The impact of renin-angiotensin-aldosterone system blockade on heart failure outcomes and mortality in patients identified to have aortic regurgitation

a large population cohort study

Douglas H. J. Elder, Li Wei, Benjamin R. Szwejkowski, Renata Libianto, Adnan Nadir, Maheshwar Pauriah, Sushma Rekhraj, Tiong K. Lim, Jacob George, Alex Doney, Stuart D. Pringle, Anna-Maria Choy, Allan D. Struthers, Chim C. Lang

    Research output: Contribution to journalArticle

    33 Citations (Scopus)

    Abstract

    Objectives The aim of this study was to investigate the effect of renin-angiotensin system blockade on outcomes in patients with aortic regurgitation (AR).

    Background Angiotensin-converting enzyme (ACE) inhibitors have the potential to reduce afterload, blunt left ventricular wall stress, and limit left ventricular dilation and hypertrophy. However, long-term studies have yielded inconsistent results, and very few have assessed clinical outcomes.

    Methods The Health Informatics Centre dispensed prescription and morbidity and mortality database for the population of Tayside, Scotland, was linked through a unique patient identifier to the Tayside echocardiography database. Patients diagnosed with at least moderate AR from 1993 to 2008 were identified. Cox regression analysis was used to assess differences in all-cause mortality and cardiovascular (CV) and AR events (heart failure hospitalizations, heart failure deaths, or aortic valve replacement) between those treated with and without ACE inhibitors or angiotensin receptor blockers (ARBs).

    Results A total of 2,266 subjects with AR (median age 74 years; interquartile range: 64 to 81 years) were studied, with a mean follow-up period of 4.4 +/- 3.7 years. Seven hundred and five patients (31%) received ACE inhibitor or ARB therapy. There were 582 all-cause deaths (25.7%). Patients treated with ACE inhibitors or ARBs had significantly lower all-cause mortality and fewer CV and AR events, with adjusted hazard ratios of 0.56 (95% confidence interval [CI]: 0.64 to 0.89; p < 0.01) for all-cause mortality, 0.77 (95% CI: 0.67 to 0.89; p < 0.01) for CV events, and 0.68 (95% CI: 0.54 to 0.87; p < 0.01) for AR events.

    Conclusions This large retrospective study shows that the prescription of ACE inhibitors or ARBs in patients with moderate to severe AR was associated with significantly reduced all-cause mortality and CV and AR events. These data need to be confirmed by a prospective randomized controlled outcome trial. (J Am Coll Cardiol 2011;58:2084-91) (C) 2011 by the American College of Cardiology Foundation

    Original languageEnglish
    Pages (from-to)2084-2091
    Number of pages8
    JournalJournal of the American College of Cardiology
    Volume58
    Issue number20
    DOIs
    Publication statusPublished - Nov 2011

    Keywords

    • Angiotensin-converting enzyme inhibitors
    • Angiotensin receptor blockers
    • Aortic regurgitation
    • Converting enzyme inhibitor
    • Term vasodilator therapy
    • Chronic volume overload
    • Asymptomatic patients
    • Mitral regurgitation
    • Myocardial infarction
    • Valve regurgitation
    • Left ventricle
    • Insufficiecy
    • Nifedipine

