Division of Cardiology, McClure 1, University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401 USA.
J Invasive Cardiol. 2021 Aug;33(8):E662-E669. doi: 10.25270/jic/20.00619.
To identify renin-angiotensin system (RAS) inhibition utilization and discontinuation after transcatheter aortic valve replacement (TAVR) and identify predictors of use and discontinuation.
RAS inhibition after TAVR has been associated with lower cardiac mortality and heart failure readmissions.
We analyzed 735 consecutive TAVR patients (2014-2019) who survived to hospital discharge at a high-volume TAVR center to determine the utilization and discontinuation of RAS inhibition after TAVR and identify predictors of use and discontinuation. Clinical characteristics, procedural variables, and hospital outcomes were compared between patients receiving vs not receiving discharge RAS inhibitors. Data were compared using t-test and Chi-square test. Multivariable analysis was used to determine independent clinical predictors.
Of the 735 patients, 41.9% were discharged with at least 1 RAS inhibitor. In TAVR patients with heart failure with reduced ejection fraction (HFrEF), defined as EF ≤40%, the utilization of RAS inhibitors at discharge was 51.1%. Patients receiving discharge RAS inhibitors had lower incidences of acute kidney injury (AKI) post procedure (8.1% vs 17.8%; P<.01). Discontinuation of RAS inhibition was observed in approximately 1 in 3 patients and was associated with AKI and pacemaker requirement. Three predictors of RAS inhibitor utilization were higher systolic blood pressure, RAS inhibitor use prior to TAVR, and HFrEF. Conversely, new pacemaker and AKI were associated with less utilization of RAS inhibitors; patients developing AKI were 74% less likely to receive RAS inhibitors than those without AKI.
Decreased RAS inhibition provides a potential mechanism for worse outcomes in TAVR patients who develop AKI.
确定经导管主动脉瓣置换术（TAVR）后肾素-血管紧张素系统（RAS）抑制的使用和停用情况，并确定使用和停用的预测因素。
TAVR 后 RAS 抑制与较低的心脏死亡率和心力衰竭再入院率相关。
我们分析了在一家高容量 TAVR 中心存活至出院的 735 例连续 TAVR 患者（2014-2019 年），以确定 TAVR 后 RAS 抑制的使用和停用情况，并确定使用和停用的预测因素。比较了接受和不接受出院 RAS 抑制剂的患者的临床特征、手术变量和医院结局。使用 t 检验和卡方检验比较数据。采用多变量分析确定独立的临床预测因素。
在 735 例患者中，有 41.9%的患者出院时至少使用了 1 种 RAS 抑制剂。在射血分数（EF）≤40%的心力衰竭伴射血分数降低（HFrEF）的 TAVR 患者中，出院时使用 RAS 抑制剂的比例为 51.1%。接受出院 RAS 抑制剂的患者术后急性肾损伤（AKI）的发生率较低（8.1% vs. 17.8%；P<.01）。大约 1/3 的患者停用了 RAS 抑制剂，且与 AKI 和起搏器需求相关。RAS 抑制剂使用的三个预测因素是较高的收缩压、TAVR 前使用 RAS 抑制剂和 HFrEF。相反，新的起搏器和 AKI 与 RAS 抑制剂的使用减少相关；发生 AKI 的患者接受 RAS 抑制剂的可能性比没有 AKI 的患者低 74%。
AKI 发生的 TAVR 患者 RAS 抑制减少提供了预后较差的潜在机制。
