[Skip to Content]
[Skip to Content Landing]
Views 953
Citations 0
Original Investigation
December 4, 2018

Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement

Author Affiliations
  • 1Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
  • 2Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
  • 3Department of Cardiac Surgery, MedStar Heart and Vascular Institute and Georgetown University School of Medicine, Washington, DC
  • 4Division of Cardiology, Department of Medicine, University of Colorado, Aurora
  • 5Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York
  • 6Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia
  • 7Department of Medicine, Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
  • 8Department of Medicine, University of Missouri–Kansas City School of Medicine, Kansas City
  • 9Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
JAMA. 2018;320(21):2231-2241. doi:10.1001/jama.2018.18077
Key Points

Question  Is there an association between prescription of a renin-angiotensin system (RAS) inhibitor at the time of hospital discharge after transcatheter aortic valve replacement (TAVR) and subsequent mortality or readmission for heart failure?

Findings  In this registry-based retrospective cohort study that included 15 896 propensity-matched patients who underwent TAVR, receiving a prescription for a RAS inhibitor at hospital discharge vs no prescription was associated with a risk for mortality of 12.5% vs 14.9%, respectively, and a risk for heart failure readmission of 12.0% vs 13.8%; both differences were statistically significant.

Meaning  Use of a RAS inhibitor after TAVR may be associated with lower mortality and risk for heart failure readmission, but the potential for selection bias requires further investigation.

Abstract

Importance  Data are lacking on the effect of a renin-angiotensin system (RAS) inhibitor prescribed after transcatheter aortic valve replacement (TAVR). Treatment with a RAS inhibitor may reverse left ventricular remodeling and improve function.

Objective  To investigate the association of prescription of a RAS inhibitor and outcomes after TAVR.

Design, Setting, and Participants  Retrospective cohort study of TAVR procedures performed in the United States (using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry) between July 2014 and January 2016 that were linked to Medicare claims data (final date of follow-up: March 31, 2017). To account for differences in demographics, echocardiographic findings, and in-hospital complications, 1:1 propensity matching was performed.

Exposures  Initial hospital discharge prescription of a RAS inhibitor after TAVR.

Main Outcomes and Measures  Primary outcomes were all-cause death and readmission due to heart failure at 1 year after discharge, which were considered separately. The secondary outcome was health status assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ; score range: 0-100, with a higher score indicating less symptom burden and better quality of life; a small effect size was defined as 5 points) at 1 year.

Results  Among 21 312 patients who underwent TAVR at 417 US sites, 8468 patients (39.7%) were prescribed a RAS inhibitor at hospital discharge. After propensity matching, 15 896 patients were included (mean [SD] age, 82.4 [6.8] years; 48.1% were women; mean [SD] left ventricular ejection fraction [LVEF], 51.9% [11.5%]). Patients with a prescription for a RAS inhibitor vs those with no prescription had lower mortality rates at 1 year (12.5% vs 14.9%, respectively; absolute risk difference [ARD], −2.4% [95% CI, −3.5% to −1.4%]; hazard ratio [HR], 0.82 [95% CI, 0.76 to 0.90]) and lower heart failure readmission rates at 1 year (12.0% vs 13.8%; ARD, −1.8% [95% CI, −2.8% to −0.7%]; HR, 0.86 [95% CI, 0.79 to 0.95]). When stratified by LVEF, having a prescription for a RAS inhibitor vs no prescription was associated with lower 1-year mortality among patients with preserved LVEF (11.1% vs 13.9%, respectively; ARD, −2.81% [95% CI, −3.95% to −1.67%]; HR, 0.78 [95% CI, 0.71 to 0.86]), but not among those with reduced LVEF (18.8% vs 19.5%; ARD, −0.68% [95% CI, −3.52% to 2.20%]; HR, 0.95 [95% CI, 0.81 to 1.12]) (P = .04 for interaction). Of 15 896 matched patients, 4837 (30.4%) were included in the KCCQ score analysis and improvements at 1 year were greater in patients with a prescription for a RAS inhibitor vs those with no prescription (median, 33.3 [interquartile range, 14.2 to 51.0] vs 31.3 [interquartile range, 13.5 to 51.1], respectively; difference in improvement, 2.10 [95% CI, 0.10 to 4.06]; P < .001), but the effect size was not clinically meaningful.

Conclusions and Relevance  Among patients who underwent TAVR, receiving a prescription for a RAS inhibitor at hospital discharge compared with no prescription was significantly associated with a lower risk of mortality and heart failure readmission. However, due to potential selection bias, this finding requires further investigation in randomized trials.

×