Angiotensin-converting enzyme inhibitors in heart failure: physicians' prescribing behavior

Impact of comorbidity on medication use in elderly patients with cardiovascular diseases: the OCTOCARDIO study

BACKGROUND

Recommended medications are under-prescribed in elderly patients with atrial fibrillation (AF), coronary artery disease (CAD), and congestive heart failure (CHF). The relationship between under-prescribing and comorbidity is unclear.

DESIGN

Single-day observational study.

METHODS

Analysis of medications taken by patients aged 80 years or over at the time of their admission to cardiology units of 32 French hospitals. Comorbidity was measured using the Charlson comorbidity index (CCI).

RESULTS

The study included 510 patients (57% men, mean age 85 years). History of AF, CHF, and CAD was present in 213 (42%), 199 (39%), and 187 (37%) patients, respectively. CCI was 0 in 110 (22%), 1-2 in 215 (42%), and ≥3 in 185 (36%) patients. Vitamin K antagonists (VKA) were prescribed to 105 (49%) and aspirin to 86 (40%) patients with AF. CCI did not influence VKA prescription but influenced aspirin use, with lower prescription rates in patients with CCI 1-2 than CCI 0 or CCI ≥3 (p = 0.02). In CHF, angiotensin-converting enzyme inhibitors (ACEI) and β-blockers were prescribed to 80 (40%) and 96 (48%) patients, respectively. Rates of prescription of ACEI, β-blockers, statins, and aspirin in patients with CAD were 43%, 56%, 56%, and 66%, respectively. CCI level did not influence any medication use in CHF and CAD.

CONCLUSION

Even in the absence of comorbidity, elderly patients with major cardiovascular diseases are denied from indicated medical treatments probably because of their age alone. Implementing measures to enhance awareness of treatment benefits and promote appropriate prescribing is necessary.

CHART: congestive cardiac failure in hospitals, an Australian review of treatment

Despite strong evidence supporting the use of angiotensin-converting enzyme inhibitors (ACED, beta-blockers, and spironolactone in heart failure, evidence suggests these drugs are under-used and under-dosed. The aim of the present study was to determine the impact of hospitalisation on heart failure pharmacotherapy in patients with congestive heart failure (CHF). A retrospective study was conducted, based on 300 consecutive admissions with the medical record diagnosis of heart failure, in each of seven grade one teaching hospitals. At admission, 49.5% of patients were treated with ACEI, 19.2% with beta-blockers and 8.1% with spironolactone. Twenty-six per cent of untreated patients started ACEI treatment during their hospital stay, and 9.4% started beta-blockers The main determinants of treatment with ACEI at discharge were a primary diagnosis of heart failure (odds ratio (OR) = 1.886) and the presence of a potential contraindication (high creatinine OR = 0.458, cough OR = 0.187, renal artery stenosis OR = 0.309). Patients were less likely to be discharged on beta-blockers if greater than 85 years of age (OR = 0.545), or there was mention of airways disease (OR = 0.347), asthma (OR = 0.238) or type 2 diabetes (OR = 0.721) on the medical record. Patients admitted by a cardiologist were more likely to be discharged on beta-blockers (OR = 3.207). Spironolactone was more likely used in patients with primary diagnosis of heart failure (OR = 1.549), aged less than 85 years (OR = 0.319), and/or admitted by a cardiologist (OR = 1.827). The substantial number of patients admitted to hospital with a secondary diagnosis of heart failure should be targeted for therapeutic optimisation.

Implementation of evidence–based therapy in patients with systolic heart failure from 1998–2000

BACKGROUND

In recent years, the incidence of systolic heart failure has increased. Besides a complete revascularization, guideline-based medication represents the most effective therapeutic approach.

AIM

Analysis of adherence of guideline-recommended and actual medication during inpatient cardiac rehabilitation as well as under subsequent outpatient conditions.

METHODS

From 01/1998 to 12/ 2000, 1346 consecutive patients (64 +/- 10 years, 73% male, LVEF 36.3 +/- 8%, 88% ischemic, 6.7% valvular cardiomyopathy, 5.3% other causes, 11.8% atrial fibrillation) were included in a singlecenter prospective register. Medication was recorded at discharge and after the follow-up period of 731 +/- 215 days. Trends in prescription rates were analyzed based on nonparametric correlations (Spearman's-Rho). Changes in medication from in- to outpatient settings were analyzed using exact McNemar test.

RESULTS

At discharge 75.3% (67.9%/68.9%/ 86.6% in 1998/1999/2000, p <0.001) of the patients were treated as recommended. This rate dropped to 68.3% at followup (p <0.0001). Mortality within the follow-up period was low (12.6%).

CONCLUSION

It could be shown that from 1998 to 2000 inpatient guideline conformity was implementable adequately. Outpatient conformity was significantly lower. Although a high proportion of correctly prescribed CHF medication could be demonstrated, a further effort to improve guideline adherence in the management of heart failure patients is desirable.

