Neurohormonal blockade therapy was found to be associated with improved 4-year survival and quality of life (QoL) after 2 years of treatment in patients with left ventricular assist devices (LVADs), according to study results published in JAMA Cardiology.
LVADs improve outcomes in patients with stage D heart failure, however, there are limited data on the impact of neurohormonal blockade in this population. As neurohormonal blockade has been associated with substantial improvements in long- and short-term clinical outcomes in patients with heart failure with reduced ejection fraction, the investigators examined whether this treatment would also improve clinical outcomes in patients with LVADs. This retrospective cohort analysis was conducted on data from the Interagency Registry for Mechanically Assisted Circulatory Support, which included 12,144 adult patients with continuous-flow LVADs who underwent implantation between 2008 and 2016 and were still alive with the device in place, 6 months after surgery. Patients were stratified into groups based on exposure to the following neurohormonal blockade treatments: angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEis/ARBs), β-blockers (BBs), and mineralocorticoid receptor antagonists (MRAs). The primary outcome was survival from 6 months to 4 years after LVAD implantation, and the secondary outcome were QoL, as defined by the Kansas City Cardiomyopathy Questionnaire, and a 6-minute walk test, both, from baseline to 2 years.
Of the 12,144 patients included in the study, 10,419 (85.8%) were taking neurohormonal blockade treatment 6 months after receiving an LVAD. At the 6-month follow-up, 1967 patients (16.2%) were receiving all 3 medication classes. There were 2741 patients (22.6%) taking a BB and an ACEi/ARB, 1200 patients (9.8%) taking a BB and an MRA, 541 patients (4.5%) taking an ACEi/ARB and an MRA, 2359 patients (19.4%) using a BB, 1035 patients (8.5%) using an ACEi/ARB, and 576 patients (4.7%) using an MRA. A total of 1725 patients (14.2%) did not receive neurohormonal blockade.
The estimated 4-year survival rate for patients receiving neurohormonal blockade was 56% (95% CI, 54.5%-57.5%) compared with 43.9% (95% CI, 40.5%-47.7%) for patients who did not receive neurohormonal blockade (P <.001). Patients who received triple therapy (ie, ACEi/ARB, BB, and MRA) at 6 months had the longest survival estimate at 4 years (66.4%; 95% CI, 63.1%-70.0%). The use of this triple therapy compared with other medication groups was associated with improved survival (hazard ratio, 0.34; 95% CI, 0.28-0.41; P <.001) in a sensitivity analysis. The average Kansas City Cardiomyopathy Questionnaire score at 2 years for patients who received neurohormonal blockade was 66.6 (bootstrapped 95% CI, 65.8-67.3) vs 63 (bootstrapped 95% CI, 60.1-65.8) for patients who did not receive NHB (P =.02). The average 6-minute walk test at 2 years for patients who received neurohormonal blockade was 1103 feet (bootstrapped 95% CI, 1084-1123 feet) vs 987 feet (bootstrapped 95% CI, 913-1060 feet) for patients who did not receive neurohormonal blockade (P <.001).
Study limitations include that differences in prescribing patterns and outcomes unique to each LVAD center were not taken into account due to lack of site-level data in sensitivity analyses, and the fact that changes in medication exposure over time were associated with the clinical status of each patient, which limited time-varying covariate analysis. ”This large, nationwide analysis of patients undergoing LVAD implant demonstrates an association between varying combinations of [heart failure] therapies and patient-centered outcomes,” concluded the study authors.
Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
McCullough M, Caraballo C, Ravindra NG, et al. Neurohormonal blockade and clinical outcomes in patients with heart failure supported by left ventricular assist devices [published online November 18, 2019]. JAMA Cardiol. doi: 10.1001/jamacardio.2019.4965