and specificity of [Na+] − [Cl−] for metabolic acidosis were 75.2% and 75.0%, respectively. To explore whether metabolic acidosis is associated with hyperkalemia after initiating ACE-I or ARB, we examined 1143 patients with CKD. Among this cohort, 403 (35.3%) patients had [Na+] − [Cl−] < 33.5 mEq/L at baseline, and the incidence of hyperkalemia was significantly higher in univariate analysis (9.2% versus 4.2%, p = 0.03). However, in multivariate analysis, [Na+] − [Cl−] < 33.5 mEq/L was not associated with hyperkalemia (odds ratio 1.13; 95% confidence interval 0.65–1.95). Conclusions Hyperchloremic metabolic acidosis was not associated with hyperkalemia after initiation of ACE-I or ARB in patients with CKD.

Comparative effectiveness of sacubitril/valsartan versus angiotensin receptor blockers in patients with heart failure with preserved ejection fraction: A real-world study.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Sacubitril/valsartan (SAC/VAL) or angiotensin receptor blockers (ARBs) are recommended therapy for heart failure with preserved ejection fraction (HFpEF), but little is known about their real-world comparative effectiveness among patients with HFpEF. The objective of this study was to determine the comparative effectiveness of SAC/VAL vs ARBs in preventing HF-related hospitalization or all-cause hospitalization among patients with HFpEF. We conducted a cohort study using IBM MarketScan commercial and Medicare supplemental databases to identify patients aged 18 years or older with a diagnosis of HFpEF and initiation of SAC/VAL (2015-2020) or ARB (2009-2014) therapy. The index date was the date of the first SAC/VAL or ARB prescription fill. After propensity score (PS) matching with a ratio of 1 up to 3, Cox proportional hazards regression was used with robust variance estimators to compare the risks of HF-related hospitalization and all-cause hospitalization between the 2 therapies. Several subgroup and sensitivity analyses were conducted to check the robustness of the main analysis. After PS matching, 2,520 patients (846 receiving SAC/VAL and 1,674 receiving an ARB) were included in the final analyses. After controlling for covariates, there was no difference in the risk of HF-related hospitalization between SAC/VAL and ARB recipients (adjusted hazard ratio [aHR], 1.33; 95% confidence interval [CI], 0.99-1.77). There was also no difference in the risk of all-cause hospitalization between SAC/VAL and ARB recipients (aHR, 1.06; 95% CI, 0.91-1.24). Among individuals with private or Medicare Advantage insurance plans, there was no significant difference in the risk of HF-related hospitalization or all-cause hospitalization between adults with HFpEF who received SAC/VAL and those who received ARB therapy.

Three-Year Cardiovascular Outcomes of Telmisartan in Patients With Hypertension: An Electronic Health Record-Based Cohort Study.

Telmisartan exhibits superior efficacy in controlling 24-h blood pressure (BP) compared with other angiotensin receptor blockers (ARBs). However, data on its cardiovascular effects in patients with hypertension are limited. This study aimed to evaluate the cardiovascular outcomes in patients taking telmisartan compared to those taking other ARBs. This multicenter retrospective study used data from the Korea University Medical Center database, built from electronic health records. A total of 19,247 patients taking two or more antihypertensive medications were identified. Patients prescribed telmisartan (telmisartan users) were compared with those prescribed an ARB other than telmisartan (other ARB users). The primary outcome was major adverse cardiac events (MACE), a composite of cardiovascular death, myocardial infarction, stroke, and hospitalizations due to heart failure. The adjusted outcomes were compared using 1:1 propensity score (PS) matching. Overall, 3,437 (17.9%) patients were telmisartan users. These patients were more likely to be younger and male and less likely to have a history of chronic kidney disease, dialysis, or heart failure. In the PS-matched cohort, BP control was similar in both groups; however, telmisartan users exhibited significantly lower visit-to-visit BP variability. The adjusted 3-year MACE rate was similar between telmisartan users (4.6%) and other ARB users (4.7%, log-rank P = 0.75), with comparable safety profiles. In real-world practice, telmisartan showed cardiovascular outcomes similar to those of other ARBs in patients with hypertension taking two or more antihypertensive drugs.

