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Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals
E F Philbin1, C Andreaou, T A Rocco
1Department of Medicine and Research Institute, Bassett Healthcare, Copperstown, NY 13326, USA.
Insights
Physicians under-prescribe angiotensin-converting enzyme (ACE) inhibitors for congestive heart failure (CHF) due to patient age, renal function, and less intense medical management. This leads to higher death rates in patients with CHF not receiving ACE inhibitors.
Area of Science:
- Cardiology
- Pharmacology
- Health Services Research
Background:
- Angiotensin-converting enzyme (ACE) inhibitors are recommended for congestive heart failure (CHF) due to symptom relief and mortality reduction.
- Despite high tolerance rates in clinical trials, actual prescription rates for ACE inhibitors in CHF patients are lower.
- The reasons for this discrepancy in ACE inhibitor prescription for CHF are not fully understood.
Purpose of the Study:
- To investigate the factors influencing physician prescribing behavior for ACE inhibitors in patients hospitalized for decompensated CHF.
- To identify demographic, clinical, laboratory, and medical care characteristics associated with ACE inhibitor use in CHF patients.
Main Methods:
- Retrospective chart review of 424 consecutive patients admitted for decompensated CHF in 1992.
- Comparison of patients receiving and not receiving ACE inhibitors at admission and discharge.
- Analysis of in-hospital and post-discharge outcomes between the two groups.
Main Results:
- Significant differences observed in patient age, left ventricular ejection fraction, serum creatinine, documentation of left ventricular function, and documentation of CHF etiology.
- Few differences noted in measures of CHF severity like New York Heart Association functional class and serum sodium levels.
- Higher death rates were observed in patients with CHF not receiving ACE inhibitors.
Conclusions:
- Under-prescription of ACE inhibitors in CHF is linked to older age, impaired renal function, left ventricular diastolic dysfunction, use of alternative vasodilators, and less intensive overall medical management.
- Educational programs for healthcare providers on appropriate ACE inhibitor use in CHF are recommended.
- Addressing identified barriers could improve ACE inhibitor utilization and patient outcomes in CHF.
Abstract:
Because they provide relief of symptoms and reduce mortality, angiotensin-converting enzyme (ACE) inhibitors have become a highly recommended part of the pharmacologic treatment of patients with congestive heart failure (CHF). Although clinical trials suggest that 80% to 90% of patients with CHF tolerate ACE inhibitors, recent surveys reveal that for fewer than this number of patients are actually receiving these drugs. The reasons for this discrepancy are not known. To better understand physician-prescribing behavior, the current study examined the demographic, clinical, laboratory, and medical care characteristics of patients treated and not treated with ACE inhibitors during hospitalization for decompensated CHF. The charts of a consecutive series of patients admitted to 2 acute care hospitals during 1992 (n = 424) were reviewed and comparisons made between those receiving and not receiving ACE inhibitors at the time of hospital admission and hospital discharge. In addition, measures of in-hospital and postdischarge outcome were compared between the groups. The results revealed significant differences in certain demographic variables (e.g., patient age), clinical measures (e.g., left ventricular ejection fraction and serum creatinine), management issues (e.g., documentation of left ventricular function and documentation of etiology of CHF), and treatment strategies (e.g., ancillary drug use). Few differences were noted in measures of severity of CHF (e.g., New York Heart Association functional class and serum sodium level). Death rates were significantly higher for those not receiving ACE inhibitors. Patterns that emerged that could explain under-prescription ACE inhibitors included older age, worse renal function, left ventricular diastolic dysfunction, use of alternate vasodilators, and overall less intense medical management. Programs to educate care providers regarding the proper use of ACE inhibitors in CHF are recommended.