Angiotensin-converting enzyme inhibitor use in older patients with heart failure and renal dysfunction

OBJECTIVE: To examine the relationship between angiotensin-converting enzyme (ACE) inhibitor use and clinical out-comes among recently hospitalized patients with congestive heart failure (CHF) and coexisting renal insufficiency. DESIGN: A prospective cohort study. SETTING: Ten community hospitals in upstate New York, PARTICIPANTS: A total of 1076 hospital survivors identified from a consecutive series of CHF inpatients, MEASUREMENTS: Patients were followed prospectively for 6 months after hospital discharge to track mortality, hospital readmission, and quality of life. Clinical outcomes were stratified by ACE inhibitor use among those with renal dysfunction, defined: as serum creatinine greater than or equal to 2.0 mg/dL, and among the remaining patients, whose serum creatinine was less than or equal to 1.9. RESULTS: ACE inhibitor use was lower among 187 patients with renal dysfunction than among 889 patients with preserved function (41 vs 69%, P < .001), Age and sex were among the significant determinants of drug use in both groups. After adjustment for covariables, ACE inhibitor use among those with abnormal renal function was not associated with a lower risk for death or readmission, or better quality of life, By comparison, ACE inhibition conferred meaningful clinical benefit among those whose creatinine was less than or equal to 1.9 mg/dL, CONCLUSION: Convincing evidence of clinical benefit from ACE inhibitor use is not readily detectable among a sample of 187 unselected older patients with CHF and moderate or severe renal insufficiency. Further studies to identify subsets of this group who might benefit are warranted.