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RENAL INSUFFICIENCY AND HEART FAILURE

Renal insufficiency as an independent predictor of mortality among women with heart failure

Kirsten Bibbins-Domingo, PhD, MD^*,,*, Feng Lin, MS, Eric Vittinghoff, PhD, Elizabeth Barrett-Connor, MD, Deborah Grady, MD, MPH^, and Michael G. Shlipak, MD, MPH^,

^* Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco
Department of Epidemiology and Biostatistics, University of California, San Francisco
Department of Family and Preventive Medicine, University of California, San Diego
Section of General Internal Medicine, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California, USA

Manuscript received June 3, 2004; revised manuscript received June 29, 2004, accepted July 16, 2004.

^* Reprint requests and correspondence: Dr. Kirsten Bibbins-Domingo, Box 1364, San Francisco General Hospital, University of California at San Francisco, San Francisco, California 94143-1364 (Email: bibbinsk{at}medicine.ucsf.edu).

OBJECTIVES: We sought to explore the association between renal insufficiency and mortality among women with heart failure (HF) and to evaluate this risk by the presence of preserved or depressed systolic function.

BACKGROUND: Although HF is common in older women, little is known about their risk factors for mortality.

METHODS: This prospective cohort study retrospectively analyzed data from the Heart and Estrogen/progestin Replacement Study (HERS). Of the 2,763 women in HERS, 702 had HF. Renal function was categorized as creatinine clearance (CrCl) >60 ml/min, 40 to 60 ml/min, and <40 ml/min. We used proportional hazards models to evaluate the association between renal insufficiency and mortality.

RESULTS: Over a mean 5.8 years, 228 women with HF died (32%). Renal insufficiency was strongly associated with mortality, even after adjustment for co-morbid conditions, systolic function, and medications (adjusted hazard ratio [HR] 1.53, 95% confidence interval [CI] 1.09 to 2.16 for CrCl 40 to 60 ml/min; adjusted HR 2.40, 95% CI 1.60 to 3.62 for CrCl <40 ml/min). Preserved or depressed systolic function did not modify the association between renal insufficiency and mortality risk, but the use of angiotensin-converting enzyme (ACE) inhibitors did modify this risk (ACE users: adjusted HR = 0.9, 95% CI 0.6 to 1.6; ACE nonusers: adjusted HR 2.1, 95% CI 1.3 to 3.2; p = 0.02 for interaction). Compared with other risk factors for mortality, renal insufficiency had the highest population attributable risk (27%).

CONCLUSIONS: Renal insufficiency was a major predictor of mortality among women with HF and preserved or depressed systolic function. This risk was attenuated by the use of ACE inhibitors.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   CI = confidence interval   CrCl = creatinine clearance   ECG = electrocardiogram/electrocardiographic   HERS = Heart and Estrogen/progestin Replacement Study   HF = heart failure   HR = hazard ratio   LVEF = left ventricular ejection fraction   NYHA = New York Heart Association

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