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Plasma renin activity, response to aliskiren, and clinical outcomes in patients hospitalized for heart failure: the ASTRONAUT trial
Author(s) -
Vaduganathan Muthiah,
Cheema Baljash,
Cleveland Erin,
Sankar Kamya,
Subacius Haris,
Fonarow Gregg C.,
Solomon Scott D.,
Lewis Eldrin F.,
Greene Stephen J.,
Maggioni Aldo P.,
Böhm Michael,
Zannad Faiez,
Butler Javed,
Gheorghiade Mihai
Publication year - 2018
Publication title -
european journal of heart failure
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 5.149
H-Index - 133
eISSN - 1879-0844
pISSN - 1388-9842
DOI - 10.1002/ejhf.973
Subject(s) - aliskiren , medicine , hazard ratio , plasma renin activity , interquartile range , confidence interval , heart failure , cardiology , quartile , proportional hazards model , placebo , clinical endpoint , ejection fraction , renin–angiotensin system , randomized controlled trial , blood pressure , alternative medicine , pathology
Aims The direct renin inhibitor, aliskiren, is known to reduce plasma renin activity (PRA), but whether the efficacy of aliskiren varies based on an individual's baseline PRA in patients hospitalized for heart failure (HF) is presently unknown. We characterized the prognostic value of PRA and determined if this risk is modifiable with use of aliskiren. Methods and results This pre‐specified neurohormonal substudy of ASTRONAUT analysed all patients hospitalized for HF with ejection fraction (EF) ≤40% with available baseline PRA data ( n = 1306, 80.9%). Risk associated with baseline PRA and short‐term changes in PRA from baseline to 1 month was modelled with respect to 12‐month clinical events. Median baseline PRA was 3.0 (interquartile range 0.6–16.4) ng/mL/h. Aliskiren significantly reduced PRA early after treatment initiation through 12‐month follow‐up compared with placebo ( P < 0.001). The lowest baseline PRA quartile (<0.6 ng/mL/h) was independently predictive of lower all‐cause mortality [adjusted hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.31–0.81] and the composite of cardiovascular mortality and HF hospitalization (adjusted HR 0.57, 95% CI 0.40–0.79). Delta log‐normalized PRA (from baseline to 1 month) was not predictive of either primary endpoint at 12 months ( P ≥ 0.43). The prognostic value of baseline PRA and short‐term changes in PRA did not vary by randomization to aliskiren or placebo (interaction P ≥ 0.13). Conclusions Plasma renin activity is reduced early and durably by aliskiren, but this did not translate into improved clinical outcomes in ASTRONAUT. Baseline PRA or short‐term reduction in PRA do not identify a subgroup who may preferentially benefit from direct renin inhibition. Clinical Trial Registration ClinicalTrials.gov Unique Identifier: NCT00894387