RAAS inhibition/blockade in patients with cardiovascular disease: implications of recent large-scale randomised trials for clinical practice

Prognostic Impact of Angiotensin-Converting Enzyme Inhibitors and Receptor Blockers on Recurrent Ventricular Tachyarrhythmias and Implantable Cardioverter-Defibrillator Therapies

This study sought to assess the prognostic impact of treatment with angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) on recurrences of ventricular tachyarrhythmias in recipients of implantable cardioverter-defibrillators (ICD). Using a large retrospective registry including consecutive ICD recipients with documented episodes of ventricular tachycardia (VT) or fibrillation (VF) from 2002 to 2016, those patients treated with ACEi/ARB were compared with patients without. The primary prognostic endpoint was the first recurrence of ventricular tachyarrhythmias and related ICD therapies at 5 years. Multivariable Cox regression analyses were applied within the entire cohort, and thereafter, Kaplan-Meier analyses were performed in propensity-matched subgroups. A total of 592 consecutive ICD recipients were included (81% treated with ACEi/ARB and 19% without). Although ACEi/ARB was associated with no differences in overall recurrence of ventricular tachyarrhythmias, ACEi/ARB was associated with improved freedom from appropriate ICD therapy within multivariable Cox regressions (hazard ratio = 0.666; P = 0.043), especially in patients with index episodes of VF, left ventricular ejection fraction <35%, coronary artery disease, secondary preventive ICD, and glomerular filtration rate <45 mL/min/1.73 m. In the propensity-matched subgroup, ACEi/ARB still prolonged freedom from appropriate ICD therapies (hazard ratio = 0.380; 95% confidence interval 0.193-0.747; P = 0.005). In conclusion, ACEi/ARB therapy was associated with improved freedom from appropriate ICD therapies.

Tolerability of angiotensin-receptor blockers in patients with intolerance to angiotensin-converting enzyme inhibitors: a systematic review and meta-analysis

BACKGROUND

Between 5% and 20% of patients treated with angiotensin-converting enzyme inhibitors (ACE inhibitors) develop intolerance. Angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) can be used as an alternative treatment.

OBJECTIVE

In this study we aimed to evaluate the tolerability of ARBs in patients with intolerance to ACE inhibitors.

DATA SOURCES

The electronic databases PubMed, MEDLINE/EMBASE via Dialog, CENTRAL, and ISI Web of Knowledge were searched.

STUDY SELECTION

Randomized controlled trials (RCTs) evaluating ARBs in patients with intolerance to ACE inhibitors were selected.

DATA SYNTHESIS

Risk ratio (RR) and 95% confidence intervals (CIs) were estimated assuming the random effects method. We found 11 RCTs comparing ARBs with ACE inhibitors, diuretics, or placebo, and one RCT comparing high-dose versus low-dose ARB.

RESULTS

ARBs had fewer cough events versus ACE inhibitors (RR 0.37; 95% CI 0.28, 0.48). ARBs had drug discontinuation (RR 0.99; 95% CI 0.84, 1.17) and cough risk (RR 1.01; 95% CI 0.74, 1.39) rates similar to placebo. Angioedema risk with ARBs was also similar to placebo (RR 1.62; 95% CI 0.17, 15.79). Compared with placebo, hypotension (RR 2.63; 95% CI 1.77, 3.92), renal dysfunction (RR 2.07; 95% CI 1.45, 2.95) and hyperkalemia (RR 3.37; 95% CI 1.60, 7.11) were more frequent with ARBs.

CONCLUSIONS

ACE inhibitor rechallenge should be discouraged in patients with previous intolerance to ACE inhibitors due to a higher risk of cough. ARBs had cough and angioedema incidences similar to placebo. Despite a significantly higher incidence of hypotension, renal dysfunction and hyperkalemia, discontinuation of ARBs was similar to placebo.

Outpatient management of pediatric heart failure

The management of heart failure in children is becoming a specialized discipline within pediatric cardiology. Unlike the treatment of heart failure in adults, for which an extensive body of literature supports current treatment regimens, management of heart failure in children is largely guided by extrapolation from adult studies and expert opinion. This review focuses on the current state-of-the-art with respect to the outpatient management of heart failure in children.

Predictors of electrical storm recurrences in patients with implantable cardioverter-defibrillators

AIMS

To determine prevalence and predictors of electrical storm recurrences (ES-Rs) in patients with implantable cardioverter-defibrillators (ICDs) as electrical storms (ESs) represent serious clinical events carrying a high risk of mortality.

METHODS AND RESULTS

Single-centre study analysing data of consecutive patients receiving an ICD between 1993 and 2008. Electrical storm was defined as ≥ 3 separate ventricular tachyarrhythmic (VT/VF) episodes ≤ 24 h. Nine hundred and fifty-five patients [mean left ventricular ejection fraction (LVEF) 35.7 ± 15.6%] were prospectively followed for 54.2 ± 35.5 months. In 274 of 955 patients (28.7%), 2871 VT/VF episodes were observed. One hundred and fifty-three ES episodes occurred in 63 of 955 patients (6.6%). Thirty-two of 63 patients (50.8%) experienced ≥ 2 ES episodes. Twenty-six of 32 patients (81.2%) with ES-Rs experienced the second ES episode within 1 year after the initial event. Cox regression analysis identified an LVEF ≤ 30% (OR 2.2; 95% CI 1.021-4.856; P = 0.044) and a patient's age >65 years (OR 3.5; 95% CI 1.207-10.176; P = 0.021) to be predictive for ES-Rs. Patients with angiotensin-converting enzyme (ACE) inhibitor therapy were less likely to experience ES-Rs (OR 0.39; 95% CI 0.187-0.817; P = 0.013).

CONCLUSIONS

Electrical storm events are not rare in a 'real-world' patient population with ICDs (6.6% in 4.5 years). The risk for ES-Rs, especially within the first year after the initial event, is high. Left ventricular ejection fraction ≤ 30%, age >65 years, and a lack of ACE inhibitor therapy are independent predictors of ES-R.