    Cite this

    Elder, Douglas H. J. ; Wei, Li ; Szwejkowski, Benjamin R. ; Libianto, Renata ; Nadir, Adnan ; Pauriah, Maheshwar ; Rekhraj, Sushma ; Lim, Tiong K. ; George, Jacob ; Doney, Alex ; Pringle, Stuart D. ; Choy, Anna-Maria ; Struthers, Allan D. ; Lang, Chim C. / The impact of renin-angiotensin-aldosterone system blockade on heart failure outcomes and mortality in patients identified to have aortic regurgitation : a large population cohort study. In: Journal of the American College of Cardiology. 2011 ; Vol. 58, No. 20. pp. 2084-2091.
    @article{26ba51b775eb489b9faefdff11472883,
    title = "The impact of renin-angiotensin-aldosterone system blockade on heart failure outcomes and mortality in patients identified to have aortic regurgitation: a large population cohort study",
    abstract = "Objectives The aim of this study was to investigate the effect of renin-angiotensin system blockade on outcomes in patients with aortic regurgitation (AR).Background Angiotensin-converting enzyme (ACE) inhibitors have the potential to reduce afterload, blunt left ventricular wall stress, and limit left ventricular dilation and hypertrophy. However, long-term studies have yielded inconsistent results, and very few have assessed clinical outcomes.Methods The Health Informatics Centre dispensed prescription and morbidity and mortality database for the population of Tayside, Scotland, was linked through a unique patient identifier to the Tayside echocardiography database. Patients diagnosed with at least moderate AR from 1993 to 2008 were identified. Cox regression analysis was used to assess differences in all-cause mortality and cardiovascular (CV) and AR events (heart failure hospitalizations, heart failure deaths, or aortic valve replacement) between those treated with and without ACE inhibitors or angiotensin receptor blockers (ARBs).Results A total of 2,266 subjects with AR (median age 74 years; interquartile range: 64 to 81 years) were studied, with a mean follow-up period of 4.4 +/- 3.7 years. Seven hundred and five patients (31{\%}) received ACE inhibitor or ARB therapy. There were 582 all-cause deaths (25.7{\%}). Patients treated with ACE inhibitors or ARBs had significantly lower all-cause mortality and fewer CV and AR events, with adjusted hazard ratios of 0.56 (95{\%} confidence interval [CI]: 0.64 to 0.89; p < 0.01) for all-cause mortality, 0.77 (95{\%} CI: 0.67 to 0.89; p < 0.01) for CV events, and 0.68 (95{\%} CI: 0.54 to 0.87; p < 0.01) for AR events.Conclusions This large retrospective study shows that the prescription of ACE inhibitors or ARBs in patients with moderate to severe AR was associated with significantly reduced all-cause mortality and CV and AR events. These data need to be confirmed by a prospective randomized controlled outcome trial. (J Am Coll Cardiol 2011;58:2084-91) (C) 2011 by the American College of Cardiology Foundation",
    keywords = "Angiotensin-converting enzyme inhibitors, Angiotensin receptor blockers, Aortic regurgitation, Converting enzyme inhibitor, Term vasodilator therapy, Chronic volume overload, Asymptomatic patients, Mitral regurgitation, Myocardial infarction, Valve regurgitation, Left ventricle, Insufficiecy, Nifedipine",
    author = "Elder, {Douglas H. J.} and Li Wei and Szwejkowski, {Benjamin R.} and Renata Libianto and Adnan Nadir and Maheshwar Pauriah and Sushma Rekhraj and Lim, {Tiong K.} and Jacob George and Alex Doney and Pringle, {Stuart D.} and Anna-Maria Choy and Struthers, {Allan D.} and Lang, {Chim C.}",
    note = "Copyright {\^A}{\circledC} 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.",
    year = "2011",
    month = "11",
    doi = "10.1016/j.jacc.2011.07.043",
    language = "English",
    volume = "58",
    pages = "2084--2091",
    journal = "Journal of the American College of Cardiology",
    issn = "0735-1097",
    publisher = "Elsevier",
    number = "20",

    }

    The impact of renin-angiotensin-aldosterone system blockade on heart failure outcomes and mortality in patients identified to have aortic regurgitation : a large population cohort study. / Elder, Douglas H. J.; Wei, Li; Szwejkowski, Benjamin R.; Libianto, Renata; Nadir, Adnan; Pauriah, Maheshwar; Rekhraj, Sushma; Lim, Tiong K.; George, Jacob; Doney, Alex; Pringle, Stuart D.; Choy, Anna-Maria; Struthers, Allan D.; Lang, Chim C.

    In: Journal of the American College of Cardiology, Vol. 58, No. 20, 11.2011, p. 2084-2091.

    Research output: Contribution to journalArticle

    TY - JOUR

    T1 - The impact of renin-angiotensin-aldosterone system blockade on heart failure outcomes and mortality in patients identified to have aortic regurgitation

    T2 - a large population cohort study

    AU - Elder, Douglas H. J.

    AU - Wei, Li

    AU - Szwejkowski, Benjamin R.

    AU - Libianto, Renata

    AU - Nadir, Adnan

    AU - Pauriah, Maheshwar

    AU - Rekhraj, Sushma

    AU - Lim, Tiong K.

    AU - George, Jacob

    AU - Doney, Alex

    AU - Pringle, Stuart D.

    AU - Choy, Anna-Maria

    AU - Struthers, Allan D.

    AU - Lang, Chim C.

