Initiation, Continuation, or Withdrawal of Angiotensin‐Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Outcomes in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

Abstract

Background Guidelines recommend continuation or initiation of guideline‐directed medical therapy, including angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers ( ACE i/ ARB ), in hospitalized patients with heart failure with reduced ejection fraction. Methods and Results Using the Get With The Guidelines‐Heart Failure Registry, we linked clinical data from 16 052 heart failure with reduced ejection fraction (ejection fraction ≤40%) patients with Medicare claims data. We divided ACE i/ ARB ‐eligible patients into 4 categories based on admission and discharge ACE i/ ARB use: continued (reference group), started, discontinued, or not started on therapy. A multivariable Cox proportional hazard model was used to determine the association between ACE i/ ARB category and outcomes. Most, 90.5%, were discharged on ACE i/ ARB (59.6% continued and 30.9% newly started). Of those discharged without ACE i/ ARB , 1.9% were discontinued, and 7.5% were eligible but not started. Thirty‐day mortality was 3.5% for patients continued and 4.1% for patients started on ACE i/ ARB . In contrast, 30‐day mortality was 8.8% for patients discontinued (adjusted hazard ratio [ HR adj ] 1.92; 95% CI 1.32‐2.81; P <0.001) and 7.5% for patients not started ( HR adj 1.50; 95% CI 1.12‐2.00; P =0.006). The 30‐day readmission rate was lowest among patients continued or started on therapy. One‐year mortality was 28.2% for patients continued and 29.7% for patients started on ACE i/ ARB compared to 41.6% for patients discontinued ( HR adj 1.35; 95% CI 1.13‐1.61; P <0.001) and 41.7% ( HR adj 1.28; 95% CI 1.14‐1.43; P <0.001) for patients not started on therapy. Conclusions Compared with continuation, withdrawal of ACE i/ ARB during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission, even after adjustment for severity of illness.