Hemodialysis: ACE Inhibitors, ARBs and Cardiovascular Death
Hemodialysis: ACE Inhibitors, ARBs and Cardiovascular Death
To compare the relative effectiveness of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in reducing cardiovascular mortality in chronic hemodialysis patients, we conducted an observational analysis of all patients initiated on ACEI or ARB therapy undergoing chronic hemodialysis at a large dialysis provider. Survival curves with mortality hazard ratios (HRs) were generated using the Kaplan–Meier method and Cox regression. Outcomes were compared using inverse probability of treatment weighting and propensity score matching. Over 6 years, 22,800 patients were newly initiated on an ACEI and 5828 on an ARB after at least 60 days of chronic hemodialysis. After adjustment for baseline cardiovascular risk factors, there was no significant difference in the risk of cardiovascular, all-cause, or cerebrovascular mortality in patients initiated on an ARB compared with an ACEI (HR of 0.96). A third of 28,628 patients, newly started on an ACEI or ARB, went on to another antihypertensive medication in succession. After adjustment for risk factors, 701 patients initiated on combined ACEI and ARB therapy (HR of 1.45) or 6866 patients on ACEI and non-ARB antihypertensive agent (HR of 1.27) were at increased risk of cardiovascular death compared with 1758 patients initiated on an ARB and non-ACEI antihypertensive therapy. Thus, an ARB, in combination with another antihypertensive medication (but not an ACEI), may have a beneficial effect on cardiovascular mortality. As observational studies may be confounded by indication, even when adjusted, randomized clinical trials are needed to confirm these findings.
More than 20,000 patients on maintenance dialysis are expected to die from cardiovascular disease this year. The risk of cardiovascular events in end-stage renal disease (ESRD) is 3.4-fold higher than that of the general population. Although risk factors for coronary artery disease (CAD), such as diabetes and hypertension, are prevalent among ESRD patients, conventional risk factors alone fail to explain all of the excess cardiovascular mortality in epidemiological studies. Furthermore, modification of these risk factors has not been shown so far to be effective in reducing cardiovascular risk in ESRD. Consequently, there is a need to evaluate alternate therapies that could potentially moderate cardiovascular disease progression in the dialysis population.
Both angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin type 1 (AT1) receptor blockers (ARBs) reduce cardiovascular events within the general population. The comparative effectiveness of ACEIs and ARBs in reducing cardiovascular mortality in patients at risk for cardiovascular disease is currently controversial, as is the efficacy of combined ACEI and ARB therapy.
Even less is known about the relative efficacy and safety of ACEIs and ARBs in ESRD, as only a few studies have examined the individual efficacy of ACEIs or ARBs versus no treatment. There have been no comparative effectiveness studies between ACEIs and ARBs in the ESRD patient population to date, despite the widespread prescription of these drugs among dialysis patients.
To compare the effects of ACEIs and ARBs on cardiovascular mortality in chronic hemodialysis (CHD) patients, we conducted an observational analysis of outcomes in all patients undergoing CHD at a large dialysis provider, who were initiated on therapy with an ACEI, ARB, or both an ACEI and an ARB.
Abstract and Introduction
Abstract
To compare the relative effectiveness of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in reducing cardiovascular mortality in chronic hemodialysis patients, we conducted an observational analysis of all patients initiated on ACEI or ARB therapy undergoing chronic hemodialysis at a large dialysis provider. Survival curves with mortality hazard ratios (HRs) were generated using the Kaplan–Meier method and Cox regression. Outcomes were compared using inverse probability of treatment weighting and propensity score matching. Over 6 years, 22,800 patients were newly initiated on an ACEI and 5828 on an ARB after at least 60 days of chronic hemodialysis. After adjustment for baseline cardiovascular risk factors, there was no significant difference in the risk of cardiovascular, all-cause, or cerebrovascular mortality in patients initiated on an ARB compared with an ACEI (HR of 0.96). A third of 28,628 patients, newly started on an ACEI or ARB, went on to another antihypertensive medication in succession. After adjustment for risk factors, 701 patients initiated on combined ACEI and ARB therapy (HR of 1.45) or 6866 patients on ACEI and non-ARB antihypertensive agent (HR of 1.27) were at increased risk of cardiovascular death compared with 1758 patients initiated on an ARB and non-ACEI antihypertensive therapy. Thus, an ARB, in combination with another antihypertensive medication (but not an ACEI), may have a beneficial effect on cardiovascular mortality. As observational studies may be confounded by indication, even when adjusted, randomized clinical trials are needed to confirm these findings.
Introduction
More than 20,000 patients on maintenance dialysis are expected to die from cardiovascular disease this year. The risk of cardiovascular events in end-stage renal disease (ESRD) is 3.4-fold higher than that of the general population. Although risk factors for coronary artery disease (CAD), such as diabetes and hypertension, are prevalent among ESRD patients, conventional risk factors alone fail to explain all of the excess cardiovascular mortality in epidemiological studies. Furthermore, modification of these risk factors has not been shown so far to be effective in reducing cardiovascular risk in ESRD. Consequently, there is a need to evaluate alternate therapies that could potentially moderate cardiovascular disease progression in the dialysis population.
Both angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin type 1 (AT1) receptor blockers (ARBs) reduce cardiovascular events within the general population. The comparative effectiveness of ACEIs and ARBs in reducing cardiovascular mortality in patients at risk for cardiovascular disease is currently controversial, as is the efficacy of combined ACEI and ARB therapy.
Even less is known about the relative efficacy and safety of ACEIs and ARBs in ESRD, as only a few studies have examined the individual efficacy of ACEIs or ARBs versus no treatment. There have been no comparative effectiveness studies between ACEIs and ARBs in the ESRD patient population to date, despite the widespread prescription of these drugs among dialysis patients.
To compare the effects of ACEIs and ARBs on cardiovascular mortality in chronic hemodialysis (CHD) patients, we conducted an observational analysis of outcomes in all patients undergoing CHD at a large dialysis provider, who were initiated on therapy with an ACEI, ARB, or both an ACEI and an ARB.