Initiation,continuation,or withdrawal of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and outcomes in patients hospitalized with heart failure with reduced ejection fraction

Background-guidelines recommend continuation or initiation of guideline-directed medical therapy,including angiotensinconverting enzyme inhibitors/angiotensin ii receptor blockers (acei/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 acei/arb-eligible patients into 4 categories based on admission and discharge acei/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 acei/arb category and outcomes. most,90.5%,were discharged on acei/arb (59.6% continued and 30.9% newly started). of those discharged without acei/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 acei/arb. in contrast,30-day mortality was 8.8% for patients discontinued (adjusted hazard ratio [hradj] 1.92; 95% ci 1.32-2.81; p < 0.001) and 7.5% for patients not started (hradj 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 acei/arb compared to 41.6% for patients discontinued (hradj 1.35; 95% ci 1.13-1.61; p < 0.001) and 41.7% (hradj 1.28; 95% ci 1.14-1.43; p < 0.001) for patients not started on therapy. conclusions-compared with continuation,withdrawal of acei/arb during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission,even after adjustment for severity of illness. © 2017 the authors.