Key result
Discharge RASi linked to ~34% lower 1-year death or HF hospitalization in HFrEF with advanced CKD.
Why the study?
RASi is often underutilized in HFrEF patients with advanced CKD due to concerns about hyperkalemia and worsening renal function, and its efficacy and safety remain uncertain because these patients were excluded from landmark trials.
Does renin-angiotensin system inhibitor (ACE inhibitor or ARB) prescription at discharge reduce the composite of all-cause death and heart failure hospitalization in patients with HFrEF (LVEF <40%) and advanced CKD (eGFR <30 mL/min/1.73 m²)?
Cohort (n=298)
Yes
Does renin-angiotensin system inhibitor (ACE inhibitor or ARB) prescription at discharge reduce the composite of all-cause death and heart failure hospitalization in patients with HFrEF (LVEF <40%) and advanced CKD (eGFR <30 mL/min/1.73 m²)?
In patients with HFrEF and advanced CKD (eGFR <30 mL/min/1.73 m²), discharge prescription of ACE inhibitors or ARBs is independently associated with a lower 1-year risk of all-cause mortality and heart failure hospitalization.
Discharge RASi prescription was associated with lower 1-year composite risk in HFrEF with advanced CKD; leaves open whether randomized trials would confirm benefit.
Background Renin-angiotensin system inhibitor (RASi) represents a cornerstone of guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF). However, RASi is often underutilized in patients with advanced chronic kidney disease (CKD) due to concerns regarding hyperkalemia and worsening renal function. Furthermore, as patients with advanced CKD were excluded from landmark clinical trials, the efficacy and safety of RASi in this specific population remains to be determined. Purpose To evaluate the association between RASi use and clinical outcomes in HFrEF patients with advanced CKD. Methods This was a post-hoc analysis of the Kyoto Congestive Heart Failure (KCHF) registry, a multicenter, prospective observational cohort study that enrolled consecutive patients hospitalized for acute decompensated heart failure in 19 hospitals in Japan between October 2014 and March 2016. Since angiotensin receptor-neprilysin inhibitors (ARNI) were not available in Japan during the study period, RASi was defined as either ACE inhibitor or ARB. The present study included patients with left ventricular ejection fraction (LVEF) of less than 40% and estimated glomerular filtration rate (eGFR) of less than 30ml/min/1.73m2 who were discharged alive. Patients were divided into two groups based on the prescription of RASi at discharge. The primary endpoint was a composite of all-cause death and heart failure hospitalization. Results Among 298 eligible patients, 147 (49.3%) were prescribed RASi at discharge. Baseline characteristics, including age, sex, LVEF, and BNP, were comparable between the two groups. The RASi group had slightly higher eGFR (21.4±6.5 vs. 19.7±6.4 mL/min/1.73 m², p=0.03) and more frequent use of beta-blockers (79.6% vs. 60.8%, p<0.001). The cumulative incidence of the primary endpoint one year after discharge was significantly lower in the RASi group (49.6% vs. 64.8%, p=0.001). After adjusting for potential confounders, RASi use remained independently associated with a reduced risk of the primary endpoint (adjusted hazard ratio 0.66; 95% confidence interval 0.47–0.93; p=0.02). Conclusion In real-world HFrEF patients with advanced CKD, the use of RASi at discharge was independently associated with a significantly lower risk of the composite of all-cause mortality and heart failure hospitalization.
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Tamaki et al. (2026) conducted a cohort in Heart failure with reduced ejection fraction (HFrEF) and advanced chronic kidney disease (CKD) (n=298). Renin-angiotensin system inhibitor (ACE inhibitor or ARB) at discharge vs. No RASi prescription at discharge was evaluated on Composite of all-cause death and heart failure hospitalization (adjusted HR 0.66, 95% CI 0.47-0.93, p=0.02). RASi use at discharge in HFrEF patients with advanced CKD lowered 1-year all-cause death or HF hospitalization (49.6% vs 64.8%; adjusted HR 0.66, 95% CI 0.47-0.93, p=0.02).
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