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Relation of dosing of the renin-angiotensin system inhibitors after cardiac resynchronization therapy to long-term prognosis
The American Journal of Cardiology, 05/15/2012
Clinical Article
Mantziari L et al. – Optimal dosing of angiotensin–converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) is an independent predictor of prognosis in patients with HF treated with cardiac resynchronization therapy (CRT) and it can be achieved by a structured follow–up within a specialized heart failure (HF) pacing clinic.
Methods- Dosing of angiotensin–converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in patients with heart failure (HF) treated with cardiac resynchronization therapy (CRT) may affect long–term outcomes.
- Retrospective data were collected at baseline and follow–up for consecutive patients who had CRT implanted and attended the institutional specialist HF pacing clinic.
- The study end point was death from any cause or hospitalization for worsening HF 24 months after implantation.
- 91 patients (72 men, 68 ± 12 years old) with decreased left ventricular ejection fraction (24 ± 6%) were included.
- At baseline 85 patients (93%) were on ACE inhibitors/ARBs.
- At 6 months 3 patients had died and 86 of 88 (98%) were on ACE inhibitors/ARBs.
- Doses were uptitrated from 55 ± 35% of target dose (TD) at baseline to 62 ± 31% TD at month 6 (p = 0.018), whereas blood pressure was unchanged.
- Patients treated with <50% TD of ACE inhibitors/ARBs (n = 20) at month 6 had worse 24–month event–free survival than those on 50% to 99% TD (n = 38, p = 0.011, log–rank test) or ≥100% TD (n = 30, p = 0.007, log–rank test).
- Failure to achieve a dose ≥50% TD of ACE inhibitors/ARBs at 6 months after CRT implantation was an independent predictor of all–cause mortality or hospitalization (hazard ratio 3.99, 95% confidence interval 1.66 to 9.62, p = 0.002) after adjustment for potential confounders including age, estimated glomerular filtration rate, diabetes and New York Heart Association class.