2
|
Adverse Events After Initiating Angiotensin-Converting Enzyme Inhibitor/Angiotensin II Receptor Blocker Therapy in Individuals with Heart Failure and Multimorbidity. Am J Med 2022; 135:1468-1477. [PMID: 36058306 DOI: 10.1016/j.amjmed.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Current clinical practice guidelines recommend routine kidney function and serum potassium testing within 30 days of initiating angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) therapy. However, evidence is lacking on whether routine follow-up testing reduces therapy-related adverse events in adults with heart failure and if multimorbidity influences the association between laboratory testing and these adverse events. METHODS We conducted a retrospective cohort study among adults with heart failure from 4 US integrated health care delivery systems. Multimorbidity was defined using counts of chronic conditions. Patients with outpatient serum creatinine and potassium tests in the 30 days after starting ACEI or ARB therapy were matched 1:1 to patients without follow-up tests. We evaluated the association of follow-up testing with 30-day all-cause mortality and hospitalization with acute kidney injury or hyperkalemia using Cox regression. RESULTS We identified 3629 matched adults with heart failure initiating ACEI or ARB therapy between January 1, 2005, and December 31, 2012. Follow-up testing was not significantly associated with 30-day all-cause mortality (adjusted hazard ratio [aHR] 0.45, 95% confidence interval [CI] 0.14; 1.39) and hospitalization with hyperkalemia (aHR 0.73, 95% CI, 0.33; 1.61). However, follow-up testing was significantly associated with hospitalization with acute kidney injury (aHR, 1.40, 95% CI, 1.01; 1.94). Interaction between multimorbidity burden and follow-up testing was not statistically significant in any of the outcome models examined. CONCLUSIONS Routine laboratory monitoring after ACEI or ARB therapy initiation was not associated with risk of 30-day all-cause mortality or hospitalization with hyperkalemia across the spectrum of multimorbidity burden in a cohort of patients with heart failure.
Collapse
|
3
|
Parikh RV, Nash DM, Brimble KS, Markle-Reid M, Tan TC, McArthur E, Khoshniat-Rad F, Sood MM, Zheng S, Pravoverov L, Nesrallah GE, Garg AX, Go AS. Kidney Function and Potassium Monitoring After Initiation of Renin-Angiotensin-Aldosterone System Blockade Therapy and Outcomes in 2 North American Populations. Circ Cardiovasc Qual Outcomes 2020; 13:e006415. [PMID: 32873054 DOI: 10.1161/circoutcomes.119.006415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical practice guidelines recommend routine kidney function and serum potassium testing within 30 days of initiating ACE (angiotensin-converting enzyme) inhibitor or angiotensin II receptor blocker therapy. However, evidence is lacking about whether follow-up testing reduces therapy-related adverse outcomes. METHODS AND RESULTS We conducted 2 population-based retrospective cohort studies in Kaiser Permanente Northern California and Ontario, Canada. Patients with outpatient serum creatinine and potassium tests in the 30 days after starting ACE inhibitor or angiotensin II receptor blocker therapy were matched 1:1 to patients without follow-up tests. We evaluated the association of follow-up testing with 30-day all-cause mortality and hospitalization with acute kidney injury or hyperkalemia using Cox regression. We also developed and externally validated a risk score to identify patients at risk of having abnormally high serum creatinine and potassium values in follow-up. We identified 75 251 matched pairs initiating ACE inhibitor or angiotensin II receptor blocker therapy between January 1, 2007, and December 31, 2017, in Kaiser Permanente Northern California. Follow-up testing was not significantly associated with 30-day all-cause mortality in Kaiser Permanente Northern California (hazard ratio, 0.75 [95% CI, 0.54-1.06]) and was associated with higher mortality in 84 905 matched pairs in Ontario (hazard ratio, 1.32 [95% CI, 1.07-1.62]). In Kaiser Permanente Northern California, follow-up testing was significantly associated with higher rates of hospitalization with acute kidney injury (hazard ratio, 1.66 [95% CI, 1.10-2.22]) and hyperkalemia (hazard ratio, 3.36 [95% CI, 1.08-10.41]), as was observed in Ontario. The risk score for abnormal potassium provided good discrimination (area under the curve [AUC], 0.75) and excellent calibration of predicted risks, while the risk score for abnormal serum creatinine provided moderate discrimination (AUC, 0.62) but excellent calibration. CONCLUSIONS Routine laboratory monitoring after ACE inhibitor or angiotensin II receptor blocker initiation was not associated with a lower risk of 30-day mortality. We identified patient subgroups in which targeted testing may be effective in identifying therapy-related changes in serum potassium or kidney function.
