Do ACE Inhibitors/Angiotensin II Type 1 Receptor Antagonists Reduce Hospitalisations in Older Patients with Heart Failure?
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Randomised controlled trials have shown a reduced risk of heart failure (HF) hospitalisation among users of ACE inhibitors (ACEIs) or angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]), but these results have limited generalisability. Some observational studies have also demonstrated reductions in hospitalisation but are potentially affected by non-random treatment selection.
To assess the effect of ACEI/ARB therapy on all-cause and HF-related hospitalisations among older adults using a propensity model to adjust for treatment-selection bias and focusing on consistent medication use as the exposure of interest.
A retrospective cohort study of continuously enrolled, older (age ≥60 years) Kansas Medicaid beneficiaries with HF, using data from May 1999 to April 2000. A propensity analysis was used to identify a comparison group of untreated persons that were otherwise clinically similar to treated persons. The effect of regular ACEI/ARB use on hospitalisations was estimated using multivariable logistic regression models. The HF sample included 887 subjects, of whom 235 (27%) received regular ACEI/ARB therapy. To be considered a regular user of ACEI/ARB therapy (‘treated’), we required evidence that a subject obtained at least 80% of their intended daily supply. The main outcome measure was the effect of regular ACEI/ARB use on all-cause and HF-related hospitalisations.
Treated subjects were matched against an equal number of untreated persons, for a final sample of 470 persons. The mean age of both treated and untreated subjects was 81 years. Regular ACEI/ARB use did not alter the adjusted odds ratio (AOR) of all-cause hospitalisation (AOR = 1.04, 95% CI 0.71, 1.52), which occurred in 40% of the sample, or the odds of an HF-related hospitalisation (AOR =1.01, 95% CI 0.65, 1.57), which occurred in 22.6% of both groups.
Although randomised controlled trials have shown that ACEI/ARB treatment is associated with reduced hospitalisations in patients with HF, this benefit was not observed in our study. Further study of ACEI/ARB outcomes is needed in a larger sample of older subjects with HF.
KeywordsAdjusted Odds Ratio Heart Failure Severity Medication Possession Ratio Candesartan Cilexetil Heart Failure Hospitalisation
This study was supported by a contract with the Kansas Department of Social and Rehabilitation Services. The opinions and conclusions of this study do not necessarily reflect the position or opinion of the Kansas Department of Social and Rehabilitation Services. SKR received salary support from the National Institute on Aging (K08 AG019516). The sponsor did not play a role in the design, methods, subject recruitment, data collections analysis and preparation of the study. The authors have no conflicts of interest that are directly relevant to the content of this study.
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