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Lund, L. H., Svennblad, B., Dahlström, U. & Ståhlberg, M. (2018). Effect of expanding evidence and evolving clinical guidelines on the prevalence of indication for cardiac resynchronization therapy in patients with heart failure. European Journal of Heart Failure, 20(4), 769-777
Open this publication in new window or tab >>Effect of expanding evidence and evolving clinical guidelines on the prevalence of indication for cardiac resynchronization therapy in patients with heart failure
2018 (English)In: European Journal of Heart Failure, ISSN 1388-9842, E-ISSN 1879-0844, Vol. 20, no 4, p. 769-777Article in journal (Refereed) Published
Abstract [en]

AIMS: To assess the prevalence of indication for cardiac resynchronization therapy (CRT) in patients with heart failure (HF) and reduced ejection fraction (EF) when recommendations from evolving European Society of Cardiology (ESC) guidelines are considered.

METHODS AND RESULTS: Unique patients (n=17 193) with EF ≤39% and key data available for evaluation of CRT indication from the Swedish HF Registry were included. Indication for CRT was defined as either CRT implanted or CRT device absent but fulfilling criteria for class I-IIa recommendations in ESC guidelines published between 2005/2007 and 2016. Prevalence was calculated as the ratio of patients with CRT indication to the study population. The prevalence of CRT indication increased from 24.5% when the 2005/2007 ESC guidelines were considered to a peak of 30.0% when the 2013 ESC guidelines were considered (P<0.001, 22.4% relative increase). Compared to the 2013 ESC guidelines, the prevalence declined significantly when the 2016 ESC guidelines were used as determinant for CRT indication (26.8%, 10.7% relative reduction, P<0.001). Actual CRT utilization was 6.8%.

CONCLUSION: Among patients with HF and reduced EF, the prevalence of CRT indication increased significantly comparing recommendations from ESC guidelines published between 2005/2007 and 2013, but then declined when the 2016 ESC guidelines were considered. The 2005-2013 increase may reflect the expansion of documented CRT efficacy to New York Heart Association class II, whereas the subsequent drop likely results from the more stringent criteria for QRS duration in the 2016 ESC guidelines. Actual CRT utilization is lower than indicated, regardless of which guidelines are considered.

Place, publisher, year, edition, pages
John Wiley & Sons, 2018
Keywords
Cardiac resynchronization therapy, Guidelines, Heart failure, Implementation, QRS width
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-144356 (URN)10.1002/ejhf.929 (DOI)000430105300024 ()28949083 (PubMedID)
Available from: 2018-01-16 Created: 2018-01-16 Last updated: 2018-07-23Bibliographically approved
Lund, L. H., Braunschweig, F., Benson, L., Ståhlberg, M., Dahlström, U. & Linde, C. (2017). Association between demographic, organizational, clinical, and socio-economic characteristics and underutilization of cardiac resynchronization therapy: results from the Swedish Heart Failure Registry.. European Journal of Heart Failure, 19(10), 1270-1279
Open this publication in new window or tab >>Association between demographic, organizational, clinical, and socio-economic characteristics and underutilization of cardiac resynchronization therapy: results from the Swedish Heart Failure Registry.
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2017 (English)In: European Journal of Heart Failure, ISSN 1388-9842, E-ISSN 1879-0844, Vol. 19, no 10, p. 1270-1279Article in journal (Refereed) Published
Abstract [en]

AIMS: Cardiac resynchronization therapy (CRT) improves outcomes in heart failure (HF) but may be underutilized. The reasons are unknown.

