Michael G. Shlipak, MD, MPH
Clinical trials have demonstrated that angiotensin-converting enzyme (ACE) inhibitors, -blockers, and spironolactone improve survival in patients with heart failure. Because patients with heart failure and renal insufficiency have been underrepresented in these trials, little evidence is available to guide clinicians in the optimal management of patients with both conditions. Approximately one third to one half of patients with heart failure have renal insufficiency (estimated glomerular filtration rate [GFR] <60 mL/min per 1.73 m2), and renal insufficiency is among the strongest predictors of mortality in patients with heart failure. Evidence supports the use of ACE inhibitors to improve survival in patients with moderate renal insufficiency (GFR, 30 to 60 mL/min per 1.73 m2), but there is little evidence with which to weigh the risks and benefits in patients with more advanced renal dysfunction. -Blockers improve survival in patients with heart failure, and their beneficial effect is unlikely to differ according to renal function. Spironolactone improves outcomes in patients with advanced heart failure, but renal insufficiency appears to increase risk for hyperkalemia and limits the use of the drug in patients with severe renal insufficiency. Future clinical trials in heart failure should include a representative number of patients with renal insufficiency to improve the evidence base and outcomes in this vulnerable population.
Renal function should be categorized by estimated glomerular filtration rate ( ), which can be calculated from the serum creatinine level. Evidence supporting a beneficial effect on clinical outcomes from each medication within subgroups of renal function is evaluated as definite, possible, or unknown by the author. These definitions are based on the range of renal function represented within the clinical trials and the reporting of results specific to patients with renal insufficiency. ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker. *Using Cockcroft–Gault equation or Modification of Diet in Renal Disease formula . †Careful monitoring of renal function and electrolytes. ‡Possibly harmful because of hyperkalemia risk. §Consider withholding therapy during states of volume depletion because of hyperkalemia risk. ‖Shown to help reduce hospitalization but not mortality.
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Shlipak MG. Pharmacotherapy for Heart Failure in Patients with Renal Insufficiency. Ann Intern Med. 2003;138:917-924. doi: 10.7326/0003-4819-138-11-200306030-00013
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Published: Ann Intern Med. 2003;138(11):917-924.
Cardiology, Heart Failure, Nephrology.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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