Spironolactone Use and Higher Hospital Readmission for Medicare Beneficiaries with Heart Failure Left Ventricular Ejection Fraction 45 and Estimated Glomerular Filtration Rate 45 ml/min/1.73m2

摘要

While randomized controlled trials have demonstrated benefits of aldosterone antagonists for patients with heart failure and reduced ejection fraction (HFrEF), they excluded patients with serum creatinine >2.5mg/dl and their use is contraindicated in those with advanced chronic kidney disease (CKD). In the current analysis, we examined the association of spironolactone use with readmission in hospitalized Medicare beneficiaries with HFrEF and advanced CKD. Of the 1140 patients with HFrEF (EF <45%) and advanced CKD (estimated glomerular filtration rate {eGFR} <45 ml/min/1.73m²), 207 received discharge prescriptions for spironolactone. Using propensity scores (PS) for the receipt of discharge prescriptions for spironolactone we estimated PS-adjusted hazard ratios (HR) and 95% confidence intervals (CI) for spironolactone-associated outcomes. Patients (mean age 76 years, 49% women, 25% African American) had mean EF 28%, mean eGFR 31 ml/min/1.73m², and mean potassium 4.5 mEq/L. Spironolactone use had significant PS-adjusted association with higher risk of 30-day (HR, 1.41; 95% CI: 1.04–1.90) and 1-year (HR, 1.36; 95% CI: 1.13–1.63) all-cause readmission. The risk of 1-year all-cause readmission was higher among 106 patients with eGFR <15 ml/min/1.73m² (HR, 4.75; 95% CI: 1.84–12.28) than among those with eGFR 15–45 ml/min/1.73m² (HR, 1.34; 95% CI, 1.11–1.61; p for interaction, 0.003). Spironolactone use had no association with HF readmission and all-cause mortality. In conclusion, among hospitalized patients with HFrEF and advanced CKD, spironolactone use was associated with higher all-cause readmission but had no association with all-cause mortality or HF readmission.