Benefits of RAS Antagonist Use in Heart Failure and Severe Renal Insufficiency | Journal Scan

Study Questions:

What is the association of renin–angiotensin receptor (RAS) antagonist therapy and mortality in patients with heart failure with reduced ejection fraction (HFrEF) and severe renal insufficiency?


The authors performed a retrospective analysis of patients with an ejection fraction (EF) ≤39% in the Swedish Heart Failure Registry. The analysis was performed in patients with severe renal insufficiency (creatinine clearance <30 ml/min); a “positive control” consistency analysis was performed in patients without severe renal insufficiency. With logistic regression, a propensity score for treatment with RAS antagonists was estimated for each patient. The endpoint was death from any cause.


A total of 2,410 patients had severe renal insufficiency. This overall cohort consisted of 1,602 (66%) treated versus 808 (34%) untreated patients. In the matched cohort, RAS antagonist use was associated with 55% (95% confidence interval [CI], 51-59) versus 45% (95% CI, 41-49) 1-year survival, p < 0.001, with a hazard ratio (HR) for mortality of 0.76 (95% CI, 0.67-0.86; p < 0.001). In positive control patients (i.e., without severe renal insufficiency), the matched HR was 0.79 (95% CI, 0.72-0.86; p < 0.001).


In patients with HFrEF and severe renal insufficiency, the use of RAS antagonists was associated with lower all-cause mortality.


Patients with severe renal insufficiency have been excluded from RAS antagonist trials. The authors performed a useful analysis of patients with HFrEF and severe renal insufficiency (chronic kidney disease stage 4 or 5). Less than three-quarters of patients with HFrEF and severe renal insufficiency used RAS antagonists. Among HFrEF patients with severe renal insufficiency, the reduction in mortality with RAS antagonist therapy (HR, 0.76) was similar to that in a positive control consistency analysis of patients without severe renal insufficiency (HR, 0.79). Certainly, these findings draw attention to the benefits of RAS antagonist therapy in this group. As the authors caution, prospective randomized trials are needed before these findings can be broadly applied in clinical practice.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Angiotensin Receptor Antagonists, Angiotensins, Creatinine, Heart Failure, Logistic Models, Propensity Score, Receptors, Angiotensin, Registries, Renal Insufficiency, Renal Insufficiency, Chronic, Renin-Angiotensin System, Retrospective Studies

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