Implications of renin-angiotensin-system blocker discontinuation in acute decompensated heart failure with systolic dysfunction

Background: Renin-angiotensin-system blockers (RASB) improve clinical outcomes in patients with chronic heart failure with reduced fraction; however, there remains ambiguity whether RASB therapy should be continued during the treatment of acute decompensated heart failure (ADHF). Hypothesis: In comparison to patients with RASB use, RASB discontinuation in ADHF will be associated with worsening renal function, hypotension, and adverse long-term clinical outcomes. Methods: Patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization (ESCAPE) trial were separated into four groups based on RASB use at baseline and discharge: continuation (n = 316), discontinuation (n = 21), initiation (n = 42), and nonuse (n = 23). Post-discharge outcomes were validated in an independent ADHF cohort admitted to the Cleveland Clinic (n = 253). Results: RASB discontinuation and nonuse were associated with higher serial creatinine and blood urea nitrogen levels than RASB continuation or initiation (P <.001 for both), but not with serial potassium and systolic blood pressure measurements. No other clinical parameter changes were significant. In comparison to RASB continuation, RASB discontinuation and nonuse was associated with ~75% increased risk of a 180-day composite of death, transplant, or rehospitalization (HR 1.87, 95% CI 1.09-3.20, P = 0.02 and HR 1.72, CI 1.04-2.82, P =.03, respectively). Post-discharge outcomes were similar in the validation cohort. Conclusion: Compared to RASB continuation, RASB discontinuation and nonuse were associated with higher baseline and serial creatinine levels during treatment for ADHF, but not with changes in SBP and potassium levels. Furthermore, RASB discontinuation and nonuse in ADHF were associated with an increased risk of adverse clinical outcomes.