Is Sacubitril/Valsartan a Superior Agent in Heart Failure With Reduced Ejection Fraction? A Review of Randomized Comparative Trials.

Background: The PARADIGM HF trial showed sacubitril/valsartan (SV) to be superior to enalapril in patients with reduced ejection fraction (HFrEF). Since its publication, several other randomized trials have compared SV to either an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in HFrEF which showed conflicting results regarding mortality, hospitalizations, and quality of life scoring. Objective: To review randomized comparative trials of SV to either ACEI or ARB in patients with HFrEF. Methods: PubMed and Embase databases were used to identify randomized comparative trials. The text terms sacubitril, angiotensin neprilysin, and LCZ696 were used for both searches. Meta-analysis, retrospective, adhoc, and cohort studies were excluded. Results: 1476 and 3983 citations were reviewed on PubMed and Embase, respectively. Of these, 11 randomized comparative trials to either ACEI or ARB were included for analysis. The mortality/quality of life benefits of SV over enalapril in the PARADIGM HF were not corroborated in any of the other trials. The effect of hospitalizations for heart failure was inconsistent among trials. Exercise tolerance was not improved with SV versus enalapril. Conclusion: The results of the PARADIGM HF trial have largely not been confirmed in subsequent randomized comparative trials.

Postoperative Angiotensin Receptor Blocker Use is Associated With Decreased Rates of Manipulation Under Anesthesia, Arthroscopic Lysis of Adhesions, and Prosthesis-Related Complications in Patients Undergoing Total Knee Arthroplasty

BackgroundThe cellular mechanisms underlying excess scar tissue formation in arthrofibrosis following total knee arthroplasty (TKA) are well-described. Angiotensin receptor blockers (ARB), particularly losartan, is a commonly prescribed antihypertensive with demonstrated antifibrotic properties. This retrospective study aimed to assess the rates of 1- and 2-year postoperative complications in patients who filled prescriptions for ARBs during the 90 days after TKA. MethodsPatients undergoing primary TKA were selected from a large national insurance database, and the impact of ARB use after TKA on complications was assessed. Of the 1,299,106 patients who underwent TKA, 82,065 had filled at least a 90-day prescription of losartan, valsartan, or olmesartan immediately following their TKA. The rates of manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOA), aseptic loosening, periprosthetic fracture, and revision at 1 and 2 years following TKA were analyzed using multivariable logistic regressions to control for various comorbidities. ResultsARB use was associated with decreased rates of MUA (odds ratio [OR] = 0.94, 95% confidence interval (CI), 0.90 to 0.99), arthroscopy/LOA (OR = 0.86, 95% CI, 0.77 to 0.95), aseptic loosening (OR = 0.71, 95% CI, 0.61 to 0.83), periprosthetic fracture (OR = 0.58, 95% CI, 0.46 to 0.71), and revision (OR = 0.79, 95% CI, 0.74 to 0.85) 2 years after TKA. ConclusionsARB use throughout the 90 days after TKA is associated with a decreased risk of MUA, arthroscopy/LOA, aseptic loosening, periprosthetic fracture, and revision, demonstrating the potential protective abilities of ARBs. Prospective studies evaluating the use of ARBs in patients at risk for postoperative stiffness would be beneficial to further elucidate this association.

Angiotensin receptor blockers in patients with hypertrophic cardiomyopathy: A comparison of VANISH and INHERIT randomized trials

To identify the cause of discrepancy between the INHERIT trial and VANISH trial in regards to disease modification of angiotensin receptor II blockers in hypertrophic cardiomyopathy (HCM). We replicated the data analysis used in VANISH, converting individual change in each component of the composite endpoint into a z-score and applying this z-score to the INHERIT results. No significant improvement was identified in the composite z-score between the 2 groups at 12-month follow-up (P=.4). With the exception of tissue Doppler systolic (s') velocity, we found no significant benefit or harm from losartan compared to placebo for any of the individual components of the composite score at 12-month follow-up. Results were similar in analyses without imputed data or when restricted to patients with sarcomeric HCM. Despite applying the potentially more sensitive composite z-score endpoint as in the VANISH trial, no statistically significant benefits from the use of losartan compared to placebo could be detected at 12-month follow-up in patients with overt HCM participating in the INHERIT trial.

