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Association of MRA Use With Mortality and Readmission in HF
Study Questions:
What is the association of mineralocorticoid receptor antagonist (MRA) use with all-cause mortality and hospital readmission in patients with acute decompensated heart failure (ADHF)?
Methods:
The investigators examined participants enrolled in the Kyoto Congestive Heart Failure (KCHF) registry, a physician-initiated, prospective, multicenter cohort study of consecutive patients admitted for ADHF, between October 1, 2014, and March 31, 2016, into 1 of 19 secondary and tertiary hospitals throughout Japan. To balance the baseline characteristics associated with the selection of MRA use, a propensity score–matched cohort design was used, yielding 2,068 patients. Data analysis was conducted from April to August 2018. Prescription of MRA at discharge from the index hospitalization was assessed. The main outcomes measure was composite of all-cause death or HF hospitalization after discharge. The authors estimated the hazard ratios (HRs) and 95% confidence intervals (CIs) for the composite endpoint with Cox proportional hazards regression model.
Results:
Among 3,717 patients hospitalized for ADHF, 1,678 patients (45.1%) had received an MRA at discharge and 2,039 (54.9%) did not. After propensity score matching, 2,068 patients (with a median [interquartile range] age of 80 [72-86] years, and of whom 937 [45.3%] were women) were included. In the matched cohort (n = 1,034 in each group), the cumulative 1-year incidence of the primary outcome was statistically significantly lower in the MRA use group than in the no MRA use group (28.4% vs. 33.9%; hazard ratio [HR], 0.81; 95% CI, 0.70-0.93; p = 0.003). Of the components of the primary outcome, the cumulative 1-year incidence of HF hospitalization was significantly lower in the MRA use group than in the no MRA use group (18.7% vs. 24.8%; HR, 0.70; 95% CI, 0.60-0.86; p < 0.001), whereas no difference in mortality was found between the two groups (15.6% vs. 15.8%; HR, 0.98; 95% CI, 0.82-1.18; p = 0.85). No difference in all-cause hospitalization was observed between the two groups (35.3% vs. 38.2%; HR, 0.88; 95% CI, 0.77-1.01; p = 0.07). In additional analyses that stratified by left ventricular ejection fraction (LVEF), the association of MRA use with the primary outcome was statistically significant in patients with LVEF of ≥40%.
Conclusions:
The authors concluded that use of MRA at discharge from ADHF hospitalization did not appear to be associated with lower mortality but was associated with a lower risk of HF readmission, and that MRA treatment at discharge may have minimal, if any, clinical advantages.
Perspective:
This study reports that the use of MRA at hospital discharge was associated with a lower risk for the primary outcome measure (a composite of all-cause death or HF hospitalization) in patients hospitalized for ADHF, but was not associated with lower mortality. The benefit was primarily related to lower HF hospitalization. Furthermore, when patients were stratified by LVEF, patients with HF and preserved EF appear to have benefited mostly. It appears, with no differences in mortality or overall rate of hospitalization, MRA use may be associated with minimal, if any, clinical net advantages. Additional studies are needed to identify the patient groups that may benefit most from MRA treatment.
Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure
Keywords: Geriatrics, Heart Failure, Hospitalization, Mineralocorticoid Receptor Antagonists, Patient Discharge, Patient Readmission, Risk, Secondary Prevention, Stroke Volume, Treatment Outcome
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