Michael G. Shlipak, MD, MPH
Grant Support: Dr. Shlipak is funded by a Research Career Development Award from the Health Services Research and Development Service of the Veterans Affairs Administration and by grant RO3 HL68099-01 from the National Institutes of Health.
Acknowledgments: The author thanks Drs. Barry Massie, Glenn Chertow, and Maria Ansari for their helpful comments on this manuscript and Ms. Michelle Odden for her technical assistance.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Michael G. Shlipak, MD, MPH, General Internal Medicine Section, Veterans Affairs Medical Center (111A1), 4150 Clement Street, San Francisco, CA 94121; e-mail, firstname.lastname@example.org.
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.
Table 1. Selected Placebo-Controlled Trials in Patients with Heart Failure: Renal Function of Participants and Medication Efficacy
Table 2. Incidence of Worsened Renal Function with Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin-Receptor Blockers in Patients with Heart Failure
Treatment algorithm for patients with systolic heart failure, based on renal function.GFR
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Shlipak MG. Pharmacotherapy for Heart Failure in Patients with Renal Insufficiency. Ann Intern Med. ;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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