After introduction of up-titration strategy, there are limited data on comparison between the effects of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blocker (ARB) in patients with heart failure with reduced ejection fraction (HFrEF). The study sought to investigate the association between treatment with ARB at discharge and clinical outcomes in patients with HFrEF compared with treatment with ACEI or no renin angiotensin system blocker (RASB).
The KorAHF registry is a prospective multicenter cohort and included patients who were hospitalized for acute heart failure (AHF). We studied 3005 patients with HFrEF (<40%), and divided into ARB (n = 1190), ACEI (n = 1090), and no RASB (n = 725) groups. Propensity score matching was performed.
All-cause death occurred in 346 patients (29.1%) in the ARB group, 315 patients (28.9%) in the ACEI group, and 305 (42.1%) in the no RASB group. After propensity score matching (ARB vs. ACEI, 827 pairs), there was no significant difference between the two groups in the rate of death (HR 0.91, 95% CI 0.76–1.09, p = 0.32). All-cause death was significantly lower in the ARB group than in the no RASB group (ARB vs. no RASB, 538 pairs, HR 0.69, 95% CI 0.56–0.83, p < 0.001). The ARB group had a significantly lower discontinuation rate than the ACEI group (20.8% vs. 33.6%, p < 0.001).
For treatment of AHF with reduced EF after hospitalization, ARB at discharge shows a mortality benefit comparable to that of ACEI. In addition, tolerability of medication was greater for ARB than for ACEI.
Abbreviations:ACEI (angiotensin converting enzyme inhibitor), AHF (acute heart failure), ARB (angiotensin receptor blocker), ARNI (angiotensin receptor-neprilysin inhibitor), CKD (chronic kidney disease), GFR (glomerular filtration rate), HFpEF (heart failure with preserved ejection fraction), HFrEF (heart failure with reduced ejection fraction), LVEF (left ventricular ejection fraction), RASB (renin angiotensin system blocker)
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- Long-term trends in the incidence of and survival with heart failure.N. Engl. J. Med. 2002; 347: 1397-1402
- Lifetime risk for developing congestive heart failure: the Framingham Heart Study.Circulation. 2002; 106: 3068-3072
- The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries.J. Am. Coll. Cardiol. 2014; 63: 1123-1133
- N. Engl. J. Med. 1987; 316: 1429-1435
- N. Engl. J. Med. 1991; 325: 293-302
- Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials.JAMA. 1995; 273: 1450-1456
- Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial.Lancet. 2003; 362: 772-776
- Effects of valsartan on morbidity and mortality in patients with heart failure not receiving angiotensin-converting enzyme inhibitors.J. Am. Coll. Cardiol. 2002; 40: 1414-1421
- Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan.Lancet. 2002; 360: 752-760
- 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J. Am. Coll. Cardiol. 2013; 62: e147-239
- 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC.Eur. Heart J. 2016; 37: 2129-2200
- A multicentre cohort study of acute heart failure syndromes in Korea: rationale, design, and interim observations of the Korean Acute Heart Failure (KorAHF) registry.Eur. J. Heart Fail. 2014; 16: 700-708
- Clinical characteristics and outcome of acute heart failure in Korea: results from the Korean Acute Heart Failure Registry (KorAHF).Korean Circ. J. 2017; 47: 341-353
- Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms.J. Am. Soc. Echocardiogr. 1989; 2: 358-367
- Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate.Ann. Intern. Med. 2006; 145: 247-254
- Angiotensin-converting enzyme inhibitors.Circulation. 1998; 97: 1411-1420
- Angiotensin II receptors and angiotensin II receptor antagonists.Pharmacol. Rev. 1993; 45: 205-251
- Proposed update of angiotensin receptor nomenclature.Hypertension. 1995; 25: 924-927
- Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both.N. Engl. J. Med. 2003; 349: 1893-1906
- Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial—the Losartan Heart Failure Survival Study ELITE II.Lancet. 2000; 355: 1582-1587
- Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. ATLAS Study Group.Circulation. 1999; 100: 2312-2318
- Effects of high-dose versus low-dose losartan on clinical outcomes in patients with heart failure (HEAAL study): a randomised, double-blind trial.Lancet. 2009; 374: 1840-1848
- PONTIAC (NT-proBNP selected prevention of cardiac events in a population of diabetic patients without a history of cardiac disease): a prospective randomized controlled trial.J. Am. Coll. Cardiol. 2013; 62: 1365-1372
- 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.J. Am. Coll. Cardiol. 2016; 68: 1476-1488
- Angiotensin-neprilysin inhibition versus enalapril in heart failure.N. Engl. J. Med. 2014; 371: 993-1004
- Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in myocardial infarction patients with renal dysfunction.J. Am. Coll. Cardiol. 2016; 67: 1687-1697
- Association between renin-angiotensin system antagonist use and mortality in heart failure with severe renal insufficiency: a prospective propensity score-matched cohort study.Eur. Heart J. 2015; 36: 2318-2326
- The role of the c-statistic in variable selection for propensity score models.Pharmacoepidemiol. Drug Saf. 2011; 20: 317-320
- An introduction to propensity score methods for reducing the effects of confounding in observational studies.Multivar. Behav. Res. 2011; 46: 399-424
Accepted: December 1, 2017
Received in revised form: October 4, 2017
Received: June 19, 2017
☆Trial registration: KorAHF registry, ClinicalTrial.gov, NCT01389843.
© 2017 Elsevier B.V. All rights reserved.
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- Analysing registries in heart failure: The case of angiotensin receptor blockers in Asians with heart failure with reduced ejection fractionInternational Journal of CardiologyVol. 257
- PreviewAngiotensin converting enzyme (ACE) inhibitors remain the foundation of treatment for heart failure with reduced ejection fraction (HFREF) . Angiotensin receptor blockers (ARB) are recommended as an alternative if the patient cannot tolerate an ACE inhibitor as a result of the findings of the CHARM-Alternative trial . In many Asian countries ARBs are given as a first line drug, rather than ACE inhibitors, as many Asian patients fail to tolerate ACE inhibitors due to cough . The reason for this racial disparity in the incidence of ACE inhibitor induced cough is not fully understood.