Ali Ahmed, MD, MPH
Grant Support: Dr. Ahmed is supported by a National Institute of Health Mentored Patient-Oriented Research Career Development Award (1-K23-AG19211-01).
Ahmed A. Use of Angiotensin-Converting Enzyme Inhibitors in Heart Failure and Renal Insufficiency. Ann Intern Med. 2004;140:931-932. doi: 10.7326/0003-4819-140-11-200406010-00020
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Published: Ann Intern Med. 2004;140(11):931-932.
TO THE EDITOR:
We agree with Shlipak (1) that it is difficult to determine the efficacy of angiotensin-converting enzyme (ACE) inhibitors in patients with heart failure and renal insufficiency on the basis of subgroup analysis of data from randomized, controlled trials of ACE inhibitors in heart failure. However, data from retrospective follow-up studies suggest that ACE inhibitors are equally or more beneficial in patients with heart failure and renal insufficiency (2-4). Our group has demonstrated that use of ACE inhibitors was associated with lower 1-year mortality rates in patients with heart failure and perceived contraindications to ACE inhibitors (adjusted hazard ratio, 0.34 [95% CI, 0.14 to 0.81]). Renal insufficiency (serum creatinine concentration ≥ 221 µmol/L [≥ 2.5 mg/dL]) was the most common condition perceived as a contraindication (56%). In patients with acute myocardial infarction and left ventricular systolic dysfunction who also had renal insufficiency (serum creatinine concentration ≥ 265 µmol/L [≥ 3 mg/dL]), use of ACE inhibitors was associated with lower 1-year mortality rates (adjusted hazard ratio, 0.63 [CI, 0.48 to 0.84]) (3). In another study, in patients with heart failure who were treated with ACE inhibitors, the odds for 6-month mortality were similar for those with normal renal function (adjusted odds ratio, 0.75 [CI, 0.50 to 1.13]) and those with renal insufficiency (serum creatinine concentration ≥ 177 µmol/L [≥ 2 mg/dL]) (adjusted odds ratio, 0.90 [CI, 0.43 to 1.82]) (4). These data are consistent with Shlipak's conclusion (1) and with the American College of Cardiology/American Heart Association guidelines regarding the use of ACE inhibitors in patients with heart failure and renal insufficiency (5).
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