Abstract Body (Do not enter title and authors here): Aims: This study aimed to explore the comparative effectiveness of sacubitril/valsartan (SV) to renin-angiotensin system (RAS) blockade in patients with concomitant heart failure with reduced ejection fraction (HFrEF) and end-stage renal disease (ESRD) on hemodialysis.
Method: We enrolled patients with HFrEF and ESRD on hemodialysis using data from the Korean National Health Insurance Service data (2017–2021) covering the entire national population. A total of 2,248 patients with HFrEF who received SV were compared with 2,528 patients with HFrEF who received RAS blockade by inverse probability treatment weights. The primary endpoint was a 2-year composite outcome of all-cause mortality or any hospitalization. Differential effects according to medication adherence were also analyzed using proportion of days covered (PDC).
Results: SV reduced the risk of the primary outcome compared to the RAS blockade group (hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.75–0.96, P = 0.009). SV significantly reduced all-cause mortality (HR 0.74; 95% CI 0.59-0.93, P = 0.008) and any hospitalization (HR 0.85; 95% CI 0.75-0.95, P = 0.007). In the group with a PDC ≥80%, SV reduced the risk of all-cause, cardiovascular mortality and any hospitalization than RAS blockade (all-cause mortality, HR 0.61; 95% CI 0.46–0.80; P <0.001, cardiovascular mortality, HR 0.59; 95% CI 0.43-0.82, P = 0.001, any hospitalization, HR 0.80; 95% CI 0.80-0.94, P = 0.007).
Conclusions: In a real-world population with concomitant HFrEF and ESRD on hemodialysis, SV significantly reduced the risk of all-cause mortality and any hospitalization compared to the RAS blockade. These benefits were more definite in a subpopulation with a PDC ≥ 80%, suggesting the importance of medication adherence in improving cardiovascular outcomes.