Collapse
Affiliation(s)
- Rishi V Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland (R.V.P., T.C.T., F.K.-R., A.S.G.)
| | - Danielle M Nash
- ICES, Ontario, Canada (D.M.N., E.M., M.M.S., A.X.G.).,Department of Health Research Methods, Evidence, and Impact (D.M.N., M.M.-R., A.X.G.), McMaster University, Hamilton, Ontario, Canada.,Ontario Renal Network, Toronto, Canada (D.M.N., G.E.N., A.X.G.)
| | - K Scott Brimble
- Department of Medicine (K.S.B.), McMaster University, Hamilton, Ontario, Canada
| | - Maureen Markle-Reid
- Department of Health Research Methods, Evidence, and Impact (D.M.N., M.M.-R., A.X.G.), McMaster University, Hamilton, Ontario, Canada.,School of Nursing (M.M.-R.), McMaster University, Hamilton, Ontario, Canada
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland (R.V.P., T.C.T., F.K.-R., A.S.G.)
| | - Eric McArthur
- ICES, Ontario, Canada (D.M.N., E.M., M.M.S., A.X.G.)
| | - Farzien Khoshniat-Rad
- Division of Research, Kaiser Permanente Northern California, Oakland (R.V.P., T.C.T., F.K.-R., A.S.G.)
| | - Manish M Sood
- ICES, Ontario, Canada (D.M.N., E.M., M.M.S., A.X.G.).,Division of Nephrology, University of Ottawa, Ontario, Canada (M.M.S.)
| | - Sijie Zheng
- Nephrology Service Line, The Permanente Medical Group (S.Z., L.P.).,Department of Nephrology, Kaiser Permanente Oakland Medical Center, CA (S.Z., L.P.)
| | - Leonid Pravoverov
- Nephrology Service Line, The Permanente Medical Group (S.Z., L.P.).,Department of Nephrology, Kaiser Permanente Oakland Medical Center, CA (S.Z., L.P.)
| | - Gihad E Nesrallah
- Ontario Renal Network, Toronto, Canada (D.M.N., G.E.N., A.X.G.).,Humber River Hospital, Toronto, Ontario, Canada (G.E.N.).,Department of Medicine, University of Toronto, Ontario, Canada (G.E.N.)
| | - Amit X Garg
- ICES, Ontario, Canada (D.M.N., E.M., M.M.S., A.X.G.).,Department of Health Research Methods, Evidence, and Impact (D.M.N., M.M.-R., A.X.G.), McMaster University, Hamilton, Ontario, Canada.,Ontario Renal Network, Toronto, Canada (D.M.N., G.E.N., A.X.G.).,Department of Medicine, Western University, London, Ontario, Canada (A.X.G.)
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland (R.V.P., T.C.T., F.K.-R., A.S.G.).,Departments of Epidemiology (A.S.G.).,Biostatistics (A.S.G.).,Medicine (A.S.G.).,University of California, San Francisco (A.S.G.).,Department of Medicine (Nephrology) and Health Research and Policy, Stanford University School of Medicine, CA (A.S.G.)