COMPARISON OF CLINICAL BENEFITS BETWEEN TELMISARTAN AND OTHER ANGIOTENSIN RECEPTOR BLOCKERS IN HYPERTENSION PATIENTS WITH COMBINATION THERAPY: MULTICENTER REAL-WORLD STUDY

Objective: Background Telmisartan have potent blood pressure lowering effect as well as the other pleiotrophic effects including PPAR-??/?? dual activation. In large clinical studies, telmisartan demonstrated the comparable clinical benefits with angiotensin converting enzyme inhibitor. However, there were few studies of direct comparison between telmisartan and the other angiotensin receptor blockers (ARBs). This study aimed to compare the cardiovascular and renal protective effect between telmisartan and the other ARBs in patients with the advanced hypertension who required two or more anti-hypertensive drugs. Design and method: This study used the Observation Medical Outcomes Partnership-Common Data Model database of three tertiary hospitals in Korea. 19,247 Patients were prescribed at least two antihypertensive drugs including ARBs, were selected from January 1, 2017 to December 31, 2019. 3,437 patients in the telmisartan group and 15,810 patients in the other ARB group were matched 1:1 through propensity score matching. Major adverse cardiovascular event (MACE), heart failure (HF) hospitalization and new-onset dialysis were compared for 3,386 patients in each group. Result: Before the matching, there was a higher proportion of patients with a history of myocardial infarction (MI) in the telmisartan group compared to the other ARB group. After the matching, average on-treatment blood pressure was similar between two groups. Over a three-year period, the incidence of MACE and HF hospitalization did not differ significantly between the two groups. Compared to the other ARB group, the telmisartan group had a lower incidence of new-onset dialysis (1.3% vs 1.9%, p-value = 0.04). However, this difference was not statistically significant in the multivariable Cox regression model. Conclusions: Telmisartan has similar cardiovascular and renal protective effects to other ARBs in patients with advanced hypertension who are taking at least two anti-hypertensive medications. Figure. Kaplan-Meier curves showing the incidence of MACE and dialysis in the telmisartan group and the other ARB group.

Comparative Efficacy of Angiotensin Converting Enzymes Inhibitors and Angiotensin Receptor Blockers in Patients with Heart Failure in Tanzania: A Prospective Cohort Study

Comparative Efficacy of Angiotensin Converting Enzymes Inhibitors and Angiotensin Receptor Blockers in Patients with Heart Failure in Tanzania: A Prospective Cohort Study

Role of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in cryoballoon ablation outcomes for paroxysmal atrial fibrillation.

Cryoballoon ablation (CBA) is recommended for patients with paroxysmal atrial fibrillation (AF) refractory to antiarrhythmic drugs. However, only 80% of patients benefit from initial CBA. There is growing evidence that pretreatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) decreases the recurrence of AF postablation, particularly in nonparoxysmal AF undergoing radiofrequency ablation. The role of ACEIs and ARBs in patients with paroxysmal AF in CBA remains unknown. We decided to investigate the role of ACEIs and ARBs in preventing the recurrence of atrial arrhythmia (AA) following CBA for paroxysmal AF. To investigate the role of ACEIs and ARBs in preventing recurrence of AA following CBA for paroxysmal AF. We followed 103 patients (age 60.6 ± 9.1 years, 29% women) with paroxysmal AF undergoing CBA 1-year post procedure. Recurrence was assessed by documented AA on electrocardiogram or any form of long-term cardiac rhythm monitoring. A multivariable Cox proportional hazard model was used to assess if ACEI or ARB treatment predicted the risk of AA recurrence. After a 1-year follow-up, 19 (18.4%) participants developed recurrence of AA. Use of ACEI or ARB therapy was noted in the study population. Patients on ACEI/ARB had a greater prevalence of hypertension and coronary artery disease. On a multivariate model adjusted for baseline demographics and risk factors for AF, ACEI or ARB therapy did not prevent recurrence of AA following CBA (P = 0.72). Similarly, on Kaplan-Meier analysis pretreatment with ACEI/ARB did not predict the time to first recurrence of AA (P = 0.2173). In our study population, preablation treatment with an ACEI or ARB had no influence on the recurrence of AA following CBA for paroxysmal AF.

Efficacy and safety of sacubitril valsartan in heart failure compared to renin angiotensin aldosterone system inhibitors: a systematic review and meta analysis of randomised controlled trials

Abstract Background Benefits and harms of the use of LCZ696 (sacubitril/valsartan, S/V), a combination of a neprilysin inhibitor and an angiotensin receptor blocker (ARB), in heart failure (HF) are unknown. Purpose To systematically assess benefits and harms of S/V as compared to angiotensin converting enzyme inhibitors (ACEI) or ARB in patients with HF. Methods We searched for randomised controlled trials (RCTs) evaluating S/V vs. ACEI or ARB in acute or chronic HF adult patients. Primary outcomes were HF hospitalisation and cardiovascular [CV] mortality; secondary outcomes were all-cause mortality, decline in renal function, myocardial dysfunction, quality of life (QoL), systolic blood pressure (SBP), diastolic blood [DBP], and adverse events (AEs) including worsening renal function (SCr≥2 mg/dL), hyperkalaemia (K+≥5.5 mmol/L), symptomatic hypotension (SBP<100 mmHg), and angio-oedema. Inverse variance random-effects meta-analyses were conducted and effects expressed as hazard ratios (HR), relative risks (RR) or mean difference (MD) and their 95% confidence intervals (CI). GRADE methodology was used to assess the certainty of evidence (CoE). Results We selected 11 RCTs (n=18766). Follow-up times ranged between 2 and 48 months; the average age of participants was 61 to 73 years-old. Five RCTs had ACEIs as control, five RCTs had ARBs as control, and one RCT had both ACEI and ARB as control. Six RCTs had low risk of bias; five RCTs had unclear risk of bias. S/V reduced the hazard of HF hospitalisations by 20% (HR 0.80, 95% CI 0.68–0.94; 3 RCTs; I2=65%; high CoE), CV mortality by 14% (HR 0.86, 95% CI 0.73 to 1.01; 2 RCTs; I2=57%; high CoE) and all-cause mortality by 11% (HR 0.89, 95% CI 0.78–1.00; 3 RCTs; I2=36%; high CoE) compared to ACEI or ARB control (Figure 1). S/V slightly improved KCCQ-QoL scores (MD 1.36 points, 95% CI 0.49 to 2.24; 6 RCTs; I2=54%). S/V did not affect LVEF and E/E' but reduced NTproBNP (SMD −0.34, 95% CI −0.52 to −0.16; 3 RCTs; I2=62%), and hs-TNT (Ratio of differences 0.84, 95% CI 0.79–0.88; 2 RCTs; I2=0%). SBP and DBP were reduced by 4 mmHg and 3 mmHg, respectively, and hypotension was increased (RR 1.69, 95% CI 1.33–2.15; 9 RCTs; I2=65%; high CoE) with S/V. Also, S/V reduced the hazard of decline in renal function by 33% (HR 0.67, 95% CI 0.39–1.14; 2RCTs; I2=78%; high CoE); hyperkalaemia and angioedema events were similar between S/V and controls. Conclusions Sacubitril/valsartan had better clinical and intermediate outcomes in HF in comparison to ACEI or ARB. Decline of renal function was less frequent with S/V in comparison to controls, and there was no difference in decline of renal function or angioedema and hyperkalaemia events. However, sacubitril/valsartan was associated with more symptomatic hypotension events vs. controls. Funding Acknowledgement Type of funding sources: None.

Comparison Between Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Patients with Unstable Angina with Preserved Left Ventricular Systolic Function.

The present study evaluated the clinical results of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) treatment in patients with unstable angina (UA) with preserved left ventricular systolic function who underwent percutaneous coronary intervention (PCI) due to uncertainty regarding the long-term prognosis using ACEI or ARB. A total of 1627 UA patients with preserved left ventricular systolic function after PCI were enrolled. After propensity score matching, there were no differences in major adverse cardiovascular and cerebrovascular events (MACCEs) (hazard ratio (HR) = .860, 95% confidence interval (CI): .465-1.590, P = .630), all-cause death (HR = .334, 95% CI: .090-1.238, P = .101), nonfatal myocardial infarction (HR = 4.929, 95% CI: .576-42.195, P = .145), stroke (HR = 1.049, 95% CI: .208-5.290, P = .954) and target vessel revascularization (TVR) (HR = 1.276, 95% CI: .537-3.031, P = .581) between the ACEI and ARB groups. In conclusion, prognoses were comparable between ACEI or ARB treatment in UA patients who had preserved left ventricular systolic function after PCI.