METHODS AND RESULTS: We linked the Swedish Heart Failure Registry to national registries with ICD-10 (International Classification of Diseases-10th Revision) co-morbidity diagnoses and demographic and socio-economic data. In patients with EF ≤39% and NYHA II-IV, we assessed prevalence of CRT indication and CRT use. In those with CRT indication, we assessed the association between 37 potential baseline covariates and CRT non-use using multivariable generalized estimating equation (GEE) models. Of 12 807 patients (mean age 71 ± 12 years, 28% female), 841 (7%) had CRT, 3094 (24%) had an indication for but non-use of CRT, and 8872 (69%) had no indication. Important variables independently associated with CRT non-use were: HF duration <6 months [risk ratio (RR) 1.21, 95% confidence interval (CI) 1.17-1.24]; non-cardiology planned follow-up (RR 1.14, 95% CI 1.09-1.18); age >75 years (RR 1.13, 95% CI 1.09-1.18); non-cardiology care at baseline (RR 1.10, 95% CI 1.07-1.14); small-town non-university centre (RR 1.08, 95% CI 1.05-1.12); female sex (RR 1.07 95% CI 1.03-1.10) (all P < 0.05); as was absence of AF, living alone; psychiatric diagnosis; smoking; and non-use of HF drugs. Education, income, cancer, or HF characteristics were not independently associated with CRT non-use.

CONCLUSION: In this population-wide HF registry, CRT was underutilized. Non-use was associated mostly with demographic and organizational, but not clinical or socio-economic factors. This calls for programmes to raise awareness of CRT indications and improve access and referrals to cardiology specialists.

Place, publisher, year, edition, pages
John Wiley & Sons, 2017
Keywords
Cardiac resynchronization therapy, Epidemiology, Guidelines, Heart failure, Implementation, Utilization
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-139104 (URN)10.1002/ejhf.781 (DOI)000412521000008 ()28176416 (PubMedID)
Note

Funding agencies: Swedish Research Council [2013-23897-104604-23]; Swedish Heart Lung Foundation [20150063, 20080498, 20110406, 20090870]; Stockholm County Council [20090556, 20110120, 20090376, 20110610]

Available from: 2017-07-01 Created: 2017-07-01 Last updated: 2018-04-13Bibliographically approved
Lim, S. L., Benson, L., Dahlström, U., Lam, C. S. P. & Lund, L. H. (2017). Association Between Use of Long-Acting Nitrates and Outcomes in Heart Failure With Preserved Ejection Fraction. Circulation Heart Failure, 10(4), Article ID e003534.
Open this publication in new window or tab >>Association Between Use of Long-Acting Nitrates and Outcomes in Heart Failure With Preserved Ejection Fraction
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2017 (English)In: Circulation Heart Failure, ISSN 1941-3289, E-ISSN 1941-3297, Vol. 10, no 4, article id e003534Article in journal (Refereed) Published
Abstract [en]

Nitrates may be beneficial in heart failure with preserved ejection fraction (HFpEF) by enhancing cGMP signaling and improving hemodynamics, but real-world data on potential efficacy are lacking.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2017
Keywords
heart failure; hemodynamics; hospitalization; mortality; propensity score
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-146064 (URN)10.1161/CIRCHEARTFAILURE.116.003534 (DOI)000426415500002 ()28377439 (PubMedID)
Available from: 2018-03-28 Created: 2018-03-28 Last updated: 2018-03-28
Szummer, K., Evans, M., Carrero, J. J., Alehagen, U., Dahlström, U., Benson, L. & Lund, L. H. (2017). Comparison of the Chronic Kidney Disease Epidemiology Collaboration, the Modification of Diet in Renal Disease study and the Cockcroft-Gault equation in patients with heart failure. Open heart, 4(2), Article ID e000568.
Open this publication in new window or tab >>Comparison of the Chronic Kidney Disease Epidemiology Collaboration, the Modification of Diet in Renal Disease study and the Cockcroft-Gault equation in patients with heart failure
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2017 (English)In: Open heart, ISSN 0168-2601, E-ISSN 2053-3624, Vol. 4, no 2, article id e000568Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: It is unknown how the creatinine-based renal function estimations differ for dose adjustment cut-offs and risk prediction in patients with heart failure.

