Renin-angiotensin inhibition in diastolic heart failure and chronic kidney disease

Background: The role of renin-angiotensin inhibition in older patients with diastolic heart failure and chronic kidney disease remains unclear. Methods: Of the 1340 patients (age ≥ 65 years) with diastolic heart failure (ejection fraction ≥ 45%) and chronic kidney disease (estimated glomerular filtration rate < 60 mL/min/1.73 m²), 717 received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Propensity scores for the use of these drugs, estimated for each of the 1340 patients, were used to assemble a cohort of 421 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 63% and 69% of matched patients with chronic kidney disease receiving and not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, respectively (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.70-0.97; P =.021). There was no association with heart failure hospitalization (HR, 0.98; 95% CI, 0.82-1.18; P =.816). Similar mortality reduction (HR, 0.81; 95% CI, 0.66-0.995; P =.045) occurred in a subgroup of matched patients with an estimated glomerular filtration rate less than 45 mL/min/1.73 m². Among 207 pairs of propensity-matched patients without chronic kidney disease, the use of these drugs was not associated with mortality (HR, 1.03; 95% CI, 0.80-1.33; P =.826) or heart failure hospitalization (HR, 0.99; 95% CI, 0.76-1.30; P =.946). Conclusions: A discharge prescription for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a significant reduction in all-cause mortality in older patients with diastolic heart failure and chronic kidney disease, including those with more advanced chronic kidney disease.