Heart failure
A Propensity-Matched Study of the Comparative Effectiveness of Angiotensin Receptor Blockers Versus Angiotensin-Converting Enzyme Inhibitors in Heart Failure Patients Age ≥65 Years

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The comparative effectiveness of angiotensin-converting enzyme (ACE) inhibitors versus angiotensin II type 1 receptor blockers (ARBs) in real-world older heart failure (HF) patients remains unclear. Of the 8,049 hospitalized HF patients aged ≥65 years discharged alive from 106 Alabama hospitals, 4,044 received discharge prescriptions of either ACE inhibitors (n = 3,383) or ARBs (n = 661). Propensity scores for ARB use, calculated for each of 4,044 patients, were used to match 655 (99% of 661) patients receiving ARBs with 661 patients receiving ACE inhibitors. The assembled cohort of 655 pairs of patients was well balanced on 56 baseline characteristics. During >8 years of follow-up, all-cause mortality occurred in 63% and 68% of matched patients receiving ARBs and ACE inhibitors, respectively (hazard ratio [HR] associated with ARB use 0.86, 95% confidence interval [CI] 0.75 to 0.99, p = 0.031). Among the 956 matched patients with data on the left ventricular ejection fraction (LVEF), the association between ARB (vs ACE inhibitor) use was significant in only 419 patients with LVEFs ≥45% (HR 0.65, 95% CI 0.51 to 0.84, p = 0.001) but not in the 537 patients with LVEFs <45% (HR 1.00, 95% CI 0.81 to 1.23, p = 0.999; p for interaction = 0.012). HRs for HF hospitalization associated with ARB use were 0.99 (95% CI 0.86 to 1.14, p = 0.876) overall, 0.80 (95% CI 0.63 to 1.03, p = 0.080) in those with LVEFs ≥45%, and 1.14 (95% CI 0.91 to 1.43, p = 0.246) in those with LVEFs <45% (p for interaction = 0.060). In conclusion, in older HF patients with preserved LVEFs, discharge prescriptions of ARBs (vs ACE inhibitors) were associated with lower mortality and a trend toward lower HF hospitalization, findings that need replication in other HF populations.

Section snippets

Methods

The present study was based on the Alabama Heart Failure Project registry, which has been previously described.6 Briefly, the Alabama Heart Failure Project was conducted by AQAF, Alabama's quality improvement organization, as a quality improvement project. Extensive data on baseline demographics, medical history including the use of medications, hospital course, discharge disposition including medications, and physician specialty were collected via chart abstraction from 8,555 patients

Results

Overall, matched patients (n = 1,310) had a mean age of 78 ± 7 years, 69% were women, and 19% were African American. Imbalances in baseline characteristics before matching and balances achieved after matching between patients prescribed ACE inhibitors and ARBs at discharge are listed in Table 1 and shown in Figure 1. Before matching, patients prescribed ARBs were more likely to be women and had a higher prevalence of hypertension and coronary revascularization, a lower prevalence of atrial

Discussion

The findings of the present propensity-matched comparative effectiveness research demonstrate that older HF patients discharged with prescriptions of ARBs (vs ACE inhibitors) had lower all-cause mortality. This association was independent of 56 baseline demographic, clinical, subclinical, and biochemical characteristics and was driven primarily by a greater mortality reduction in those with HF-PEF. Although ARB use had no significant association with hospitalizations overall, there was a trend

References (31)

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Dr. Ahmed is supported by grants R01-HL085561 and R01-HL097047 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland, and a generous gift from Ms. Jean B. Morris, Birmingham, Alabama. Dr. Allman was supported in part by the NIH grant award 1UL 1RR025777.

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