    N1 - Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

    PY - 2011/11

    Y1 - 2011/11

    N2 - Objectives The aim of this study was to investigate the effect of renin-angiotensin system blockade on outcomes in patients with aortic regurgitation (AR).Background Angiotensin-converting enzyme (ACE) inhibitors have the potential to reduce afterload, blunt left ventricular wall stress, and limit left ventricular dilation and hypertrophy. However, long-term studies have yielded inconsistent results, and very few have assessed clinical outcomes.Methods The Health Informatics Centre dispensed prescription and morbidity and mortality database for the population of Tayside, Scotland, was linked through a unique patient identifier to the Tayside echocardiography database. Patients diagnosed with at least moderate AR from 1993 to 2008 were identified. Cox regression analysis was used to assess differences in all-cause mortality and cardiovascular (CV) and AR events (heart failure hospitalizations, heart failure deaths, or aortic valve replacement) between those treated with and without ACE inhibitors or angiotensin receptor blockers (ARBs).Results A total of 2,266 subjects with AR (median age 74 years; interquartile range: 64 to 81 years) were studied, with a mean follow-up period of 4.4 +/- 3.7 years. Seven hundred and five patients (31%) received ACE inhibitor or ARB therapy. There were 582 all-cause deaths (25.7%). Patients treated with ACE inhibitors or ARBs had significantly lower all-cause mortality and fewer CV and AR events, with adjusted hazard ratios of 0.56 (95% confidence interval [CI]: 0.64 to 0.89; p < 0.01) for all-cause mortality, 0.77 (95% CI: 0.67 to 0.89; p < 0.01) for CV events, and 0.68 (95% CI: 0.54 to 0.87; p < 0.01) for AR events.Conclusions This large retrospective study shows that the prescription of ACE inhibitors or ARBs in patients with moderate to severe AR was associated with significantly reduced all-cause mortality and CV and AR events. These data need to be confirmed by a prospective randomized controlled outcome trial. (J Am Coll Cardiol 2011;58:2084-91) (C) 2011 by the American College of Cardiology Foundation

    AB - Objectives The aim of this study was to investigate the effect of renin-angiotensin system blockade on outcomes in patients with aortic regurgitation (AR).Background Angiotensin-converting enzyme (ACE) inhibitors have the potential to reduce afterload, blunt left ventricular wall stress, and limit left ventricular dilation and hypertrophy. However, long-term studies have yielded inconsistent results, and very few have assessed clinical outcomes.Methods The Health Informatics Centre dispensed prescription and morbidity and mortality database for the population of Tayside, Scotland, was linked through a unique patient identifier to the Tayside echocardiography database. Patients diagnosed with at least moderate AR from 1993 to 2008 were identified. Cox regression analysis was used to assess differences in all-cause mortality and cardiovascular (CV) and AR events (heart failure hospitalizations, heart failure deaths, or aortic valve replacement) between those treated with and without ACE inhibitors or angiotensin receptor blockers (ARBs).Results A total of 2,266 subjects with AR (median age 74 years; interquartile range: 64 to 81 years) were studied, with a mean follow-up period of 4.4 +/- 3.7 years. Seven hundred and five patients (31%) received ACE inhibitor or ARB therapy. There were 582 all-cause deaths (25.7%). Patients treated with ACE inhibitors or ARBs had significantly lower all-cause mortality and fewer CV and AR events, with adjusted hazard ratios of 0.56 (95% confidence interval [CI]: 0.64 to 0.89; p < 0.01) for all-cause mortality, 0.77 (95% CI: 0.67 to 0.89; p < 0.01) for CV events, and 0.68 (95% CI: 0.54 to 0.87; p < 0.01) for AR events.Conclusions This large retrospective study shows that the prescription of ACE inhibitors or ARBs in patients with moderate to severe AR was associated with significantly reduced all-cause mortality and CV and AR events. These data need to be confirmed by a prospective randomized controlled outcome trial. (J Am Coll Cardiol 2011;58:2084-91) (C) 2011 by the American College of Cardiology Foundation

    KW - Angiotensin-converting enzyme inhibitors

    KW - Angiotensin receptor blockers

    KW - Aortic regurgitation

    KW - Converting enzyme inhibitor

    KW - Term vasodilator therapy

    KW - Chronic volume overload

    KW - Asymptomatic patients

    KW - Mitral regurgitation

    KW - Myocardial infarction

    KW - Valve regurgitation

    KW - Left ventricle

    KW - Insufficiecy

    KW - Nifedipine

    U2 - 10.1016/j.jacc.2011.07.043

    DO - 10.1016/j.jacc.2011.07.043

    M3 - Article

    VL - 58

    SP - 2084

    EP - 2091

    JO - Journal of the American College of Cardiology

    JF - Journal of the American College of Cardiology

    SN - 0735-1097

    IS - 20

    ER -