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Renin-angiotensin system inhibitors improve outcomes after TAVR
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Patients who received a prescription for a renin-angiotensin system inhibitor after hospital discharge for transcatheter aortic valve replacement had decreased risk for HF readmission and mortality compared with those who did not receive a prescription, according to a study published in JAMA.
Taku Inohara, MD, PhD, cardiology fellow at Duke Clinical Research Institute, and colleagues analyzed data from 21,312 patients from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry with Medicare who underwent TAVR between July 2014 and January 2016.
Patients were categorized by whether they received a prescription for a renin-angiotensin system inhibitor at hospital discharge. The patients who were prescribed renin-angiotensin system inhibitors were prescribed ACE inhibitors, angiotensin II receptor antagonists or both after discharge.
The primary outcomes were readmission due to HF and all-cause mortality, both within 1 year after discharge. Secondary outcomes included health status at 1 year. Health status was assessed by the Kansas City Cardiomyopathy Questionnaire at baseline, 30 days and 1 year after TAVR.
Of the patients in the study, 39.7% were prescribed a renin-angiotensin system inhibitor at hospital discharge.
After propensity matching, 15,896 patients (mean age, 82 years; 48% women) were included in the analysis based on their renin-angiotensin system inhibitor prescription status.
At 1 year, patients prescribed a renin-angiotensin system inhibitor had a significantly lower rate of HF readmission (12% vs. 13.8%; absolute risk difference [ARD] = –1.8 percentage points; 95% CI, –2.8 to –0.7; HR = 0.86; 95% CI, 0.79-0.95) and mortality (12.5% vs. 14.9%; ARD = –2.4 percentage points; 95% CI, –3.5 to –1.4; HR = 0.82; 95% CI, 0.76-0.9) compared with those who were not prescribed one.
In patients with preserved left ventricular ejection fraction, those who were prescribed a renin-angiotensin system inhibitor had a lower rate of mortality at 1 year vs. those without a prescription (11.1% vs. 13.9%; ARD = –2.81 percentage points; 95% CI, –3.95 to –1.67; HR = 0.78; 95% CI, 0.71-0.86). This was not seen in patients with reduced LVEF (18.8% vs. 19.5%; ARD = –0.68 percentage points; 95% CI, –3.52 to 2.2; HR = 0.95; 95% CI, 0.81-1.12).
In the patients who were propensity-matched, 30.4% had available information from the Kansas City Cardiomyopathy Questionnaire at baseline and 1 year. Improvements were greater in patients with a prescription at discharge vs. those without a prescription (median change, 33.3 vs. 31.3; P < .001), although the effect did not meet the minimal clinically important difference of 5 points.
“Due to potential selection bias, this finding requires further investigation in randomized trials,” Inohara and colleagues wrote. – by Darlene Dobkowski
Disclosures: Inohara reports he received grants from Boston Scientific, JSPS Overseas Research fellowship, Miyata Cardiac Research Promotion Foundation and Pfizer Health Research Foundation. Please see the study for all other authors’ relevant financial disclosures.
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