Researchers at Baylor Scott & White recently co-authored a paper published in CardioRenal Medicine addressing RAASi applications for acute heart failure patients.
The renin-angiotensin-aldosterone system’s (RAAS) central role in the pathophysiology of both acute and chronic heart failure is well documented. The current body of work includes significant data related to the use of inhibitors to modulate the system in chronic heart failure cases. However, there is far less clarity surrounding the application of RAAS inhibitors (RAASi) in acute heart failure cases to inform care practices.
The study authors, including Peter McCullough, MD and Aaron Kluger, MPH at Baylor Scott & White, first outlined available data and guidelines related to the initiation, continuation, and withdrawal of four specific RAASi. Each of the four, angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), angiotensin receptor neprilysin inhibitors(ARNi)/valsartan, and mineralocorticoid receptor antagonists (MRA), are part of the RAAS-targeting guideline-directed medical therapy portfolio currently in place for heart failure patients. A detailed integration of the relevant aspects of the physiology of RAAS in acute heart failure was also applied to the evaluation.
The authors then used the overall analysis to inform an opinion-based decision-making pathway that could help cardiologists and nephrologists treating acute heart failure patients enhance clinical practice and optimize patient outcomes at various stages of disease progression. Conclusions reflected in the authors’ analysis include:
- There is strong evidence supporting the benefits of RAASi with respect to mortality, readmissions, and rehospitalization rates in acute heart failure patients
- Premature RAASi discontinuation based on anticipated renal complications may cause acute heart failure patients to lose the advantages such interventions provide
- Further trials are needed to address the question of titration of RAASi in patients with heart failure and kidney disease