Prognostic impact of RAASi and MRA Use in de novo HFrEF Patients with Renal Dysfunction and Hyperkalemia: Insights from the COEDO-AHF Registry"

Abstract Introduction Optimal medical therapy has been shown to improve prognosis in heart failure. (HF) patients, but its implementation in real-world clinical practice remains suboptimal. In particular, the use of renin-angiotensin-aldosterone system inhibitors (RAASI), including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and angiotensin receptor-neprilysin inhibitors, as well as mineralocorticoid receptor antagonists (MRA), is often restricted due to concems about renal dysfunction and hyperkalemia, leading to a low prescription rate. Purpose This study aimed to evaluate the clinical benefits of prescribing RAASI and MRA in patients with chronic kidney disease (CKD) and/or hyperkalemia (HK). Methods This was a single-center, retrospective observational study using the COEDO-AHF registry, which included consecutive hospitalized patients with heart failure. We extracted patients with de novo HF and left ventricular ejection fraction (LVEF) 4.5 mEq/L) at discharge. Then, patients with CKD and/or HK were further divided into three subgroups according to the prescription of RAASi and MRA at discharge: (1) Both RAASi and MRA, (2) Either RAASI or MRA, and (3) Neither RAASI nor MRA. The primary endpoint was a composite of all-cause death, rehospitalization for HF, or worsening HF requiring an increase in diuretic dosage. Results A total of 249 de novo HF patients with LVEF 50% were included in the study. Patients with CKD and/or HK had worse prognoses compared to those without CKD or HK (Figure A, Log-rank p=0.03). Among patients with CKD and/or HK, significant differences were observed among the three treatment groups. Patients who received both RAASi and MRA had a better prognosis than those in the other two groups (Figure B, Log-rank p=0.015). Conclusion Patients with CKD and/or HK represent a high-risk population. Our findings suggest that prescribing both RAASi and MRA in these patients is associated with better prognoses, highlighting the importance of optimizing medical therapy despite concerns about renal dysfunction and hyperkalemia.