Renal Insufficiency and Heart Failure: Prognostic and Therapeutic Implications From a Prospective Cohort Study
Background-The prevalence, prognostic import, and impact of renal insufficiency on the benefits of ACE inhibitors and ␤-blockers in community-dwelling patients with heart failure are uncertain. Methods and Results-We analyzed data from a prospective cohort of 754 patients with heart failure who had ejection fraction, serum creatinine, and weight measured at baseline. Median age was 69 years, and 43% had an ejection fraction Ն35%. By the Cockcroft-Gault equation, 118 patients (16%) had
... (16%) had creatinine clearances Յ30 mL/min and 301 (40%) had creatinine clearances between 30 and 59 mL/min. During follow-up (median 926 days), 385 patients (37%) died. Even after adjustment for all other prognostic factors, survival was significantly associated with renal function (Pϭ0.002) in patients with either systolic or diastolic dysfunction; patients exhibited a 1% increase in mortality for each 1-mL/min decrease in creatinine clearance. The associations with 1-year mortality reductions were similar for ACE inhibitors (OR 0.46 [95% CI 0.26 to 0.82] versus OR 0.28 [95% CI 0.11 to 0.70]) and ␤-blockers (OR 0.40 [95% CI 0.23 to 0.70] versus OR 0.41 [95% CI 0.19 to 0.85]) in patients with creatinine clearances Ͻ60 mL/min versus Ն60 mL/min, although these drugs were used less frequently in patients with renal insufficiency. Conclusions-Renal insufficiency is more prevalent in patients with heart failure than previously reported and is an independent prognostic factor in diastolic and systolic dysfunction. ACE inhibitors and ␤-blockers were associated with similar reductions in mortality in patients with and without renal insufficiency.