Renin-Angiotensin Inhibition in Systolic Heart Failure and Chronic Kidney Disease

BACKGROUND: The role of renin-angiotensin inhibition in older patients with systolic heart failure with chronic kidney disease remains unclear. METHODS: Of the 1665 patients (aged >= 65 years) with systolic heart failure (ejection fraction < 45%) and chronic kidney disease (estimated glomerular filtration rate < 60 mL/min/1.73 m(2)), 1046 received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Propensity scores for the receipt of these drugs, estimated for each of the 1665 patients, were used to assemble a matched cohort of 444 pairs of patients receiving and not receiving these drugs who were balanced on 56 baseline characteristics. RESULTS: During more than 8 years of follow-up, all-cause mortality occurred in 75% and 79% of matched patients with chronic kidney disease receiving and not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, respectively (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.74-0.996; P = .045). There was no significant association with heart failure hospitalization (HR, 0.86; 95% CI, 0.72-1.03; P = .094). Similar mortality reduction (HR, 0.83; 95% CI, 0.70-1.00; P = .046) occurred in a subgroup of matched patients with estimated glomerular filtration rate less than 45 mL/min/1.73 m(2). Among 171 pairs of propensity-matched patients without chronic kidney disease, the use of these drugs was associated with a significant reduction in all-cause mortality (HR, 0.72; 95% CI, 0.55-0.94; P = .015) and heart failure hospitalization (HR, 0.71; 95% CI, 0.52-0.95; P = .023). CONCLUSION: Discharge prescription of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a significant modest reduction in all-cause mortality in older patients with systolic heart failure with chronic kidney disease, including those with more advanced chronic kidney disease. Published by Elsevier Inc. The American Journal of Medicine (2012) 125, 399-410