Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement

Importance: Data are lacking on the effect of a renin-angiotensin system (RAS) inhibitor prescribed after transcatheter aortic valve replacement (TAVR). Treatment with a RAS inhibitor may reverse left ventricular remodeling and improve function. Objective: To investigate the association of prescription of a RAS inhibitor and outcomes after TAVR. Design, Setting, and Participants: Retrospective cohort study of TAVR procedures performed in the United States (using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry) between July 2014 and January 2016 that were linked to Medicare claims data (final date of follow-up: March 31, 2017). To account for differences in demographics, echocardiographic findings, and in-hospital complications, 1:1 propensity matching was performed. Exposures: Initial hospital discharge prescription of a RAS inhibitor after TAVR. Main Outcomes and Measures: Primary outcomes were all-cause death and readmission due to heart failure at 1 year after discharge, which were considered separately. The secondary outcome was health status assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ; score range: 0-100, with a higher score indicating less symptom burden and better quality of life; a small effect size was defined as 5 points) at 1 year. Results: Among 21 312 patients who underwent TAVR at 417 US sites, 8468 patients (39.7%) were prescribed a RAS inhibitor at hospital discharge. After propensity matching, 15 896 patients were included (mean SD age, 82.4 6.8 years; 48.1% were women; mean SD left ventricular ejection fraction LVEF, 51.9% 11.5%). Patients with a prescription for a RAS inhibitor vs those with no prescription had lower mortality rates at 1 year (12.5% vs 14.9%, respectively; absolute risk difference ARD, -2.4% 95% CI, -3.5% to -1.4%; hazard ratio HR, 0.82 95% CI, 0.76 to 0.90) and lower heart failure readmission rates at 1 year (12.0% vs 13.8%; ARD, -1.8% 95% CI, -2.8% to -0.7%; HR, 0.86 95% CI, 0.79 to 0.95). When stratified by LVEF, having a prescription for a RAS inhibitor vs no prescription was associated with lower 1-year mortality among patients with preserved LVEF (11.1% vs 13.9%, respectively; ARD, -2.81% 95% CI, -3.95% to -1.67%; HR, 0.78 95% CI, 0.71 to 0.86), but not among those with reduced LVEF (18.8% vs 19.5%; ARD, -0.68% 95% CI, -3.52% to 2.20%; HR, 0.95 95% CI, 0.81 to 1.12) (P = .04 for interaction). Of 15 896 matched patients, 4837 (30.4%) were included in the KCCQ score analysis and improvements at 1 year were greater in patients with a prescription for a RAS inhibitor vs those with no prescription (median, 33.3 interquartile range, 14.2 to 51.0 vs 31.3 interquartile range, 13.5 to 51.1, respectively; difference in improvement, 2.10 95% CI, 0.10 to 4.06; P < .001), but the effect size was not clinically meaningful. Conclusions and Relevance: Among patients who underwent TAVR, receiving a prescription for a RAS inhibitor at hospital discharge compared with no prescription was significantly associated with a lower risk of mortality and heart failure readmission. However, due to potential selection bias, this finding requires further investigation in randomized trials.