Abstract
BACKGROUND: Evidence regarding the prognostic impact of angiotensin-converting enzyme inhibitors (ACEi) vs. receptor blockers (ARB) in heart failure with mildly reduced ejection fraction (HFmrEF) is limited. METHODS: We retrospectively studied consecutive patients hospitalized with HFmrEF from 2016 until 2022 at a German university hospital. The prognostic impact of treatment with ACEi compared with ARB was investigated regarding the primary endpoint of all-cause mortality at 30 months. The key secondary endpoint was heart failure (HF)-related rehospitalization. RESULTS: A total of 1,551 patients discharged on renin-angiotensin system inhibitors (ACEi: n = 1,055; ARB: n = 496) were included. Patients treated with ARB were older and had a higher burden of comorbidities. All-cause mortality at 30 months occurred in 251/1,055 (23.8%) patients treated with ACEi and in 147/496 (29.6%) patients treated with ARB [unadjusted hazard ratio [HR] = 0.762, 95% confidence interval [CI] 0.622-0.934; log-rank p = 0.009]. After multivariable adjustment, ACEi were still associated with improved long-term survival (adjusted HR = 0.786, 95% CI: 0.625-0.989; p = 0.040). This association was still found after propensity score matching (n = 440 per group) (23.2% vs. 29.5%; HR = 0.749, 95% CI: 0.578-0.971; p = 0.029). In contrast, the risk of HF-related rehospitalization at 30 months did not differ between the two groups in the unmatched cohort (12.7% vs. 14.5%; HR = 0.849, 95% CI: 0.638-1.130; p = 0.262) and after propensity score matching (16.1% vs. 14.8%; HR = 1.080, 95% CI: 0.772-1.512; p = 0.653). CONCLUSIONS: In patients hospitalized with HFmrEF, ACEi therapy was associated with reduced 30-month all-cause mortality compared with ARB, whereas the risk of HF-related rehospitalization did not differ.