Continuation of chronic heart failure therapies during heart failure hospitalization—a review
Open accessAbstract
Randomized controlled trials have demonstrated the benefits of guideline-directed medical therapy in the outpatient setting for treatment of chronic heart failure. However, the benefits of continuation (or discontinuation) of major chronic heart failure therapies when treating acute heart failure during hospitalization are less clear. Real and anticipated worsening renal function, hyperkalemia and hypotension are the three major reasons for discontinuation of renin-angiotensin-aldosterone system inhibitors during hospitalization, and a failure to resume renin-angiotensin-aldosterone system inhibitors before discharge could worsen cardiovascular outcomes. Available data, mostly observational, shows that continuation or initiation of renin-angiotensin-aldosterone system inhibitors appears efficacious, safe, and well tolerated in majority of acute heart failure patients during hospitalization. Worsening renal function portends poor prognosis only if associated with congestion in acute heart failure, and clinicians should not de-escalate diuretic therapy routinely for worsening renal function.
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Stopping RAS blockers or reducing the RAS blocker dose has been associated with increased risk of cardiovascular events in observational studies.
“stopping RAS blockers or reducing the RAS blocker dose has been associated with increased risk of cardiovascular events in observational studies. 72,73”
From KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (2022) · cites this paper as [73]
The review reports that, in an observational heart-failure registry, stopping ACE inhibitors or ARBs at discharge was associated with higher mortality and a higher one-year composite of mortality or readmission. It also discusses dose reduction, but the dose-reduction study it describes reports longer hospital stays, not increased cardiovascular events. The evidence is therefore narrower than the claim for dose reduction. (LLM, conf=0.84)
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- Authors
- Singhania, G., Ejaz, A. A., McCullough, P. A., Kluger, A. Y., Balamuthusamy, S., Dass, B., Singhania, N., & Agarwal, A.
- Affiliations
- CHI St. Vincent (US)
- University of Florida (US)
- Baylor University Medical Center (US)
- Baylor Scott & White Research Institute (US)
- University of North Texas (US)
- Mount Carmel East (US)
- University of Utah (US)
- Corresponding author
- Singhania, Girish
- ORCID
- Venue
- Reviews in Cardiovascular Medicine
- Publisher
- IMR Press
- Published
- 2019-09-30
- Volume
- 20
- Issue
- 3
- Pages
- 111-120
- ISSN
- 1530-6550 (ISSN-L)
- 2153-8174
- OpenAlex
- W2977742019
- Cited by
- 20
- References
- 25
- Citations by year
- 2026: 1 · 2024: 1 · 2023: 1 · 2022: 2 · 2021: 8 · 2020: 7
- FWCI
- 0.77
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- Reviews in Cardiovascular Medicine (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Electrolyte and hormonal disorders
- Health Sciences › Medicine › Nephrology › Acute Kidney Injury Research
- Keywords
- chronic heart failure, acute heart failure, heart failure hospitalization, guideline-directed medical therapy, renin-angiotensin-aldosterone system inhibitors, worsening renal function, hyperkalemia, hypotension, fluid congestion, hospital discharge
- MeSH terms
- Clinical Decision-Making, Angiotensin-Converting Enzyme Inhibitors, Diuretics, Drug Administration Schedule, Heart Failure, Humans, Patient Admission, Renin-Angiotensin System, Risk Factors, Treatment Outcome, Angiotensin Receptor Antagonists, Cardio-Renal Syndrome
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