A propensity score analysis of the impact of angiotensin-converting enzyme inhibitors on long-term survival of older adults with heart failure and perceived contraindications

Objectives The purpose of this study is to determine the association between discharge use of angiotensin-converting enzyme (ACE) inhibitors in patients with perceived contraindications to these drugs and 4-year post-discharge survival among hospitalized older adults discharged alive with a primary discharge diagnosis of systolic heart failure. Background Perceived contraindications to the use of ACE inhibitors are often associated with underuse of these life-saving drugs. Methods Chronic renal insufficiency, hypotension, hyperkalemia, and severe aortic stenosis were conditions perceived as contraindications. Using a multivariable logistic regression model, we at first determined propensity scores for receipt of ACE inhibitors for each patient. Bivariate and multivariable Cox proportional hazard analyses were used to determine crude and adjusted risks of 4-year mortality compared with patients without perceived contraindications who were discharged on an ACE inhibitor (referent group). Results Compared with the referent group, patients with perceived contraindications who were not discharged on an ACE inhibitor had a significant 2-fold increase in the risk of 4-year mortality (adjusted hazard ratio [HR] = 2.33, 95% CI = 1.30-4.19). Patients with perceived contraindications who were discharged on ACE inhibitors had a non significant 23% higher risk of 4-year mortality (versus the referent group) (adjusted HR = 1.23, 95% CI = 0.71-2.13). Conclusion Discharge use of ACE inhibitors was associated with significant long-term survival benefit in patients considered to have contraindication to these drugs.