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Background  Our objective is to estimate the effects associated with higher rates of renin‐angiotensin system antagonists, angiotensin‐converting enzyme inhibitors and angiotensin receptor blockers ( ACEI / ARB s), in secondary prevention for geriatric (aged >65 years) patients with new ischemic strokes by chronic kidney disease ( CKD ) status.    Methods and Results  The effects of  ACEI / ARB s on survival and renal risk were estimated by  CKD  status using an instrumental variable ( IV ) estimator. Instruments were based on local area variation in  ACEI / ARB  use. Data abstracted from charts were used to assess the assumptions underlying the instrumental estimator.  ACEI / ARB s were used after stroke by 45.9% and 45.2% of  CKD  and non‐ CKD  patients, respectively.  ACEI / ARB  rate differences across local areas grouped by practice styles were nearly identical for  CKD  and non‐ CKD  patients. Higher  ACEI / ARB  use rates for non‐ CKD  patients were associated with higher 2‐year survival rates, whereas higher  ACEI / ARB  use rates for patients with  CKD  were associated with lower 2‐year survival rates. While the negative survival estimates for patients with  CKD  were not statistically different from zero, they were statistically lower than the estimates for non‐ CKD  patients. Confounders abstracted from charts were not associated with the instrumental variable used.    Conclusions  Higher  ACEI / ARB  use rates had different survival implications for older ischemic stroke patients with and without  CKD .  ACEI / ARB s appear underused in ischemic stroke patients without  CKD  as higher use rates were associated with higher 2‐year survival rates. This conclusion is not generalizable to the ischemic stroke patients with  CKD , as higher  ACEI / ARBS  use rates were associated with lower 2‐year survival rates that were statistically lower than the estimates for non‐ CKD  patients.

Use of Angiotensin‐Converting Enzyme Inhibitors and Angiotensin Receptor Blockers for Geriatric Ischemic Stroke Patients: Are the Rates Right?