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Background: The safety of restarting angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) after acute kidney injury (AKI) is unclear. There is concern that previous users do not restart ACEI/ARB despite ongoing indications. We sought to determine the risk of adverse events after an episode of AKI, comparing prior ACEI/ARB users who stop treatment to those who continue.Methods: We conducted two parallel cohort studies in English and Swedish primary and secondary care, 2006-2016. We used multivariable Cox regression to estimate hazard ratios (HR) for hospital admission with heart failure (primary analysis), AKI, stroke, or death within 2 years after hospital discharge following a first AKI episode. We compared risks of admission between people who stopped ACEI/ARB treatment to those who were prescribed ACEI/ARB within 30 days of AKI discharge. We undertook sensitivity analyses, including propensity score-matched samples, to explore the robustness of our results.Results: In England, we included 7303 people with AKI hospitalisation following recent ACEI/ARB therapy for the primary analysis. Four thousand three (55%) were classified as stopping ACEI/ARB based on no prescription within 30 days of discharge. In Sweden, we included 1790 people, of whom 1235 (69%) stopped treatment. In England, no differences were seen in subsequent risk of heart failure (HR 1.10; 95% confidence intervals (CI) 0.93-1.30), AKI (HR 0.90; 95% CI 0.77-1.05), or stroke (HR 0.99; 95% CI 0.71-1.38), but there was an increased risk of death (HR 1.27; 95% CI 1.15-1.41) in those who stopped ACEI/ARB compared to those who continued. Results were similar in Sweden: no differences were seen in risk of heart failure (HR 0.91; 95% CI 0.73-1.13) or AKI (HR 0.81; 95% CI 0.54-1.21). However, no increased risk of death was seen (HR 0.94; 95% CI 0.78-1.13) and stroke was less common in people who stopped ACEI/ARB (HR 0.56; 95% CI 0.34-0.93). Results were similar across all sensitivity analyses.Conclusions: Previous ACEI/ARB users who continued treatment after an episode of AKI did not have an increased risk of heart failure or subsequent AKI compared to those who stopped the drugs. [ABSTRACT FROM AUTHOR]

Objective: To describe adherence to international guidelines for chronic heart failure (CHF) management concerning diagnostics, pharmacological treatment and self-care behaviour in primary health care. Design: A cross-sectional descriptive study of patients with CHF, using data obtained from medical records and a postal questionnaire. Setting: Three primary health care centres in Sweden. Subjects: Patients with a CHF diagnosis registered in their medical record. Main outcome measures: Adherence to recommended diagnostic tests and pharmacological treatment by the European Society of Cardiology guidelines and self-care behaviour, using the European Heart Failure Self-care Behaviour Scale (EHFScBS-9). Results. The 155 participating patients had a mean age of 79 (SD9) years and 89 (57%) were male. An ECG was performed in all participants, 135 (87%) had their NT-proBNP measured, and 127 (82%) had transthoracic echocardiography performed. An inhibitor of the renin angiotensin system (RAS) was prescribed in 120 (78%) patients, however only 45 (29%) in target dose. More men than women were prescribed RAS-inhibition. Beta blockers (BBs) were prescribed in 117 (76%) patients, with 28 (18%) at target dose. Mineralocorticoidreceptor antagonists were prescribed in 54 (35%) patients and daily diuretics in 96 (62%). The recommended combination of RAS-inhibitors and BBs was prescribed to 92 (59%), but only 14 (9%) at target dose. The mean score on the EHFScBS-9 was 29 (SD 6) with the lowest adherence to daily weighing and consulting behaviour. Conclusion: Adherence to guidelines has improved since prior studies but is still suboptimal particularly with regards to medication dosage. There is also room for improvement in patient education and self-care behaviour. [ABSTRACT FROM AUTHOR]

Aims: In heart failure with reduced ejection fraction, drug and device therapy improve survival. We studied contemporary trends in utilization of evidence-based therapy and associated survival.Methods and Results: We studied 5908 patients with NYHA class II-IV heart failure, EF <30%, and duration of heart failure ≥6 months registered in the Swedish Heart Failure Registry between 2003 and 2012. Regression using generalized estimation equations was used to examine temporal trends in crude and risk-adjusted rates of utilization of evidence-based heart failure therapy and 30-day, 1-year, and 3-year survival. In 2003 vs. 2012, the risk-adjusted use of therapy and P-values for trends were as follows: renin-angiotensin system antagonists, 88% vs. 86% (P = 0.091); beta-blockers, 85% vs. 93% (P = 0.008); mineralocorticoid receptor antagonists, 53% vs. 42% (P < 0.001); CRT, 2.4% vs. 8.2% (P = 0.074); and implantable cardioverter-defibrillators, 4.0% vs. 10.7% (P = 0.004). During the same period, the risk-adjusted 30-day, 1-year, and 3-year survival was 92% vs. 94% (P = 0.532), 81% vs. 77% (P = 0.260), and 58% vs. 54% (P = 0.425), respectively.Conclusions: In this large nationwide registry, over the last decade the use of evidence-based drug therapy was high and remained stable over time, but, despite an increased use of device therapy, the absolute use was poor. This was associated with an absence of improvement in survival. The improvements in therapy and prognosis over the last generation may be levelling off, and efforts should be directed at improving implementation of evidence-based therapy. [ABSTRACT FROM AUTHOR]