Early prophylaxis of cardiomyopathy with beta-blockers and angiotensin receptor blockers in patients with Duchenne muscular dystrophy.

Early prophylaxis of cardiomyopathy with beta-blockers and angiotensin receptor blockers in patients with Duchenne muscular dystrophy.

Sacubitril/Valsartan for heart failure: A protocol for systematic review and meta-analysis.

Background:Sacubitril–valsartan has been shown to have superior effects over angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients with heart failure (HF). However, the effects of sacubitril–valsartan have never been systematically evaluated. Therefore, we performed a protocol for systematic review and meta-analysis to evaluate the efficacy and safety of sacubitril–valsartan in patients with HF.Methods:We selected 8 databases, including PubMed, the Web of Science, Embase, Cochrane Library, the Chinese National Knowledge Infrastructure, the Chinese Science Journal Database, Wanfang Data, and the Chinese Biomedical Literature Database. The search time was from database establishment to March 2022. Two reviewers will screen the records and include quality studies according to inclusion criteria independently. Two reviewers will assess the risk of bias of the included studies by the “Risk of Bias Assessment Tool” of the Cochrane Handbook for randomized controlled trials. Statistical analysis will be performed with Review Manager software 5.3.Results:A synthesis of current evidence of sacubitril–valsartan for treating HF will be provided in this protocol.Conclusion:The results of this study will provide a theoretical basis for the clinical use of sacubitril–valsartan to treat HF.

Nephroprotective effect of vitamin E added to angiotensin receptor blocker in patients with diabetic nephropathy

Background: Diabetes mellitus is a condition associated with increased oxidative stress as a consequence of hyperglycemia. Therefore, the use of antioxidants in people with diabetes has been advocated. Vitamin E is the most prevalent naturally occurring anti-oxidant. Aim: To evaluate the effect of the combination of angiotensin receptor blocker (ARB) and vitamin E on urine protein in patients with diabetic nephropathy. Methods: One hundred and six patients with diabetic nephropathy, who visited the Alsader medical city in Najaf governorate and Al-Furat Al-Awsat general hospital in Kufa, were investigated, 39 of them are type 1diabetics, and 67 of them are type 2 diabetics. Each patient was followed up for 3 months with valsartan (160mg/day), then for 3 months with addition of tocopherol (400mg). At the screening visits, proteinuria was determined in two 24 h urine sample, arterial blood pressure was measured twice at ten minutes rest with 2 minutes interval and serum level of potassium, sodium & creatinine were determined. Results: Proteinuria was significantly lowered when tocopherol 400mg was added to valsartan, as compared with valsartan without tocopherol. Valsartan alone caused a mean reduction of 24 h urine protein of 27% from the baseline, while the addition of tocopherol caused a mean reduction of 24 hour proteinuria of 30% from result of valsartan. That is mean the combination therapy of valsartan and tocopherol caused a reduction in proteinuria of 44% from baseline. Conclusion: The current study suggests that combination therapy of ARB and vitamin E offers an additional antiproteinuric and nephroprotective effect. Recommendation: Antioxidants, in particular vitamin E have promising nephroprotective effects. However, studies on other antioxidants like vitamin C are needed in the efforts of prevention of diabetic nephropathy

Renin-Angiotensin System Blocker in COVID-19. A Single Center Study.

