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Background  Guidelines recommend continuation or initiation of guideline‐directed medical therapy, including angiotensin‐converting enzyme inhibitors/angiotensin  II  receptor blockers ( ACE i/ ARB ), in hospitalized patients with heart failure with reduced ejection fraction.    Methods and Results  Using the Get With The Guidelines‐Heart Failure Registry, we linked clinical data from 16 052 heart failure with reduced ejection fraction (ejection fraction ≤40%) patients with Medicare claims data. We divided  ACE i/ ARB ‐eligible patients into 4 categories based on admission and discharge  ACE i/ ARB  use: continued (reference group), started, discontinued, or not started on therapy. A multivariable Cox proportional hazard model was used to determine the association between  ACE i/ ARB  category and outcomes. Most, 90.5%, were discharged on  ACE i/ ARB  (59.6% continued and 30.9% newly started). Of those discharged without  ACE i/ ARB , 1.9% were discontinued, and 7.5% were eligible but not started. Thirty‐day mortality was 3.5% for patients continued and 4.1% for patients started on  ACE i/ ARB . In contrast, 30‐day mortality was 8.8% for patients discontinued (adjusted hazard ratio [ HR  adj ] 1.92; 95%  CI  1.32‐2.81;  P <0.001) and 7.5% for patients not started ( HR  adj  1.50; 95%  CI  1.12‐2.00;  P =0.006). The 30‐day readmission rate was lowest among patients continued or started on therapy. One‐year mortality was 28.2% for patients continued and 29.7% for patients started on  ACE i/ ARB  compared to 41.6% for patients discontinued ( HR  adj  1.35; 95%  CI  1.13‐1.61;  P <0.001) and 41.7% ( HR  adj  1.28; 95%  CI  1.14‐1.43;  P <0.001) for patients not started on therapy.    Conclusions  Compared with continuation, withdrawal of  ACE i/ ARB  during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission, even after adjustment for severity of illness.

journal of the american heart association

Initiation, Continuation, or Withdrawal of Angiotensin‐Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Outcomes in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction