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Heart Failure Patients With Renal Insufficiency Often Undermedicated: Presented at HF

By Paula Moyer

HELSINKI, FINLAND -- June 22, 2006 -- Patients with congestive heart failure who also have renal insufficiency often receive less than optimal doses of their heart failure medications, according to investigators who presented their findings here at the Heart Failure Congress of the European Society of Cardiology (HF).

French investigators conducted the study because of their awareness that chronic renal insufficiency is associated with a poor prognosis in patients with chronic heart failure, and that they renal insufficiency diagnosis could be associated with a reduced likelihood that a patient would be receiving heart failure medication that was proven to be effective.

They reviewed data from a survey conducted by cardiologists in France and involving 1,917 stable outpatients with congestive heart failure. Patients were an average of 70 years old and had an average left ventricular ejection fraction (LVEF) of 33%. Almost all patients (95%) had class II to IV heart failure using according to New York Heart Association (NYHA) criteria.

Renal insufficiency was defined as a creatinine level >220 mcmol/L. Using this definition, a total of 249 of the 1,917 patients (13%) had renal insufficiency.

Among those with renal insufficiency, 58% were taking ACE inhibitors compared with 73% of those with adequate renal function (P < .0001). Similarly, 58% of those with renal insufficiency were taking beta blockers compared with 66% of those with adequate renal function (P < .01).

A similar proportion of patients in each group were on angiotensin receptors blockers (22% vs 20%, respectively).

However, more patients with adequate renal function were on an ACE inhibitor, an ARB, or both, compared with those who had renal insufficiency (93%vs 79%, P < .01). And more patients with adequate renal function than those with renal insufficiency were on an ACE inhibitor or an ARB as well as a beta clocker (63% vs 48%, P < .01).

On the other hand, 92% of those with renal insufficiency were on loop and thiazide diuretics compared to 82% of those with normal renal function (P < .01).

As was expected, those with renal insufficiency were less likely to be on spironolactone; monotherapy compared with those with normal renal function (21% vs 37%, P < .01). Within this group, 12% of those with renal insufficiency were on spironolactone along with ACE inhibitors or ARBs compared with 22% of those with normal renal function (P = .0008).

Renal insufficiency was associated with lower doses of ACE inhibitors, ARBs, spironolactone, and beta blockers, although the difference was not statistically significant. Renal insufficiency was also associated with a significantly lower dose of carvedilol (17.5 mg for those with renal insufficiency vs 26.6 mg for those with normal renal function, P = .03).

The odds ratio for use of ACE inhibitors in renal insufficiency was 0.51; the OR was 0.54 for spironolactone, and it was 2.16 for diuretics.

"We found that renal failure is a predictor of underuse of classes of drugs that are recommended for heart failure," said senior investigator Michel Komajda, MD, professor of cardiology, Hôpital Pitié-Salpêtrière, Paris, France.

"Although spironolactone is a concern in such patients, we were surprised that angiotensin-converting enzyme (ACE) inhibitors are also underused in such patients," Dr. Komajda said in his presentation on June 19^th.


[Presentation title: Chronic Renal Insufficiency Is Associated With an Underuse of Recommended Heart Failure Therapies. Abstract 530]

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