Early during the Coronavirus disease 2019 (Covid-19) pandemic, concerns were raised regarding potential adverse outcomes in patients taking angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs). These concerns were based on animal studies showing increased ACE-2 expression in mice treated with ACEI/ARB. This is a single-center, retrospective, cohort study of 289 patients diagnosed with 2019 Novel Coronavirus (SARS-CoV-2) hospitalized between March of 2020 and June of 2020. The study was intended to investigate the impact of ACEIs and/or ARBs on in-hospital mortality, intensive care unit (ICU) admission, postadmission hemodialysis requirement, and the need for mechanical ventilation in patients with COVID-19. This cohort of 289 patients included 139 of 289 women (48%) with a mean age of 61 ± 19 years. Patients using ACEIs/ARBs were older (69.68 vs. 57.9 years; P < 0.0001), more likely to have a history of hypertension (97% vs. 36%; P < 0.0001), diabetes mellitus (48% vs. 20.9%; P < 0.0001), chronic heart failure (11.39% vs. 4.29%; P < 0.0512), coronary artery disease (20.25% vs. 7.14%; P < 0.0025), stroke/Transient Ischemic Attack (7.59% vs. 2.38%; P < 0.0761), chronic kidney disease (11.39% vs. 3.33%; P < 0.0167), atrial fibrillation/flutter (18.99% vs. 7.14%; P < 0.0080), and dementia (22.7% vs. 11.4%; P < 0.0233) compared with the nonuser group. There was significantly higher in-hospital mortality in patients using ACEIs/ARBs than nonusers, respectively (32.9% vs. 15.2%; P < 0.0015). However, a multivariate logistics regression analysis performed to adjust for common confounders demonstrated no significant difference in all-cause in-patient mortality (P 0.7141). Admission to ICU, postadmission hemodialysis requirement, and mechanical ventilation showed no significant differences between the 2 groups (P = NS). This study suggests that the use of ACEIs and ARBs in patients with COVID-19 was not found to significantly increase all-cause in-hospital mortality, ICU admissions, and hemodialysis and mechanical ventilation requirements.

Investigation of the effects of angiotensin converting enzyme inhibitors and angiotensin receptor blockers on anemia in patients with normal or mildly low glomerular filtration rate.

The relationship between the activation of the renin-angiotensin system and the increase in erythropoiesis has been shown in many studies. In addition, the use of angiotensin converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARB) has been reported to reduce hemoglobin levels in various patient groups at risk for secondary erythrocytosis/polycythemia. The aim of our study is to investigate whether there is a change in hemoglobin levels after starting ACEIs or ARBs in patients who have not used them before. Three hundred and fifty-one patients who were started on renin angiotensin aldosterone system (RAAS) blockers were evaluated retrospectively. None of the patients had anemia before starting RAAS blockers. A median of 6 (4-12) months after the start of the drug, complete blood count and kidney function tests were evaluated. Hemoglobin values before and after the start of the drug were compared statistically. A statistically significant decrease in mean Hb value was found after starting ACEIs or ARBs (14.39 ± 1.29 g/dL vs 13.98 ± 1.36 g/dL, p < 0.001). The decrease in control Hb values was higher in the ARB group than in the ACEI group (-0.53 ± 0.06 g/dL vs -0.29 ± 0.06 g/dL, p < 0.001). A significant decrease in mean Hb level was detected in the first year following the first administration of ACEIs or ARBs.

Abstract 14496: The Role of ACE Inhibitors and Angiotensin Receptor Blockers in Cryoballoon Ablation Outcomes for Paroxysmal Atrial Fibrillation

Background: Cryoballoon ablation (CBA) is recommended for patients with paroxysmal atrial fibrillation (AF) refractory to anti-arrhythmic drugs. However, only 70% of patients benefit from an initial CBA. There is a growing evidence that pretreatment with angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blocker (ARB) decreases recurrence of AF post ablation, particularly in non-paroxysmal AF undergoing radiofrequency ablation. The role of ACE-I and ARB in patients with paroxysmal AF in CBA remains unknown. We decided to investigate the role of ACE-I and ARB in preventing recurrence of atrial arrhythmias (AA) following CBA for paroxysmal AF. Methods: We followed 103 patients (Age 60.6 ± 9.1, 29% women) with paroxysmal AF undergoing CBA for one year post procedure. Recurrence was assessed by documented AA on EKG or any form of long-term cardiac rhythm monitoring. A multivariable cox proportional hazard model was used to assess if ACE-I or ARB treatment predicted risk of AA recurrence. Results: After a one year follow up, 19 (18.4%) participants developed recurrence of AA. Use of ACE-I or ARB therapy was noted in the study population. Patients on ACE-I/ARB had a greater prevalence of hypertension and coronary artery disease. On a multivariate model adjusted for baseline demographics and risk factors for AF, ACEI or ARB therapy did not prevent recurrence of AA following CBA (Table, p=0.72). Similarly, on Kaplan-Meier analysis pretreatment with ACE-I/ARB did not predict time to first recurrence of AA (Figure, p=0.2173). Conclusion: In our study population pre-ablation treatment with an ACE-I or an ARB had no influence on the recurrence of AA following CBA for paroxysmal AF.