| |
Collapse
|
4
|
Fu EL, Trevisan M, Clase CM, Evans M, Lindholm B, Rotmans JI, van Diepen M, Dekker FW, Carrero JJ. Association of Acute Increases in Plasma Creatinine after Renin-Angiotensin Blockade with Subsequent Outcomes. Clin J Am Soc Nephrol 2019; 14:1336-1345. [PMID: 31395593 PMCID: PMC6730502 DOI: 10.2215/cjn.03060319] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 07/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Data from observational and interventional studies provide discordant results regarding the relationship between creatinine increase after renin-angiotensin system inhibition (RASi) and adverse outcomes. We compared health outcomes among patients with different categories of increase in creatinine upon initiation of RASi in a large population-based cohort. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective analysis of the Stockholm CREAtinine Measurements database, which contains complete information on diagnoses, medication dispensation claims, and laboratory test results for all Stockholm citizens accessing health care. Included were 31,951 adults initiating RASi during 2007-2011 with available pre- and postinitiation creatinine monitoring. Multivariable Cox regression was used to compare mortality, cardiovascular and ESKD events among individuals with different ranges of creatinine increases within 2 months after starting treatment. RESULTS In a median follow-up of 3.5 years, acute increases in creatinine were associated with mortality (3202 events) in a graded manner: compared with creatinine increases <10%, a 10%-19% increase showed an adjusted hazard ratio (HR) of 1.15 (95% confidence interval [95% CI], 1.05 to 1.27); HR 1.22 (95% CI, 1.07 to 1.40) for 20%-29%; HR 1.55 (95% CI, 1.36 to 1.77) for ≥30%. Similar graded associations were present for heart failure (2275 events, P<0.001) and ESKD (52 events; P<0.001), and, less consistently, myocardial infarction (842 events, P=0.25). Results were robust across subgroups, among continuing users, when patients with decreases in creatinine were excluded from the reference group, and after accounting for death as a competing risk. CONCLUSIONS Among real-world monitored adults, increases in creatinine (>10%) after initiation of RASi are associated with worse health outcomes. These results do not address the issue of discontinuation of RASi when plasma creatinine increases but do suggest that patients with increases in creatinine have higher subsequent risk of cardiovascular and kidney outcomes.
Collapse
Affiliation(s)
- Edouard L Fu
- Departments of Clinical Epidemiology and .,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Catherine M Clase
- Department of Medicine and.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; and
| | - Marie Evans
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Joris I Rotmans
- Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| |
Collapse
|
6
|
Schmidt M, Mansfield KE, Bhaskaran K, Nitsch D, Sørensen HT, Smeeth L, Tomlinson LA. Adherence to guidelines for creatinine and potassium monitoring and discontinuation following renin-angiotensin system blockade: a UK general practice-based cohort study. BMJ Open 2017; 7:e012818. [PMID: 28069618 PMCID: PMC5223644 DOI: 10.1136/bmjopen-2016-012818] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To examine adherence to serum creatinine and potassium monitoring and discontinuation guidelines following initiation of treatment with ACE inhibitors (ACEI) or angiotensin receptor blockers (ARBs); and whether high-risk patients are monitored. DESIGN A general practice-based cohort study using electronic health records from the UK Clinical Practice Research Datalink and Hospital Episode Statistics. SETTING UK primary care, 2004-2014. SUBJECTS 223 814 new ACEI/ARB users. MAIN OUTCOME MEASURES Proportion of patients with renal function monitoring before and after ACEI/ARB initiation; creatinine increase ≥30% or potassium levels >6 mmol/L at first follow-up monitoring; and treatment discontinuation after such changes. Using logistic regression models, we also examined patient characteristics associated with these biochemical changes, and with follow-up monitoring within the guideline recommendation of 2 weeks after treatment initiation. RESULTS 10% of patients had neither baseline nor follow-up monitoring of creatinine within 12 months before and 2 months after initiation of an ACEI/ARB, 28% had monitoring only at baseline, 15% only at follow-up, and 47% both at baseline and follow-up. The median period between the most recent baseline monitoring and drug initiation was 40 days (IQR 12-125 days). 34% of patients had baseline creatinine monitoring within 1 month before initiating therapy, but <10% also had the guideline-recommended follow-up test recorded within 2 weeks. Among patients experiencing a creatinine increase ≥30% (n=567, 1.2%) or potassium level >6 mmol/L (n=191, 0.4%), 80% continued treatment. Although patients with prior myocardial infarction, hypertension or baseline potassium >5 mmol/L were at high risk of ≥30% increase in creatinine after ACEI/ARB initiation, there was no evidence that they were more frequently monitored. CONCLUSIONS Only one-tenth of patients initiating ACEI/ARB therapy receive the guideline-recommended creatinine monitoring. Moreover, the vast majority of the patients fulfilling postinitiation discontinuation criteria for creatinine and potassium increases continue on treatment.
Collapse
Affiliation(s)
- Morten Schmidt
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Internal Medicine, Regional Hospital of Randers, Denmark
| | - Kathryn E Mansfield
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Krishnan Bhaskaran
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Laurie A Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|