scholarly journals Impact of sex-specific target dose in chronic heart failure patients with reduced ejection fraction

2020 ◽  
pp. 204748732092318
Author(s):  
Jesse F Veenis ◽  
Hans-Peter Brunner-La Rocca ◽  
Gerard CM Linssen ◽  
Ayten Erol-Yilmaz ◽  
Arjen CB Pronk ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Renin Angiotensin System ◽  
Target Dose ◽  
Dosing Schedule ◽  
Angiotensin System ◽  
Men And Women ◽  
Renin Angiotensin ◽  
Reduced Ejection Fraction ◽  
Β Blockers

Aims A recent study suggested that women with heart failure and heart failure reduced ejection fraction might hypothetically need lower doses of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers ( = renin-angiotensin-system inhibitors) and β-blockers than men to achieve the best outcome. We assessed the current medical treatment of heart failure reduced ejection fraction in men and women in a large contemporary cohort and address the hypothetical impact of changing treatment levels in women. Methods This analysis is part of a large contemporary quality of heart failure care project which includes 5320 (64%) men and 3003 (36%) women with heart failure reduced ejection fraction. Detailed information on heart failure therapy prescription and dosage were collected. Results Women less often received renin-angiotensin-system inhibitors (79% vs 83%, p < 0.01), but more often β-blockers (82% vs 79%, p < 0.01) than men. Differences in guideline-recommended target doses between sexes were relatively small. Implementing a hypothetical sex-specific dosing schedule (at 50% of the current recommended dose in the European Society of Cardiology guidelines in women only) would lead to significantly higher levels of women receiving appropriate dosing (β-blocker 87% vs 54%, p < 0.01; renin-angiotensin-system inhibitor 96% vs 75%, p < 0.01). Most interestingly, the total number of women with >100% of the new hypothetical target dose would be 24% for β-blockers and 52% for renin-angiotensin-system inhibitors, which can be considered as relatively overdosed. Conclusion In this large contemporary heart failure registry, there were significant but relatively small differences in drug dose between men and women with heart failure reduced ejection fraction. Implementation of the hypothetical sex-specific target dosing schedule would lead to considerably more women adequately treated. In contrast, we identified a group of women who might have been relatively overdosed with increased risk of side-effects and intolerance.

scholarly journals Renin-Angiotensin System Fingerprints of Heart Failure With Reduced Ejection Fraction

2016 ◽  
Vol 68 (25) ◽  
pp. 2912-2914 ◽  
Author(s):  
Noemi Pavo ◽  
Raphael Wurm ◽  
Georg Goliasch ◽  
Johannes Franz Novak ◽  
Guido Strunk ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Renin Angiotensin System ◽  
Angiotensin System ◽  
Renin Angiotensin ◽  
Reduced Ejection Fraction

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

Circulation ◽  
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.

Combined neprilysin and renin-angiotensin system inhibition in heart failure with reduced ejection fraction: a meta-analysis

2016 ◽  
Vol 18 (10) ◽  
pp. 1238-1243 ◽  
Author(s):  
Scott D. Solomon ◽  
Brian Claggett ◽  
John J.V. McMurray ◽  
Adrian F. Hernandez ◽  
Gregg C. Fonarow
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Meta Analysis ◽  
Renin Angiotensin System ◽  
Angiotensin System ◽  
Renin Angiotensin ◽  
Reduced Ejection Fraction

HFrEF pharmacological treatment: ACEIs and/or ARBs

ESC CardioMed ◽  
2018 ◽  
pp. 1844-1848
Author(s):  
Marc A. Pfeffer
Keyword(s):  
Heart Failure ◽  
Angiotensin Receptor Blockers ◽  
Antihypertensive Agents ◽  
Drug Effects ◽  
Renin Angiotensin System ◽  
Angiotensin Converting Enzyme Inhibitors ◽  
Converting Enzyme Inhibitors ◽  
Angiotensin System ◽  
Renin Angiotensin ◽  
Reduced Ejection Fraction

Several classes of inhibitors of the renin–angiotensin system were developed as antihypertensive agents. Following the early observations of favourable haemodynamic effects of angiotensin-converting enzyme inhibitors (ACEIs) in patients with congestive heart failure, a series of major randomized outcome trials demonstrated morbidity and mortality benefits of these agents across the spectrum of patients with heart failure with reduced ejection fraction (HFrEF). Angiotensin receptor blockers (ARBs) were then also shown to have similar benefits with a suggestion of some incremental improvements when used together. However, in the trials that randomized patients to a proven dose of an ACEI plus either placebo or an ARB, the combination of the two inhibitors of the renin–angiotensin system resulted in more adverse drug effects without a meaningful improvement in clinical outcomes. This chapter reviews the fundamental underpinnings for use of either an ACEI or ARB to improve prognosis of patients with HFrEF.

scholarly journals Safety and Tolerability of Initiating Maximum-Dose Sacubitril-Valsartan in Patients on Target Dose Renin-Angiotensin System Inhibitors

2019 ◽  
Vol 2019 ◽  
pp. 1-6 ◽  
Author(s):  
Helena Norberg ◽  
Ellinor Bergdahl ◽  
Krister Lindmark
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Ace Inhibitors ◽  
Maximum Dose ◽  
Angiotensin Receptor Blockers ◽  
Renin Angiotensin System ◽  
Target Dose ◽  
Reduced Ejection Fraction ◽  
Receptor Blockers

Aim. Sacubitril-valsartan has proven beneficial in heart failure with reduced ejection fraction. Guidelines recommend initiating half-dose sacubitril-valsartan before up-titration even to patients already on target dose angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). To reduce the number of titration steps needed in order to simplify for the patient as well as the clinic, we aimed to investigate the safety and tolerability of switching patients on target dose ACE inhibitors or ARBs directly to maximum-dose sacubitril-valsartan. Methods. This prospective cohort study was conducted between April 2016 and November 2017. A total of 66 patients with heart failure and reduced ejection fraction already on guideline-recommended target dose ACE inhibitors or ARBs (equivalent to enalapril 10 mg twice daily) were switched to maximum-dose sacubitril-valsartan (200 mg twice daily). The patients were followed for twelve months. Results. Patients had a mean age of 72 ± 10 years, mean systolic blood pressure of 121 ± 17 mmHg, and 92% were male. At 12-month follow-up, nine patients (14%) had discontinued sacubitril-valsartan, four patients (6%) had a dose reduction, and 17 patients (26%) had developed symptomatic hypotension. No angioedema occurred within the 12-month follow-up and there were no hospitalizations or emergency room visits within the first 14 days. Conclusions. Switching directly from target dose ACE inhibitors or ARBs to maximum-dose sacubitril-valsartan was safe and generally well tolerated.

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