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Outpatient Lisinopril and Losartan Blood Levels are Associated With In-Hospital Acute Kidney Injury Among Patients with Acute Heart Failure
The 22nd Annual Scientific Meeting HFSA treatment in furosemide group (0.27 [-0.07 to 0.61]) and as well as in torsemide group (0.13 [-0.04- 0.31]). There were more patients with improvement of NYHA functional class in the Torsemide group (Risk ratio 0.84 [0.73-0.95], P value 0.02). Conclusion: Torsemide is associated with numerically more drop in the blood pressure and more efficacious in improving NYHA functional class.
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enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB). Despite morbidity and mortality benefits of ACEI/ARBs, these medications may cause transient rise in creatinine and occasionally contribute to hypotension, which in turn may result in acute kidney injury (AKI). Previous studies of AKI in the setting of ACEI/ARBs have not assessed medication levels. Hypothesis: We hypothesized ACEI/ARB plasma levels in/above reference range for patients with AHF treated by intravenous (IV) diuretics would be associated with increased risk of in-hospital AKI compared to undetectable/low ACEI/ARB plasma levels. Methods: From June 2016 to June 2017, adults with AHF were approached for consent. Patients were excluded for: 1) no outpatient ACEI/ARB, 2) systolic blood pressure <90 mm Hg, 3) IV diuretic before enrollment, 4) allergy to furosemide or bumetanide, or 5) any dialysis. Patients were given an initial IV dose of diuretic (2x their daily dose) and received standard clinical care during hospitalization. LC/MS/MS assessed medication plasma levels at ED presentation, before AHF therapy. Standardized plasma concentrations for each medication were computed using the median published reference range. AKI was defined as a rise in creatinine at 48 hours (or at hospital discharge, if unavailable) of 0.3 mg/dL or 1.5x baseline. Results: Mean age for the 37 patients was 65.9 years (sd 14.6), 20 (54.0%) were female, 11 (29.7%) were African American, 10 (32.3%) had an ejection fraction <40%, and 11 (29.8%) did not have detectible ACEI/ARB levels. Of the 5 (13.5%) patients who developed in-hospital AKI, 4 had medications in/above reference range. ACEI/ARB levels were higher for patients with AKI (Figure), and ACEI/ARB levels in/above reference range at the time of ED presentation were associated with an in-hospital rise in creatinine (beta 0.22, 95% confidence interval 0.02-0.42, P=0.03, adjusted for age, sex, and race). Conclusions: Patients with AHF may be more likely to develop AKI in the hospital if they have ACEI/ARB blood levels in/above reference range at ED presentation. Bioanalytical assessment of ACEI/ARB levels may prove useful for guiding in-hospital medical therapy for AHF.
069 A Comparison of Digitalis use on Mortality and Morbidity among Special Populations with Heart Failure Reduced Ejection Fractions James O. Ampadu, Hassan Alkhawam, Tarek Helmy, Elsayed Abo-Salem; Saint Louis University School of Medicine, Saint Louis, MO
068 Outpatient Lisinopril and Losartan Blood Levels are Associated With InHospital Acute Kidney Injury Among Patients with Acute Heart Failure Candace McNaughton1, Sean Collins1, JoAnn Lindenfeld1, J Scott Daniels2, Ryan Morrison2, Thomas Wang1; 1VUMC, Nashville, TN; 2Sano Informed Prescribing, Brentwood, TN Introduction: We report on a novel tandem liquid chromatography mass spectrometry (LC/MS/MS) method for the simultaneous bioanalytical assessment of blood levels for multiple commonly prescribed medications, including angiotensin-converting
Introduction: The DIG trial introduced the benefit of digitalis (dig) in HFrEF, a reduction in HF hospitalizations. However, the study consisted of less than 15% nonwhite patients, making generalizability difficult. Genetic polymorphisms have been described to add variability in drug responses for varying races. No studies have compared outcomes of dig use among races. In this study, we assessed the effect of dig use on the length of hospitalization, readmission rates, and mortality in different racial groups with HFrEF. Method: A retrospective cohort study of 1,047 patients admitted from 2005-2014 with decompensated HFrEF. Patients were split into three groups, Hispanic, African American (AA), and Caucasian. The primary outcomes of interest at 1, 6 and 12 months were length of hospital stay, readmission rates, and overall mortality. Results: Out of 1,047 HFrEF patients, 244 patients were on dig treatment and 803 patients were not. There was racial discordance among groups; AA and Hispanics were more likely to receive dig compared to Caucasians. There was no difference among the Caucasian group with or without dig. Among the Hispanic group who received dig, they had lower ejection fractions (EF), higher 30-day, 6 month, and 1-year readmission rates compared to the non-dig group. Among the AA group, the dig group was composed of lower EF and had lower 30-day, 6 month and 1-year readmission rates compared to non-dig group. However, readmission rates were not statistically significant. Conclusion: Our study concluded that among HFrEF patients, Hispanics had worse outcomes with dig use while Caucasians had no difference. In the AA group, dig use had lower EF but insignificantly lower 30-day, 6 month and 1 year readmission rates. However, our study may suggest benefit in AA. More
