RENAL INSUFFICIENCY AND HEART FAILURE
The association among renal insufficiency, pharmacotherapy, and outcomes in 6,427 patients with heart failure and coronary artery disease
Justin Ezekowitz, MB, BCh, MSc*,
Finlay A. McAlister, MD, MSc ,*,
Karin H. Humphries, MBA, DSc ,
Colleen M. Norris, PhD ,
Marcello Tonelli, MD, MSc||,
William A. Ghali, MD, MPH¶,
Merril L. Knudtson, MD# APPROACH Investigators
* Division of Cardiology, University of Alberta, Edmonton, Canada
Division of General Internal Medicine, University of Alberta, Edmonton, Canada
|| Division of Nephrology, University of Alberta, Edmonton, Canada
Division of Cardiology, University of British Columbia, Vancouver, Canada
Faculty of Nursing, University of Alberta, Edmonton, Canada
¶ Division of General Internal Medicine, University of Calgary, Calgary, Canada
# Division of Cardiology, University of Calgary, Calgary, Canada
Manuscript received March 1, 2004;
revised manuscript received June 15, 2004,
accepted June 22, 2004.
* Reprint requests and correspondence: Dr. Finlay A. McAlister, 2E3.24 WMC, University of Alberta Hospital, 8440 112th Street, Edmonton, Alberta, Canada T6G 2R7
(Email: Finlay.McAlister{at}ualberta.ca).
OBJECTIVES: This study was designed to examine the use of cardiovascular medications and outcomes in patients with heart failure (HF) and renal dysfunction.
BACKGROUND: Renal insufficiency is associated with poorer outcomes in patients with HF, but the mechanisms are uncertain. In particular, the degree of therapeutic nihilism in these patients, and whether it is appropriate, is unclear.
METHODS: This was a prospective cohort study with a one-year follow-up.
RESULTS: In 6,427 patients with cardiologist-diagnosed HF and angiographically proven coronary artery disease (mean age 69 years; 65% men; one-year mortality, 10%), 39% had creatinine clearances <60 ml/min. Patients with renal insufficiency were less likely to be prescribed angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, statins, or aspirin (all p < 0.001). However, users of aspirin (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.57 to 0.85), statins (OR 0.79, 95% CI 0.64 to 0.97), and beta-blockers (OR 0.75, 95% CI 0.62 to 0.90) were less likely to die in the subsequent 12 months than nonusers, irrespective of renal function (all OR adjusted for covariates including atherosclerotic burden and ejection fraction). Although ACE inhibitor users with creatinine clearances  60 ml/min had lower 12-month mortality (OR 0.72, 95% CI 0.48 to 0.99), ACE inhibitor users with clearances <60 ml/min did not (OR 1.21, 95% CI 0.97 to 1.51).
CONCLUSIONS: Renal insufficiency is common in patients with HF and coronary artery disease, and these patients have more advanced coronary atherosclerosis. Patients with renal insufficiency are less likely to be prescribed efficacious therapies, but have better outcomes if they receive these medications.
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Abbreviations and Acronyms
| | ACE = angiotensin-converting enzyme | | CAD = coronary artery disease | | CI = confidence interval | | HF = heart failure | | LV = left ventricular | | OR = odds ratio |
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