METHOD AND RESULTS: The renal function was similar with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) (median 59 mL/min/1.73 m2, IQR 42 to 77) and Modification of Diet in Renal Disease Study (MDRD) (59 mL/min/1.73 m2, IQR 43 to 75) and slightly lower with the Cockcroft-Gault (CG) equation (57 mL/min, IQR 39 to 82). Across the commonly used renal function stages, the CKD-EPI and the MDRD classified patients into the same stage in 87.2% (kappa coefficient 0.83, p<0.001); the CKD-EPI and the CG equation agreed in 52.3% (kappa coefficient 0.39, p<0.001). Hence, a differing number of patients will receive dose adjustment depending on which formula is used as cut-off. The CG equation predicted worse prognosis better (c-statistics 0.740, 95% CI 0.734 to 0.746) than CKD-EPI (0.697, 95% CI 0.690 to 0.703, p<0.001) and MDRD (0.680, 95% CI 0.734 to 0.746). Using net reclassification improvement (NRI), the CG identified 12.8% more patients at higher risk of death as compared with the CKD-EPI equation. Patients registered in the Swedish Heart Failure Registry (n= 40 736) with standardised creatinine values between 2000 and 2012 had their renal function estimated with the CKD-EPI, the MDRD and the CG. Agreement between the formulas was compared for categories. Prediction of death was assessed with c-statistics and with NRI.

CONCLUSION: The choice of renal function estimation formula has clinical implications and differing results at various cut-off levels. For prognosis, the CG predicts mortality better than the CKD-EPI and MDRD.

Place, publisher, year, edition, pages
Gateshead, United Kingdom: Open House International Association, 2017
Keywords
application, creatinine, heart failure, prognosis, register, renal function estimation
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-144357 (URN)10.1136/openhrt-2016-000568 (DOI)28761677 (PubMedID)2-s2.0-85020645932 (Scopus ID)
Available from: 2018-01-16 Created: 2018-01-16 Last updated: 2018-02-12Bibliographically approved
Jonsson, Å., Hallberg, A.-C., Edner, M., Lund, L. H. & Dahlström, U. (2016). A comprehensive assessment of the association between anemia, clinical covariates and outcomes in a population-wide heart failure registry. International Journal of Cardiology, 211, 124-131
Open this publication in new window or tab >>A comprehensive assessment of the association between anemia, clinical covariates and outcomes in a population-wide heart failure registry
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2016 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 211, p. 124-131Article in journal (Refereed) Published
Abstract [en]

Background: The aim was to investigate the prevalence of, predictors of, and association with mortality and morbidity of anemia in a large unselected cohort of patients with heart failure (HF) and reduced ejection fraction (HFrEF) and to explore if there were specific subgroups of high risk. Methods: In patients with HFrEF in the Swedish Heart Failure Registry, we assessed hemoglobin levels and associations between baseline characteristics and anemia with logistic regression. Using propensity scores for anemia, we assessed the association between anemia and outcomes with Cox regression, and performed interaction and sub-group analyses. Results: There were 24 511 patients with HFrEF (8303 with anemia). Most important independent predictors of anemia were higher age, male gender and renal dysfunction. One-year survival was 75% with anemia vs. 81% without (p &lt; 0.001). In the matched cohort after propensity score the hazard ratio associated with anemia was for all-cause death 1.34 (1.28-1.40; p &lt; 0.0001), CV mortality 1.28 (1.20-1.36; p &lt; 0.0001), and combined CV mortality or HF hospitalization 1.24 (1.18-1.30; p &lt; 0.0001). In interaction analyses, anemia was associated with greater risk with lower age, male gender, EF 30-39%, and NYHA-class I-II. Conclusion: In HFrEF, anemia is associated with higher age, male gender and renal dysfunction and increased risk of mortality and morbidity. The influence of anemia on mortality was significantly greater in younger patients, in men, and in those with more stable HF. The clinical implication of these findings might be in the future to perform targeted treatment studies. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Place, publisher, year, edition, pages
ELSEVIER IRELAND LTD, 2016
Keywords
Heart failure; Reduced ejection fraction; Anemia; Outcomes; Observational study
National Category
Mathematics Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-127741 (URN)10.1016/j.ijcard.2016.02.144 (DOI)000373918100029 ()26999301 (PubMedID)
Note

Funding Agencies|Swedish National Board of Health and Welfare; Swedish Association of Local Authorities and Regions; Swedish Society of Cardiology; Linkoping University; Swedish HF Registry foundation

Available from: 2016-05-12 Created: 2016-05-12 Last updated: 2017-11-30
Karlström, P., Johansson, P., Dahlström, U., Boman, K. & Alehagen, U. (2016). Can BNP-guided therapy improve health-related quality of life, and do responders to BNP-guided heart failure treatment have improved health-related quality of life? Results from the UPSTEP study.. BMC Cardiovascular Disorders, 16
Open this publication in new window or tab >>Can BNP-guided therapy improve health-related quality of life, and do responders to BNP-guided heart failure treatment have improved health-related quality of life? Results from the UPSTEP study.
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2016 (English)In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 16Article in journal (Refereed) Published
Abstract [en]

Background: To investigate whether B-type natriuretic peptide (NP)-guided treatment of heart failure (HF) patients improved their health related quality of life (Hr-QoL) compared to routine HF treatment, and whether changes in Hr-QoL differed depending on whether the patient was a responder to NP-guided therapy or not.

Methods: A secondary analysis of the UPSTEP-study, a Scandinavian multicentre study using a prospective, randomized, open, blinded evaluation design on patients with HF with New York Heart Association (NYHA) class II-IV. NP-guiding was aimed to reduce BNP <150 ng/L if<75 years or BNP<300 ng/L if>75 years. A responder was defined as a patient with a BNP<300 ng/L and/or a decrease in BNP of at least 40 % in week 16 compared to study start. Short form-36 (SF-36) was used to measure Hr-QoL. At the study start, 258 patients presented evaluable SF-36 questionnaires, 131 in the BNP group and 127 in the control group. At the study end 100 patients in the NP-guided group and 98 in the control group, presenting data from both the study start and the study end.

Results: There were no significant differences in Hr-QoL between NP-guided HF treatment and control group; however significant improvements could be seen in four of the eight domains in the NP-guided group, whereas in the control group improvements could be seen in six of the domains.

Among the responders improvements could be noted in four domains whereas in the non-responders improvements could be seen in only one domain evaluating within group changes.

Conclusions: Improved Hr-QoL could be demonstrated in several of the domains in both the NP-guided and the control group. In the responder group within group analyses showed more increased Hr-QoL compared to the non-responder group. However, all groups demonstrated increase in Hr-QoL.

Place, publisher, year, edition, pages
BioMed Central, 2016
Keywords
Heart failure, treatment guided by natriuretic peptides, Health related quality of life, responders, BNP, SF-36
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-124558 (URN)10.1186/s12872-016-0221-7 (DOI)000370472800001 ()
Note

Vid tiden för disputationen förelåg publikationen endast som manuskript

Funding agencies:  Swedish Heart-lung foundation [20060596]; Regional Research Foundation in south-eastern Sweden [FORSS-3963]; Regional Research Foundation in northern Sweden; Biosite international; Infiniti Medical AB

Available from: 2016-02-03 Created: 2016-02-03 Last updated: 2017-11-30Bibliographically approved
Crespo-Leiro, M. G., Anker, S. D., Maggioni, A. P., Coats, A. J., Filippatos, G., Ruschitzka, F., . . . Mebazaa, A. (2016). European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT): 1-year follow-up outcomes and differences across regions. European Journal of Heart Failure, 18(6), 613-625
Open this publication in new window or tab >>European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT): 1-year follow-up outcomes and differences across regions
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2016 (English)In: European Journal of Heart Failure, ISSN 1388-9842, E-ISSN 1879-0844, Vol. 18, no 6, p. 613-625Article in journal (Refereed) Published
Abstract [en]

AimsThe European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT-R) was set up with the aim of describing the clinical epidemiology and the 1-year outcomes of patients with heart failure (HF) with the added intention of comparing differences between participating countries. Methods and resultsThe ESC-HF-LT-R is a prospective, observational registry contributed to by 211 cardiology centres in 21 European and/or Mediterranean countries, all being member countries of the ESC. Between May 2011 and April 2013 it collected data on 12440 patients, 40.5% of them hospitalized with acute HF (AHF) and 59.5% outpatients with chronic HF (CHF). The all-cause 1-year mortality rate was 23.6% for AHF and 6.4% for CHF. The combined endpoint of mortality or HF hospitalization within 1year had a rate of 36% for AHF and 14.5% for CHF. All-cause mortality rates in the different regions ranged from 21.6% to 36.5% in patients with AHF, and from 6.9% to 15.6% in those with CHF. These differences in mortality between regions are thought reflect differences in the characteristics and/or management of these patients. ConclusionThe ESC-HF-LT-R shows that 1-year all-cause mortality of patients with AHF is still high while the mortality of CHF is lower. This registry provides the opportunity to evaluate the management and outcomes of patients with HF and identify areas for improvement.

