ACEi/ARB Withdrawal Linked to Worse Outcomes in Hospitalized HF Patients
Withdrawal of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB) during hospitalization for heart failure was tied to higher rates of post-discharge mortality and readmission. Findings from this study were published online in the Journal of the American Heart Association.
Current guidelines recommend hospitalized patients with heart failure continue or initiate guideline-directed treatment, which includes ACEi/ARB. Researchers obtained clinical data from 16,052 heart failure patients with reduced ejection fraction (≤40%) with Medicare claims data. Patients who were eligible for ACEi/ARB therapy were divided into four categories based on admission and discharge ACEi/ARB use: continued (reference group), started, discontinued, or not started on therapy.
The analysis showed most patients (90.5%) were discharged on ACEi/ARB medications: 59.6% continued and 30.9% newly started. Among patients not discharged with ACEi/ARB, 1.9% were discontinued and 7.5% were eligible but not initiated on therapy.
For patients continued on ACEi/ARB or started on ACEi/ARB, the 30-day mortality rate was 3.5% and 4.1%, respectively. However, in patients who discontinued or did not initiate treatment, the 30-day mortality rate was 8.8% (adjusted hazard ratio 1.92, 95% CI: 1.32–2.81; P<0.001) and 7.5% (adjusted hazard ratio 1.50, 95% CI: 1.12–2.00; P=0.006), respectively. One-year mortality was 28.2% in patients continued and 29.7% in patients started on ACEi/ARB vs. 41.6% in patients discontinued (adjusted hazard ratio 1.35, 95% CI: 1.13–1.61; P<0.001) and 41.7% (adjusted hazard ratio 1.28, 95% CI: 1.14–1.43; P<0.001) in patients not started on ACEi/ARB therapy.
In addition, patients who continued or started on ACEi/ARB exhibited lower readmission rates at 30 days and 90 days.
"Based on the results of this study, additional work adequately powered to determine if there is indeed a true disadvantage to discontinuing versus not starting therapy or if there is a true advantage to continuing versus starting therapy, should be considered," the authors concluded.
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