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Sacubitril/valsartan vs ACEi/ARB at hospital discharge and 5-year survival in older patients with heart failure with reduced ejection fraction: A decision analysis approach.
- Source :
-
American heart journal [Am Heart J] 2022 Aug; Vol. 250, pp. 23-28. Date of Electronic Publication: 2022 May 04. - Publication Year :
- 2022
-
Abstract
- Background: In clinical trials, sacubitril/valsartan has demonstrated significant survival benefits compared to angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEi/ARB). Whether older patients with heart failure with reduced ejection fraction (HFrEF) benefit as much, due to higher rates of comorbidities, frailty and drug discontinuation, is unknown.<br />Methods and Results: Using a cohort of Medicare beneficiaries hospitalized with HFrEF between 2016 and 2018, we determined all-cause mortality and HF-readmission rates among patients not given ACEi/ARB or sacubitril/valsartan at hospital discharge, by age. We then used risk reductions from the SOLVD, PARADIGM-HF and PIONEER-HF trials to estimate the benefits of ACEi/ARB and sacubitril/valsartan. We then incorporated age-specific estimates of drug discontinuation from Medicare. A Markov decision process model was used to simulate 5-year survival and estimate number needed to treat, comparing discharge on ACEi/ARB vs sacubitril/valsartan by age. After accounting for drug discontinuation rates, which were surprisingly slightly higher among those discharged on ACEi/ARB (2.3%/month vs 1.9%/month), there was a small but significant survival advantage to discharge on sacubitril/valsartan over 5 years (+0.81 months [95% CI 0.80, 0.81]). The benefit of sacubitril/valsartan over ACEi/ARB did not decrease with increasing age - the number needed to treat among 66 to 74-year-old patients was 84 and among 85+ year-old patients was 67.<br />Conclusions: Even after accounting for "real world" rates of drug discontinuation, discharge on sacubitril/valsartan after conferred a small, but significant, survival advantage which does not appear to wane with increasing age.<br /> (Copyright © 2022 Elsevier Inc. All rights reserved.)
- Subjects :
- Aged
Aged, 80 and over
Aminobutyrates therapeutic use
Angiotensin Receptor Antagonists therapeutic use
Angiotensin-Converting Enzyme Inhibitors therapeutic use
Biphenyl Compounds therapeutic use
Decision Support Techniques
Drug Combinations
Humans
Medicare
Patient Discharge
Stroke Volume physiology
Survival Analysis
United States epidemiology
Valsartan therapeutic use
Heart Failure drug therapy
Heart Failure physiopathology
Subjects
Details
- Language :
- English
- ISSN :
- 1097-6744
- Volume :
- 250
- Database :
- MEDLINE
- Journal :
- American heart journal
- Publication Type :
- Editorial & Opinion
- Accession number :
- 35525261
- Full Text :
- https://doi.org/10.1016/j.ahj.2022.04.007