Written by Peter Liu
Spoon Feed
In octogenarians treated for heart failure with reduced ejection fraction (HFrEF) at the VA, prescription of renin-angiotensin system inhibitors (RASIs) at target dosing (vs. below-target dosing) was associated with decreased mortality and hospitalizations.
Synopsis
The study explored the impact of target-dose renin-angiotensin system inhibitors (RASIs) on death and kidney failure in octogenarians with heart failure with reduced ejection fraction (HFrEF). This propensity-score-matched cohort study included 13,284 veterans, balanced across 66 baseline characteristics, comparing target- and below-target-dose RASIs over five years. Results showed a lower all-cause mortality rate (69.5% vs. 71.2%; HR: 0.95; p=0.009) and a non-significant reduction in kidney failure (1.5% vs. 1.8%; HR: 0.80; p=0.094) with target-dose therapy. Limitations include potential residual confounding and male-predominant data. The findings support target-dose RASIs to improve survival without increasing kidney-related risks in this population. (AI-assisted)
For heart failure guideline-directed medical therapy (GDMT), keep the target dose in mind
This observational study provides evidence that clinicians should strive to maintain RASI dosages at targets recommended by the American Heart Association, even in patients over the age of 80. The study design involved propensity-score matching to limit confounding, but as with most non-RCT studies, unmeasured confounding factors remain likely. Further, the study was performed on patients treated in the Veterans Affair (VA) healthcare system. As a result, non-Black and non-white patients were underrepresented, as were female patients. Finally, in subgroup analyses, the association between target-dose RASIs and better outcomes also did not appear to hold for several important subgroups, including patients with GFR under 30. The data presented encourages clinicians to heed target dosing of RASIs (e.g. Table 14 in the 2022 AHA Heart Failure Guidelines). I, for one, will have a stronger commitment to trying to get older patients to these target doses, especially if they have favorable renal function.
Source
Lower Risk of Death and Kidney Failure Associated with Higher Target (vs. Below-Target) Doses of RAS Inhibitors in Octogenarians with HFrEF. Am J Med. 2024 Nov 12:S0002-9343(24)00710-1. doi: 10.1016/j.amjmed.2024.10.019. Epub ahead of print. PMID: 39551174
