Renin-angiotensin inhibitors may reduce mortality and heart failure readmissions in patients with transcatheter aortic valve replacement

1. In this retrospective cohort study of transcatheter aortic valve replacement (TAVR) patients, Renin-Angiotensin System (RAS) inhibitors administered at hospital discharge reduced mortality and hospital readmission in patients with preserved but not reduced Left Ventricular Ejection Fraction (LVEF).

2. There was no clinically meaningful difference in disease-specific health status with RAS inhibitors.

Evidence Rating Level: 2 (Good)

Study Rundown: Inhibition of the Renin-Angiotensin System (RAS) with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blockers (ARB) is associated with modulation of adverse left ventricular remodeling and reduction in myocardial hypertrophy and fibrosis. While these represent useful treatments for patients with heart failure, it is unclear if they benefit patients who have undergone a transcatheter aortic valve replacement (TAVR). In this registry-based retrospective cohort study, patients who received a RAS inhibitor were less likely to die and be readmitted for heart failure at 1 year. However, RAS inhibitors lowered mortality in patients with preserved left ventricular ejection fraction (LVEF) but not in those with reduced LVEF. In addition, RAS inhibitors did not result in a clinically meaningful difference in disease-specific health status.

While use of RAS inhibitors post-TAVR may be effective in some patients, several limitations of this study should be noted. First, the study may have been sub-optimal due to selection bias, especially in terms of disease-specific health status measurements, of which only 30% of the data was usable. Further, RAS inhibitor medication adherence was not able to be assessed, representing one of a few potentially unmeasured confounders. Though these results are promising, randomized controlled trials would be especially beneficial in determining whether RAS inhibitors should be routinely given post-TAVR.

Click to read the study in JAMA

Relevant Reading: Renin-angiotensin system blockade therapy after transcatheter aortic valve implantation

In-Depth [retrospective cohort]: 15,896 patients older than 65 years with Medicare who underwent TAVR between July 2014 and January 2016 were assessed in this study. Exclusion criteria were dying during index hospitalization, being discharged against medical advice/transfer, having contraindication to use of both ACE inhibitors and ARBs, age <65 years, and inability to be linked to Medicare & Medicaid Services. Primary outcomes were all-cause mortality within 1 year of hospital discharge and readmission due to heart failure within 1 year of discharge. A secondary outcome was quality-of-life at 1 year as determined by the Kansas City Cardiomyopathy Questionnaire (KCCQ) in 30.4% of patients (n = 4837). Patients who received RAS inhibitors had lower mortality rates than the those without (12.5% vs. 14.9%; absolute risk difference was -2.4%; CI₉₅ -3.5 to -1.4%). There was significantly fewer heart failure readmissions (12.0% vs. 13.8%; ARD -1.8%; CI₉₅ -2.8% to -0.7). KCCQ scores improved 2.10 (CI₉₅ 0.10 to 4.06) with treatment. There was also no difference between the two groups in the risk for subsequent myocardial infarctions (ARD 0.39%; CI₉₅ -0.04 to 0.81%).

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