A Propensity-Matched Study of the Comparative Effectiveness of Angiotensin Receptor Blockers versus Angiotensin-Converting Enzyme Inhibitors in Heart Failure Patients Age ≥65 Years

摘要

The comparative effectiveness of angiotensin-converting enzyme inhibitors (ACEIs) versus angiotensin receptor blockers (ARBs) in real-world older heart failure (HF) patients remains unclear. Of the 8049 hospitalized HF patients ≥65 years discharged alive from 106 Alabama hospitals, 4044 received discharge prescriptions of either ACEIs (n=3383) or ARBs (n=661). Propensity scores for ARB use, calculated for each of 4044 patients, were used to match 655 (99% of 661) patients receiving ARBs with 661 patients receiving ACEIs. The assembled cohort of 655 pairs of patients was well-balanced on 56 baseline characteristics. During over 8 years of follow-up, all-cause mortality occurred in 63% and 68% of matched patients receiving ARBs and ACEIs respectively (hazard ratio {HR} associated with ARB use, 0.86; 95% confidence interval {CI}, 0.75–0.99; p=0.031). Among the 956 matched patients with data on left ventricular ejection fraction (LVEF), the association between ARB (versus ACEI) use was significant only in 419 patients with LVEF≥45% (HR, 0.65; 95% CI, 0.51–0.84; p=0.001) but not in the 537 patients with LVEF <45% (HR, 1.00; 95% CI, 0.81–1.23; p=0.999; p for interaction= 0.012). HRs (95% CIs) for HF hospitalization associated with ARBs use were 0.99 (0.86–1.14; p=0.876) overall, 0.80 (0.63–1.03; p=0.080) among those with LVEF≥45% and 1.14 (0.91–1.43; p=0.246) among those with LVEF <45% (p for interaction, 0.060). In conclusion, in older HF patients with preserved LVEF, a discharge prescription of ARBs (versus ACEI) was associated with lower mortality and a trend toward lower HF hospitalization, findings which need replication in other HF populations.