Estefania Oliveros1, Ebenezer T Oni2, Anum Shahzad3, Aaron Y Kluger4,5, Kevin Bryan Lo2, Janani Rangaswami2,3, Peter A McCullough4,6,7,8. 1. Mount Sinai Icahn School of Medicine, New York, New York, USA, estefaniaoliveros@gmail.com. 2. Einstein Medical Center, Philadelphia, Pennsylvania, USA. 3. Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA. 4. Baylor Heart and Vascular Institute, Dallas, Texas, USA. 5. Baylor Scott & White Research Institute, Dallas, Texas, USA. 6. Baylor University Medical Center, Dallas, Texas, USA. 7. Baylor Heart and Vascular Hospital, Dallas, Texas, USA. 8. Texas A&M College of Medicine Health Science Center, Dallas, Texas, USA.
Abstract
BACKGROUND: The renin-angiotensin-aldosterone axis plays a pivotal role in the pathophysiology of acute and chronic heart failure (HF) and represents an important target for guideline-directed medical therapy. SUMMARY: The use of appropriate directed medical therapies for inhibition of the renin-angiotensin-aldosterone axis in chronic HF has been the subject of several landmark clinical trials, with high levels of adherence exhibited in the outpatient setting. However, less clarity exists with respect to the initiation, continuation, and cessation of renin-angiotensin-aldosterone system inhibitors (RAASi) in the setting of acute HF and exacerbation of HF necessitating hospitalization. In this review, we summarize relevant aspects of the physiology of the renin-angiotensin-aldosterone axis in acute HF and during decongestion. We also summarize the available evidence for the risks and benefits of initiating and continuing RAASi in acute HF. Key Message: We offer a decision-making pathway for the use of RAASi in the setting of acute HF that would help guide the cardiologist and nephrologist caring for patients with acute HF and cardiorenal syndrome.
BACKGROUND: The renin-angiotensin-aldosterone axis plays a pivotal role in the pathophysiology of acute and chronic heart failure (HF) and represents an important target for guideline-directed medical therapy. SUMMARY: The use of appropriate directed medical therapies for inhibition of the renin-angiotensin-aldosterone axis in chronic HF has been the subject of several landmark clinical trials, with high levels of adherence exhibited in the outpatient setting. However, less clarity exists with respect to the initiation, continuation, and cessation of renin-angiotensin-aldosterone system inhibitors (RAASi) in the setting of acute HF and exacerbation of HF necessitating hospitalization. In this review, we summarize relevant aspects of the physiology of the renin-angiotensin-aldosterone axis in acute HF and during decongestion. We also summarize the available evidence for the risks and benefits of initiating and continuing RAASi in acute HF. Key Message: We offer a decision-making pathway for the use of RAASi in the setting of acute HF that would help guide the cardiologist and nephrologist caring for patients with acute HF and cardiorenal syndrome.