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Why are angiotensin converting enzyme inhibitors underutilised in the treatment of heart failure by general
1Department of Cardiovascular Medicine, University Hospital, Nottingham, UK. andrew.houghton@nottingham.ac.uk
Insights
General practitioners often underuse beneficial heart failure medications like ACE inhibitors due to concerns about side effects, despite awareness of their survival benefits. Further research is needed to guide safe initiation in primary care.
Area of Science:
- Cardiology
- General Practice
- Pharmacology
Background:
- Angiotensin converting enzyme (ACE) inhibitors significantly reduce morbidity and mortality in heart failure patients.
- Underutilization of ACE inhibitors in general practice is a persistent issue.
- Understanding barriers to ACE inhibitor prescription is crucial for improving heart failure management.
Purpose of the Study:
- To investigate the reasons behind the underutilization of ACE inhibitors in general practice.
- To assess general practitioners' awareness of heart failure prognosis and ACE inhibitor benefits.
- To identify concerns influencing ACE inhibitor prescribing habits.
Main Methods:
- An anonymous questionnaire survey was distributed to 515 general practitioners in the Nottingham Health District.
- The survey assessed awareness of heart failure prognosis, knowledge of ACE inhibitor benefits, and concerns regarding adverse effects.
- Response rate was 60.2%.
Main Results:
- 39.3% of general practitioners underestimated the poor prognosis of heart failure.
- 98% were aware of the prognostic benefits of ACE inhibitors.
- 46.3% expressed concerns about adverse effects, primarily hypotension and renal impairment.
- Concerns about adverse effects were significantly associated with less frequent initiation of ACE inhibitors (P<0.01).
Conclusions:
- General practitioners' concerns about adverse effects, particularly hypotension and renal impairment, are a significant barrier to prescribing ACE inhibitors for heart failure.
- Despite awareness of benefits, underestimation of heart failure prognosis and fear of side effects contribute to underutilization.
- Further research is required to identify patient groups suitable for ACE inhibitor therapy in primary care, and practitioners should be encouraged to refer patients when uncertain about initiation.
Abstract:
Treatment with angiotensin converting enzyme inhibitors confers significant morbidity and mortality benefits in patients with heart failure, yet previous studies have repeatedly shown that these drugs are underutilised in general practice. To investigate why this is the case, we conducted an anonymous questionnaire survey of 515 general practitioners in the Nottingham Health District. The response rate was 60.2%. We found that although 39.3% of respondents underestimated the poor prognosis associated with heart failure, 98% were aware of the prognostic benefits conferred by angiotensin converting enzyme inhibitors. However, 46.3% of respondents expressed concern about the potential adverse effects associated with angiotensin converting enzyme inhibitors, the main fears being hypotension and renal impairment. General practitioners who were concerned about adverse effects were significantly less likely to have initiated an angiotensin converting enzyme inhibitor for heart failure than those who were not (P<0.01). Further research is needed to identify which patients can safely be commenced on angiotensin converting enzyme inhibitors in general practice. In the meantime, general practitioners should be encouraged to refer patients whenever they are concerned about initiating angiotensin converting enzyme inhibitors in the community.