Coeliac disease enteropathy and symptoms may be aggravated by angiotensin receptor blockers in patients on a gluten-free diet.

BackgroundAngiotensin receptor blocker‐associated enteropathy (ARB‐e) is an increasingly recognised clinical entity with symptoms and histological findings identical to coeliac disease (CD). There is evidence to suggest immune‐mediated mucosal injury in ARB‐e with a high prevalence of DQ2/DQ8; however, as IgA anti‐tissue transglutaminase (anti‐TTG) is usually negative, an insult other than TTG‐mediated injury is suspected. The impact of ARBs on disease activity in patients with CD is not known.ObjectiveTo assess the effect of ARB exposure on patients with established CD.MethodsA patient record search of 1142 individual patients attending a dedicated coeliac clinic from 2010 to the present identified 59 patients treated with ARB. Those with CD confirmed by serology (TTG + ve/EMA + ve) and histopathology (Marsh criteria) were included (n = 40, 0.52%). Data collected included disease duration, compliance with gluten‐free diet (GFD), reported symptoms (diarrhoea, weight loss and abdominal pain), surrogate markers of absorption (Vitamin D, Iron, Calcium and Haemoglobin), in addition to anti‐TTG titre and histological grade at last follow up. Patients were age and sex‐matched in a 1:2 ratio with CD patients not taking ARBs (controls), with comparable rates of disease duration and compliance with GFD.ResultsThe ARB and control groups were matched in terms of age (mean 66.2 years) and gender (female 63%). Strict compliance with GFD was reported in 55% and 56%, respectively. Persistent symptoms were reported in 10/40 (25%) of the ARB group compared with 7/82 (9%) of controls (p = 0.0181). There were lower rates of mucosal healing (Marsh grade 0) in the ARB group (36% n = 11) compared to controls (55%, n = 33). There was no significant difference in anti‐TTG titres. Surrogate markers of absorption were comparable across the groups, except for Vitamin D which was lower in those taking olmesartan (p = 0.0015).ConclusionsARBs may aggravate the enteropathy and lead to increased symptoms in patients with bone fide diagnosed CD following a GFD.

Potentially inappropriate prescribing of cardiovascular system and antiplatelet/anticoagulant drugs among elderly patients: a Korean population-based national study.

OBJECTIVESTo investigate the prevalence of potentially inappropriate prescribing (PIP) for cardiovascular system (CVS) and antiplatelet/anticoagulant (AP/AC) drugs among Korean elderly patients, using the Screening Tool of Older Persons’ Prescriptions (STOPP) criteria version 2 and to identify the risk factors related to PIP.METHODSThe 2016 National Aged Patient Sample data, comprising National Health Insurance claim records for a random sample of 20% of patients aged ≥ 65 years, were used to calculate PIP prevalence of outpatient prescriptions. For criteria including drug-disease interactions, PIP prevalence per indication was estimated.RESULTSAmong 1,274,148 elderly patients and 27,062,307 outpatient prescription claims, 100,085 patients (7.85%) and 341,664 claims (1.27%) had one or more PIP. The most frequent PIP was “non-steroidal anti-inflammatory drug with concurrent antiplatelet agent (s) without proton-pump inhibitor prophylaxis” in the claim-level (0.97%) and patient-level (6.33%) analyses. “Beta-blocker with bradycardia” (16.47% of claims) and “angiotensin receptor blockers in patients with hyperkalaemia” (23.89% of claims) showed the highest PIP prevalence per indication. Logistic regression analysis revealed that, among the patient and health care provider characteristics, female, older age, more severe comorbidities, polypharmacy, higher level of healthcare organization, and specialty of prescriber were significantly associated with a higher risk of PIP.CONCLUSIONSOur findings of a high prevalence of PIP for CVS and AP/AC drugs among the elderly suggest that an effective strategy is urgently needed to improve the prescription practices of these drugs.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist