Impact of contrast-induced acute kidney injury on the association between renin-angiotensin system inhibitors and long-term mortality in heart failure patients

Introduction: Renin-angiotensin system inhibitors (RASi) reduce mortality among heart failure (HF) patients, but their effect among those complicating contrast-induced acute kidney injury (CI-AKI) remains unexplored. We aimed to investigate whether the relationship between RASi prescription at discharge and mortality differs between HF patients with or without CI-AKI following coronary angiography (CAG). Methods: About 596 HF patients from an observational cohort were divided into a CI-AKI group ( n = 104) and a non-CI-AKI group ( n = 492) based on whether they had CI-AKI following CAG. The endpoint was all-cause mortality. Multivariable Cox regression was performed in each group to explore the associations between RASi at discharge and mortality. Results: During the median follow-up time of 2.26 (1.70; 3.24) years, higher mortality rate was observed in the CI-AKI group compared to the non-CI-AKI group (18.3% vs 8.9%, p = 0.002). Among HF patients with CI-AKI, after adjusting for confounding factors, the association was not significant between RASi prescription at discharge and mortality (HR: 0.39, 95%CI: 0.12–1.31, p = 0.128), while it was among those without CI-AKI (HR: 0.39, 95%CI: 0.18–0.84, p = 0.016). Conclusion: RASi prescription at discharge for HF patients complicating CI-AKI tended to be ineffective, while it benefited those without CI-AKI. Further randomized evidence is needed to confirm this trend.

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Long-Term Adherence to Renin–Angiotensin System Inhibitors and β-Blockers After Heart Failure Hospitalization in Senior Patients

Journal of Cardiovascular Pharmacology and Therapeutics ◽

10.1177/1074248420931617 ◽

2020 ◽

Vol 25 (6) ◽

pp. 531-540

Author(s):

Xiwen Qin ◽

Joseph Hung ◽

Tiew-Hwa Katherine Teng ◽

Tom Briffa ◽

Frank M. Sanfilippo

Keyword(s):

Heart Failure ◽

Medication Adherence ◽

Renin Angiotensin System ◽

Angiotensin System ◽

Renin Angiotensin ◽

Β Blocker ◽

Β Blockers ◽

Senior Patients

Aims: We investigated long-term adherence to renin–angiotensin system inhibitors (RASIs) and β-blockers, and associated predictors, in senior patients after hospitalization for heart failure (HF). Methods: A population-based data set identified 4488 patients who survived 60 days following their index hospitalization for HF in Western Australia from 2003 to 2008 with a 3-year follow-up. Their person-linked Pharmaceutical Benefits Scheme records identified medications dispensed during follow-up. Drug discontinuation was defined as the first break ≥90 days following the previous supply. Medication adherence was calculated using the proportion of days covered (PDC), with PDC ≥ 80% defined as being adherent. Multivariable logistic regression models were used to identify predictors of PDC < 80%. Results: In the cohort (57% male, mean age: 76.6 years), 77.4% were dispensed a RASI and 52.7% a β-blocker within 60 days postdischarge. Over the 3-year follow-up, 28% and 42% of patients discontinued RASI and β-blockers, respectively. Only 64.6% and 47.5% of RASI and β-blocker users, respectively, were adherent to their treatment over 3 years, with adherence decreasing over time (trend P < .0001 for RASI and trend P = .02 for β-blockers). Older age, increasing Charlson comorbidity score, chronic kidney disease, and chronic obstructive pulmonary disease were independent predictors of PDC < 80% for both drug groups. Conclusion: Among seniors hospitalized for HF, discontinuation gaps were common for RASI and β-blockers postdischarge, and long-term adherence to these medications was suboptimal. Where appropriate, strategies to improve long-term medication adherence are indicated in HF patients, particularly in elderly patients with comorbidities.

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Incidence of and risk factors for severe acute kidney injury in children with heart failure treated with renin–angiotensin system inhibitors

European Journal of Pediatrics ◽

10.1007/s00431-015-2680-8 ◽

2015 ◽

Vol 175 (5) ◽

pp. 631-637 ◽

Cited By ~ 6

Author(s):

Chikako Terano ◽

Kenji Ishikura ◽

Masaru Miura ◽

Riku Hamada ◽

Ryoko Harada ◽

...

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Acute Kidney Injury ◽

Kidney Injury ◽

Renin Angiotensin System ◽

Angiotensin System ◽

Renin Angiotensin

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Abstract 13942: Down-titration of Renin-angiotensin System Inhibitors After Hospitalization for Heart Failure With Reduced Ejection Fraction

Circulation ◽

10.1161/circ.142.suppl_3.13942 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Parag Goyal ◽

Ligong Chen ◽

Robert S Rosenson ◽

John Umejiego ◽

Alessandro Pontes-Arruda ◽

...

Keyword(s):

Heart Failure ◽

Acute Kidney Injury ◽

Ejection Fraction ◽

Kidney Injury ◽

Renin Angiotensin System ◽

Fee For Service ◽

Medicare Beneficiaries ◽

Angiotensin System ◽

Renin Angiotensin ◽

Reduced Ejection Fraction

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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