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enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB). Despite morbidity and mortality benefits of ACEI/ARBs, these medications may cause transient rise in creatinine and occasionally contribute to hypotension, which in turn may result in acute kidney injury (AKI). Previous studies of AKI in the setting of ACEI/ARBs have not assessed medication levels. Hypothesis: We hypothesized ACEI/ARB plasma levels in/above reference range for patients with AHF treated by intravenous (IV) diuretics would be associated with increased risk of in-hospital AKI compared to undetectable/low ACEI/ARB plasma levels. Methods: From June 2016 to June 2017, adults with AHF were approached for consent. Patients were excluded for: 1) no outpatient ACEI/ARB, 2) systolic blood pressure <90 mm Hg, 3) IV diuretic before enrollment, 4) allergy to furosemide or bumetanide, or 5) any dialysis. Patients were given an initial IV dose of diuretic (2x their daily dose) and received standard clinical care during hospitalization. LC/MS/MS assessed medication plasma levels at ED presentation, before AHF therapy. Standardized plasma concentrations for each medication were computed using the median published reference range. AKI was defined as a rise in creatinine at 48 hours (or at hospital discharge, if unavailable) of 0.3 mg/dL or 1.5x baseline. Results: Mean age for the 37 patients was 65.9 years (sd 14.6), 20 (54.0%) were female, 11 (29.7%) were African American, 10 (32.3%) had an ejection fraction <40%, and 11 (29.8%) did not have detectible ACEI/ARB levels. Of the 5 (13.5%) patients who developed in-hospital AKI, 4 had medications in/above reference range. ACEI/ARB levels were higher for patients with AKI (Figure), and ACEI/ARB levels in/above reference range at the time of ED presentation were associated with an in-hospital rise in creatinine (beta 0.22, 95% confidence interval 0.02-0.42, P=0.03, adjusted for age, sex, and race). Conclusions: Patients with AHF may be more likely to develop AKI in the hospital if they have ACEI/ARB blood levels in/above reference range at ED presentation. Bioanalytical assessment of ACEI/ARB levels may prove useful for guiding in-hospital medical therapy for AHF.
069 A Comparison of Digitalis use on Mortality and Morbidity among Special Populations with Heart Failure Reduced Ejection Fractions James O. Ampadu, Hassan Alkhawam, Tarek Helmy, Elsayed Abo-Salem; Saint Louis University School of Medicine, Saint Louis, MO
068 Outpatient Lisinopril and Losartan Blood Levels are Associated With InHospital Acute Kidney Injury Among Patients with Acute Heart Failure Candace McNaughton1, Sean Collins1, JoAnn Lindenfeld1, J Scott Daniels2, Ryan Morrison2, Thomas Wang1; 1VUMC, Nashville, TN; 2Sano Informed Prescribing, Brentwood, TN Introduction: We report on a novel tandem liquid chromatography mass spectrometry (LC/MS/MS) method for the simultaneous bioanalytical assessment of blood levels for multiple commonly prescribed medications, including angiotensin-converting
Introduction: The DIG trial introduced the benefit of digitalis (dig) in HFrEF, a reduction in HF hospitalizations. However, the study consisted of less than 15% nonwhite patients, making generalizability difficult. Genetic polymorphisms have been described to add variability in drug responses for varying races. No studies have compared outcomes of dig use among races. In this study, we assessed the effect of dig use on the length of hospitalization, readmission rates, and mortality in different racial groups with HFrEF. Method: A retrospective cohort study of 1,047 patients admitted from 2005-2014 with decompensated HFrEF. Patients were split into three groups, Hispanic, African American (AA), and Caucasian. The primary outcomes of interest at 1, 6 and 12 months were length of hospital stay, readmission rates, and overall mortality. Results: Out of 1,047 HFrEF patients, 244 patients were on dig treatment and 803 patients were not. There was racial discordance among groups; AA and Hispanics were more likely to receive dig compared to Caucasians. There was no difference among the Caucasian group with or without dig. Among the Hispanic group who received dig, they had lower ejection fractions (EF), higher 30-day, 6 month, and 1-year readmission rates compared to the non-dig group. Among the AA group, the dig group was composed of lower EF and had lower 30-day, 6 month and 1-year readmission rates compared to non-dig group. However, readmission rates were not statistically significant. Conclusion: Our study concluded that among HFrEF patients, Hispanics had worse outcomes with dig use while Caucasians had no difference. In the AA group, dig use had lower EF but insignificantly lower 30-day, 6 month and 1 year readmission rates. However, our study may suggest benefit in AA. More