The Effect of Renin-Angiotensin System Inhibition on All-Cause Mortality in Hospitalized Elderly Systolic Heart Failure Patients with Chronic Kidney Disease

Anemia is a common comorbidity in chronic heart failure (CHF) and is associated with highrisk.However,epidemiologicaldatafromLatin-Americancountriesarescarce.We sought to evaluate prevalence, clinical profile and factors associated with anemia in pa- tients with CHF. Material and method: A cohort of 2051 ambulatory patients prospec- tively recruited in Argentinean Hospical II Registry (13 provinces, 309 physicians, 36% non-cardiologists), with diagnosis of CHFand hemogram availablewere included inthepresentanalysis.Anemiawasdefinedbyhemoglobinlevel #11g/dlorhematocrit #33%inwomen,and #12g/dlor36%inmen.Results:Anemiawasdiagnosedin22% (n5460).Inpatientswithandwithoutanemia,meanagewas74vs71years(p!0.0001), and were male 63 vs 50% (p!0.0001). Patients with anemia had more prevalence of stroke (8 vs 5%, p!0.0001), neoplasia (5 vs 3%, 0.035), renal failure (17 vs 7%, !0.0001), history of acute pulmonary edema (17 vs 12%, 0.014), coronary artery dis- ease (46 vs 40%, 0,015), heart failure hospitalizations (52 vs 42%, p!0.0001), NYHA classIII-IV(40vs32%,0.006),withlessprevalenceofobesity(23vs33%,!0.0001).In anemicsubjectcomparedwiththosewithoutanemia,systolicbloodpressure(SBP)was 128vs133 mmHg(!0.0001),urea54vs46g/l(!0.0001),creatinine1.44vs1.22mg/ dl (!0.0001),andsodium138 vs139 mEq/l(0.002).In the logisticregressionanalysis, variables significantly associated with anemia were: age (OR51.02;IC51.006-1.03), male (OR51.45;IC51.09-1.94), neoplasia (OR51.99;IC51.06-1.376), renal failure (OR51.97;IC51.29-3.01), obesity (OR50.63;IC50.46-0.88), SBP (OR50.99; IC50.986-0.998) and creatinine (OR51.84;IC51.32-2.56). Conclusions: In Argenti- na, one out of four patients with CHF has anemia. This co-morbid condition was asso- ciated with male gender, older age, chronic co-existing diseases and a cardiovascular profile of high-risk. scribed ACEI or ARB. Propensity scores (PS) for ACEI or ARB use were used to assemble a cohort of 783 and 413 patients with and without ACEI or ARB use re- spectively who were well-balanced on 60 baseline characteristics. Cox-regression models were used to estimate association of ACEI or ARB use with 4-year all-cause mortality. We repeated our analysis in 1937 pre-match HF patients with CKD using multivariable and PS-adjusted models. Results: Patients had a mean (6SD) age of 78 (68) years, 51% women, 20% were non-whites. Mortality occurred at a rate of 2749 and 3222 events / 10,000 PYs of follow-up among matched patients receiving and not receiving ACEI or ARB, respectively (HR when ACEI or ARB use was compared with their nonuse50.87; 95% CI50.73e1.03; P50.112). Among 1937 unmatched patients, unadjusted, multivariable-adjusted and PS-adjusted HRs (95% CIs) for mor- tality associated with ACEI or ARB use were 0.77 (0.69e0.86; P!0.0001), 0.85 (0.75e0.96; P50.007), and 0.90 (0.80e1.03; P50.119), respectively. Conclusions: Although ACEI or ARB use was associated with reduced mortality by multivariable analysis, the relationship was no longer significant when PS methods were used. These data suggest that ACEI or ARBs are safe in elderly SHF patients with CKD, but their effect on mortality and other clinical outcomes, including hospitali- zations and quality of life, requires further study.