Place, publisher, year, edition, pages
WILEY-BLACKWELL, 2016
Keywords
Heart failure; Registry; Acute; Chronic; Survival; Outcomes
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-130439 (URN)10.1002/ejhf.566 (DOI)000379257200005 ()27324686 (PubMedID)
Available from: 2016-08-06 Created: 2016-08-05 Last updated: 2017-11-28
Karlström, P., Johansson, P., Dahlström, U., Boman, K. & Alehagen, U. (2016). Time since heart failure diagnosis influences outcomes more than age when handling heart failure patients: Results from the UPSTEP study.
Open this publication in new window or tab >>Time since heart failure diagnosis influences outcomes more than age when handling heart failure patients: Results from the UPSTEP study
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2016 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Heart failure (HF) is a life-threatening condition and optimal handling is necessary to reduce risk of therapy failure.

Objectives: The aims of this study were (I) to evaluate the impact of patient age on clinical outcomes, (II) to evaluate the impact of duration of the HF disease on outcomes, and (III) to evaluate the impact of age and HF duration on B-type Natriuretic Peptide (BNP) concentration.

Methods and Results: With data from the UPSTEP (Use of PeptideS in Tailoring hEart failure Project) study we retrospectively evaluated how age and HF duration affected HF outcome. HF duration was divided into <1 year (group 1), 1-5 years (group 2) and >5 years (group 3). The multivariate Cox proportional hazard regression analysis showed that HF duration influenced outcome more than age, even when adjusted for comorbidities(<1 year versus >5 years: HR 1.65; 95 % CI 1.28-2.14; p <0.0002) on HF mortality and hospitalizations. The influence of age on BNP showed increased BNP as age increased. However, there was a significant effect on BNP concentration comparing HF duration of < one year to HF duration >five years even when adjusted for age.

Conclusions: Patients with longer HF duration had significantly worse outcome compared to those with short duration, even when adjusted for patient age and comorbidities. Age itself did not influence outcome in this evaluation. Age had impact on BNP concentration; however BNP concentration increased as HF duration increased even when adjusted for age.

Keywords
Heart failure, B-type natriuretic peptides, age, heart failure duration
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-124559 (URN)
Available from: 2016-02-03 Created: 2016-02-03 Last updated: 2016-02-03Bibliographically approved
Thorvaldsen, T., Benson, L., Dahlström, U., Edner, M. & Lund, L. H. (2016). Use of evidence-based therapy and survival in heart failure in Sweden 2003-2012. European Journal of Heart Failure, 18(5), 503-511
Open this publication in new window or tab >>Use of evidence-based therapy and survival in heart failure in Sweden 2003-2012
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2016 (English)In: European Journal of Heart Failure, ISSN 1388-9842, E-ISSN 1879-0844, Vol. 18, no 5, p. 503-511Article in journal (Refereed) Published
Abstract [en]

Aims In heart failure with reduced ejection fraction, drug and device therapy improve survival. We studied contemporary trends in utilization of evidence-based therapy and associated survival. Methods and results We studied 5908 patients with NYHA class II-IV heart failure, EF amp;lt;30%, and duration of heart failure amp;gt;= 6 months registered in the Swedish Heart Failure Registry between 2003 and 2012. Regression using generalized estimation equations was used to examine temporal trends in crude and risk-adjusted rates of utilization of evidence-based heart failure therapy and 30-day, 1-year, and 3-year survival. In 2003 vs. 2012, the risk-adjusted use of therapy and P-values for trends were as follows: renin-angiotensin system antagonists, 88% vs. 86% (P = 0.091); beta-blockers, 85% vs. 93% (P = 0.008); mineralocorticoid receptor antagonists, 53% vs. 42% (P amp;lt; 0.001); CRT, 2.4% vs. 8.2% (P = 0.074); and implantable cardioverter-defibrillators, 4.0% vs. 10.7% (P = 0.004). During the same period, the risk-adjusted 30-day, 1-year, and 3-year survival was 92% vs. 94% (P = 0.532), 81% vs. 77% (P = 0.260), and 58% vs. 54% (P = 0.425), respectively. Conclusions In this large nationwide registry, over the last decade the use of evidence-based drug therapy was high and remained stable over time, but, despite an increased use of device therapy, the absolute use was poor. This was associated with an absence of improvement in survival. The improvements in therapy and prognosis over the last generation may be levelling off, and efforts should be directed at improving implementation of evidence-based therapy.

