Initiation, Continuation, or Withdrawal of Angiotensin‐Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Outcomes in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

<jats:sec xml:lang="en"> <jats:title>Background</jats:title> <jats:p xml:lang="en"> Guidelines recommend continuation or initiation of guideline‐directed medical therapy, including angiotensin‐converting enzyme inhibitors/angiotensin <jats:styled-content style="fixed-case">II</jats:styled-content> receptor blockers ( <jats:styled-content style="fixed-case">ACE</jats:styled-content> i/ <jats:styled-content style="fixed-case">ARB</jats:styled-content> ), in hospitalized patients with heart failure with reduced ejection fraction. </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Methods and Results</jats:title> <jats:p xml:lang="en"> Using the Get With The Guidelines‐Heart Failure Registry, we linked clinical data from 16 052 heart failure with reduced ejection fraction (ejection fraction ≤40%) patients with Medicare claims data. We divided <jats:styled-content style="fixed-case">ACE</jats:styled-content> i/ <jats:styled-content style="fixed-case">ARB</jats:styled-content> ‐eligible patients into 4 categories based on admission and discharge <jats:styled-content style="fixed-case">ACE</jats:styled-content> i/ <jats:styled-content style="fixed-case">ARB</jats:styled-content> use: continued (reference group), started, discontinued, or not started on therapy. A multivariable Cox proportional hazard model was used to determine the association between <jats:styled-content style="fixed-case">ACE</jats:styled-content> i/ <jats:styled-content style="fixed-case">ARB</jats:styled-content> category and outcomes. Most, 90.5%, were discharged on <jats:styled-content style="fixed-case">ACE</jats:styled-content> i/ <jats:styled-content style="fixed-case">ARB</jats:styled-content> (59.6% continued and 30.9% newly started). Of those discharged without <jats:styled-content style="fixed-case">ACE</jats:styled-content> i/ <jats:styled-content style="fixed-case">ARB</jats:styled-content> , 1.9% were discontinued, and 7.5% were eligible but not started. Thirty‐day mortality was 3.5% for patients continued and 4.1% for patients started on <jats:styled-content style="fixed-case">ACE</jats:styled-content> i/ <jats:styled-content style="fixed-case">ARB</jats:styled-content> . In contrast, 30‐day mortality was 8.8% for patients discontinued (adjusted hazard ratio [ <jats:styled-content style="fixed-case">HR</jats:styled-content> <jats:sub>adj</jats:sub> ] 1.92; 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> 1.32‐2.81; <jats:italic>P</jats:italic> <0.001) and 7.5% for patients not started ( <jats:styled-content style="fixed-case">HR</jats:styled-content> <jats:sub>adj</jats:sub> 1.50; 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> 1.12‐2.00; <jats:italic>P</jats:italic> =0.006). The 30‐day readmission rate was lowest among patients continued or started on therapy. One‐year mortality was 28.2% for patients continued and 29.7% for patients started on <jats:styled-content style="fixed-case">ACE</jats:styled-content> i/ <jats:styled-content style="fixed-case">ARB</jats:styled-content> compared to 41.6% for patients discontinued ( <jats:styled-content style="fixed-case">HR</jats:styled-content> <jats:sub>adj</jats:sub> 1.35; 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> 1.13‐1.61; <jats:italic>P</jats:italic> <0.001) and 41.7% ( <jats:styled-content style="fixed-case">HR</jats:styled-content> <jats:sub>adj</jats:sub> 1.28; 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> 1.14‐1.43; <jats:italic>P</jats:italic> <0.001) for patients not started on therapy. </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Conclusions</jats:title> <jats:p xml:lang="en"> Compared with continuation, withdrawal of <jats:styled-content style="fixed-case">ACE</jats:styled-content> i/ <jats:styled-content style="fixed-case">ARB</jats:styled-content> during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission, even after adjustment for severity of illness. </jats:p> </jats:sec>