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Comparative associations between angiotensin converting enzyme inhibitors, angiotensin receptor blockers and their combination, and outcomes in patients with heart failure and reduced ejection fraction
Karolinska Institute, Sweden; University of Naples Federico II, Italy.
Karolinska Institute, Sweden.
Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.ORCID iD: 0000-0001-6353-8041
University of Naples Federico II, Italy.
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2015 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 199, 415-423 p.Article in journal (Refereed) Published
Abstract [en]

Background: Angiotensin converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) are recommended in heart failure with reduced ejection fraction (HFREF), but there is limited data on ARB vs. ACE-I and their combination in unselected populations. The purpose of this study was to compare the associations between the use of ACE-I, ARB and their combination, and outcomes in HFREF. Methods and results: We prospectively studied 22,947 patients with HFREF (ejection fraction b 40%) enrolled in the Swedish Heart Failure Registry who received ACE-I but not ARB (n = 15,801, 69%), ARB but not ACE-I (n = 4335, 19%), their combination (n = 571, 2%) or neither (n = 2240, 10%). As compared with ACE-I alone, the hazard ratios (HRs) for ARB alone for all-cause mortality was 0.97 (95% CI = 0.91-1.03; p = 0.27), for HF hospitalization 1.08 (CI = 1.02-1.15; p less than 0.01) and for the composite outcome 1.03 (CI = 0.99-1.08; p = 0.15). ACE-I and ARB combination had for death HR = 0.98 (95% CI = 0.84-1.14; p = 0.76), for HF hospitalization HR = 1.49 (CI = 1.33-1.68; p less than 0.01) and for the composite outcome HR = 1.35 (CI = 1.21-1.50; p less than 0.01). Use of neither ACE-I nor ARB was associated with HR for death 1.41 (CI = 1.33-1.50; p less than 0.01), for HF hospitalization 1.16 (CI = 1.08-1.25; p less than 0.01) and for the composite outcome 1.28 (CI = 1.21-1.35; p less than 0.01). Conclusion: This large generalizable analysis confirms the current recommendation of using ACE-I as first choice in HFREF. ARB can be considered an alternative in patients who cannot use ACE-I but should not routinely replace ACE-I. The combination of ACE-I and ARB was not associated with additional benefit over either one alone, and may potentially be harmful. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

Place, publisher, year, edition, pages
ELSEVIER IRELAND LTD , 2015. Vol. 199, 415-423 p.
Keyword [en]
Heart failure with reduced ejection fraction; Angiotensin converting enzyme inhibitors; Angiotensin receptor blockers; Registry; Prognosis
National Category
Clinical Medicine
URN: urn:nbn:se:liu:diva-121886DOI: 10.1016/j.ijcard.2015.07.051ISI: 000361150100085PubMedID: 26247798OAI: diva2:860772

Funding Agencies|County Council of Stockholm [20110120, 20140220]; Swedish Heart and Lung Foundation [20100419, 20120321]; Swedish Research Council [2013-23897-104604-23]

Available from: 2015-10-13 Created: 2015-10-12 Last updated: 2015-10-13

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Dahlström, Ulf
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Division of Cardiovascular MedicineFaculty of Medicine and Health SciencesDepartment of Cardiology in Linköping
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