Place, publisher, year, edition, pages
WILEY-BLACKWELL, 2016
Keywords
Heart failure; Evidence-based therapy; Guidelines; Utilization; Implementation; Outcomes
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-130443 (URN)10.1002/ejhf.496 (DOI)000379258400010 ()26869252 (PubMedID)
Available from: 2016-08-06 Created: 2016-08-05 Last updated: 2017-11-28
Edner, M., Benson, L., Dahlström, U. & Lund, L. H. (2015). Association between renin-angiotensin system antagonist use and mortality in heart failure with severe renal insufficiency: a prospective propensity score-matched cohort study. European Heart Journal, 36(34), 2318-2326
Open this publication in new window or tab >>Association between renin-angiotensin system antagonist use and mortality in heart failure with severe renal insufficiency: a prospective propensity score-matched cohort study
2015 (English)In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 36, no 34, p. 2318-2326Article in journal (Refereed) Published
Abstract [en]

Aims In heart failure (HF) with reduced ejection fraction (EF), renin-angiotensin receptor (RAS) antagonists reduce mortality. However, severe renal insufficiency was an exclusion criterion in trials. We tested the hypothesis that RAS antagonists are associated with reduced mortality also in HF with severe renal insufficiency. Methods and results We studied patients with EF less than= 39% registered in the prospective Swedish Heart Failure Registry. In patients with creatinine greater than221 mu mol/L or creatinine clearance less than30 mL/min, propensity scores for RAS-antagonist use were derived from 36 variables. The association between RAS antagonist use and all-cause mortality was assessed with Cox regression in a cohort matched 1:1 based on age and propensity score. To assess consistency, we performed the same analysis as a positive control in patients without severe renal insufficiency. Between 2000 and 2013, there were 24 283 patients of which 2410 [age, mean (SD), 82 (9), 45% women] had creatinine greater than221 mu mol/L or creatinine clearance less than30 mL/min and were treated (n = 1602) or not treated (n = 808) with RAS antagonists. In the matched cohort of 602 vs. 602 patients [age 83 (8), 42% women], RAS antagonist use was associated with 55% [95% confidence interval (CI) 51-59] vs. 45% (41-49) 1-year survival, P less than 0.001, with a hazard ratio (HR) for mortality of 0.76 (95% CI 0.67-0.86, P less than 0.001). In positive control patients without severe renal insufficiency [n = 21 873; age 71 (12), 27% women], the matched HR was 0.79 (95% CI 0.72-0.86, P less than 0.001). Conclusion In HF with severe renal insufficiency, the use of RAS antagonists was associated with lower all-cause mortality. Prospective randomized trials are needed before these findings can be applied to clinical practice.

Place, publisher, year, edition, pages
OXFORD UNIV PRESS, 2015
Keywords
Heart failure; Renin-angiotensin system antagonists; ACE-inhibitor; Angiotensin receptor blocker; Renal insufficiency; Chronic kidney disease; Creatinine clearance
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-121745 (URN)10.1093/eurheartj/ehv268 (DOI)000361206300014 ()26069212 (PubMedID)
Note

Funding Agencies|Swedish National Board of Health and Welfare; Swedish Association of Local Authorities and Regions; Swedish Society of Cardiology; Swedish Heart-Lung Foundation; Swedish Research Council from the Swedish Heart-Lung Foundation [2013-23897-104604-23, 20080409, 20100419]; Stockholm County Council [00556-2009, 20110120]

Available from: 2015-10-07 Created: 2015-10-05 Last updated: 2017-12-01
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0001-6353-8041

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