ACE inhibitors and angiotensin receptor blockers found to improve survival.

NEW ORLEANS—Most heart failure patients with renal failure can be managed successfully with ACE inhibitors or angiotensin receptor blockers (ARBs), and the treatment is associated with better outcomes, said Virgina B. Thayer, MS, at the 2008 scientific sessions of the American Heart Association.

After being managed in a heart failure clinic, 90% of patients with renal failure were successfully treated with ACE inhibitors/ARBs, and most were still on the medications at one year.

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She and colleagues conducted a retrospective evaluation of 621 patients admitted to the Gundersen Lutheran heart failure disease management clinic in La Crosse, Wis. Renal failure was defined as a serum creatinine level of 2.0 mg/dL or greater and/or a history of renal failure upon discharge from the heart failure clinic.

The patients received aggressive medication management coupled with education on medication and self-management.

“Once medications are started by a dedicated team in a heart failure clinic, patients enjoyed high adherence rates,” according to Thayer, of the Gundersen Lutheran health care network.

Ninety-six percent of patients without renal failure were maintained on ACE inhibitors/ARBs at discharge, compared with 90% of patients with renal failure. At one year, 94% of patients without renal failure and 89% with renal failure were still on ACE inhibitors/ARBs. At two years, 95% of the non-renal failure patients were maintained on ACE inhibitors/ARBs, compared with 85% of the patients with renal failure.

Two thirds of patients with renal failure could be treated with optimal doses of ACE inhibitors/ARBs at one year, defined as the equivalent of 20 mg/day or higher of lisinopril, Thayer noted.

The patients were followed for a median of 6.8 years. At one year, mortality was 17% in the patients with renal failure and 8% in those without renal failure. At five years, the mortality rates were 61% and 34%, respectively.

Hospitalization rates at one year were 41% in patients with renal failure and 28% in patients without renal failure; at five years, the rates were 88% and 69%, respectively.

Kaplan-Meier analysis revealed significantly higher all-cause mortality and all-cause hospitalizations in the patients with renal failure. The death rates were significantly lower at one year among patients with renal failure who were treated with ACE inhibitors/ARBs compared with those who were not treated (17% vs. 23%), although hospitalization rates were similar (41% vs. 43%).

Prospective studies of patients with renal failure and heart failure are warranted; these patients are traditionally excluded from clinical trials of heart failure management, she said.