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.