A study of the prevalence of significant increases in serum creatinine following angiotension-converting enzyme inhibitor administration

Angiontension-converting enzyme inhibitors (ACEIs) are beneficial in the treatment of diabetic and nondiabetic kidney disease, coronary artery disease and congestive heart failure. One adverse effect of ACEIs use is a rise in serum creatinine and potential renal failure. This paper attempts to quantify this risk and assess the need for pre- and post-ACEI serum creatinine measurements. A computerized search of Kaiser Permanente Northwest's electronic medical record was conducted to find patients over the age of 40 years taking lisinopril between July 1, 2000 and June 30, 2002. Patient demographic information and presence in diabetes and coronary artery disease registries was collected. A subsequent search for pre- and postlisinopril serum creatinine levels within 6 months of initial lisinopril prescription was conducted. Patients with prelisinopril creatinine < or = 1.2 mg/dl and postlisinopril creatinine > 2.5 mg/dl underwent chart review to discern adverse events associated with the rise in serum creatinine. A total of 18,977 patients were prescribed lisinopril between July 1, 2000 and June 30, 2002. In all 13 166 patients had a pre- and postlisinopril creatinine checked. In all, 31 patients had a rise in creatinine from < or = 1.2 mg/dl to > 2.5 mg/dl (0.2%). Possible contributors to rise in creatinine included congestive heart failure, dehydration and infection. No patients developed end-stage renal disease, although three died. In conclusion, end-stage renal disease is an unlikely outcome among patients prescribed lisinopril and is most likely associated with other events.

National patterns of use and effectiveness of angiotensin-converting enzyme inhibitors in older patients with heart failure and left ventricular systolic dysfunction

BACKGROUND

Although ACE inhibitors are underprescribed for heart failure, factors associated with their use are not well described. Furthermore, the effectiveness of ACE inhibitors has been questioned in some populations, potentially contributing to underuse. Our objectives were to assess the correlates of ACE inhibitor use and the relationship between ACE inhibitor prescription and mortality in older patients with heart failure.

METHODS AND RESULTS

We studied a national sample aged > or =65 years who had survived hospitalization for heart failure between April 1998 and March 1999 or July 2000 and June 2001, restricting the analysis to patients with left ventricular systolic dysfunction and without a documented contraindication to use of ACE inhibitors (n=17 456). Factors associated with ACE inhibitor prescription at discharge and the relationship between ACE inhibitor prescription and death within 1 year were assessed with hierarchical logistic models. Secondary analyses assessed therapeutic substitution with angiotensin receptor blockers (ARBs). ACE inhibitors were prescribed to only 68% of this ideal cohort, and 76% received either an ACE inhibitor or an ARB. Patient, physician, and hospital factors were weak predictors of prescription, except for serum creatinine (RR for 133 to 221 micromol/L=0.87, 95% CI 0.85 to 0.89; RR for > or =222 micromol/L=0.53, 95% CI 0.49 to 0.57 compared with < or =132 micromol/L). ACE inhibitor prescription was associated with lower crude 1-year mortality (33.0% versus 42.1%, P<0.001), lower risk of death after adjustment (RR 0.86, 95% CI 0.82 to 0.90), and lower mortality regardless of patient gender, age, race, or serum creatinine level.

CONCLUSIONS

ACE inhibitors were widely underprescribed despite evidence of a favorable impact on survival in a broad range of patients with heart failure. These results emphasize the importance of ongoing efforts to translate clinical trial results into practice.

The relevance of heart failure severity for treatment with evidence-based pharmacotherapy in general practice

AIMS

Internationally, research indicates that pharmacotherapy for chronic heart failure (CHF) is sub-optimal. Traditionally, assessment of drug use in heart failure has focused on the use of individual agents irrespective of CHF severity. This study investigates drug use for CHF patients in general practice with respect to the available evidence, incorporating both disease severity and the use of combination drug regimes.

METHODS AND RESULTS

A cross-sectional survey of 769 Dutch CHF patients was performed as part of IMPROVEMENT of HF study. For each New York Heart Association severity classification the minimum treatment appropriate for the heart failure severity according to the scientific evidence available at the time of the study (1999) was defined. The proportion of patients treated with each drug increased with increasing severity, with the exception of the beta-blockers. Patients with less severe heart failure were approximately four to eight times more likely to receive evidence-based treatment than those with more severe heart failure.

DISCUSSION

To assess pharmacological treatment of heart failure, in relation to the available evidence, it is important to take severity into account. While the number of drugs prescribed increased with increasing severity, the use of evidence-based regimes was lower in patients with more severe heart failure.

How patients with heart failure are managed in Portugal

The prevalence of heart failure is increasing all over the world. It is a common and growing public health problem in Portugal as in many other European countries. This article provides a review of health service organization and current heart failure management in Portugal, discusses primary care and ward practices in different hospitals and reports on the use of proven standard therapies for the treatment of heart failure in the community. Despite major advances in diagnosis and treatment, heart failure is only satisfactorily managed. Furthermore efforts are necessary before the beneficial effects observed in trials have a real impact in clinical practice. A broader view and priority for the management of this syndrome on a national level are needed to improve the quality of heart failure care in Portugal.

Diuretic resistance predicts mortality in patients with advanced heart failure

BACKGROUND

In patients with chronic heart failure (CHF), diuretic requirements increase as the disease progresses. Because diuretic resistance can be overcome with escalating doses, the evaluation of CHF severity and prognosis may be incomplete without considering the intensity of therapy.

METHODS

The prognostic importance of diuretic resistance (as evidenced by a high-dose requirement) was retrospectively evaluated in 1153 patients with advanced CHF who were enrolled in the Prospective Randomized Amlodipine Survival Evaluation (PRAISE). The relation of loop diuretic and angiotensin-converting enzyme inhibitor doses (defined by their median values) and other baseline characteristics to total and cause-specific mortality was determined by proportion hazards regression.

RESULTS

High diuretic doses were independently associated with mortality, sudden death, and pump failure death (adjusted hazard ratios [HRs] 1.37 [P =.004], 1.39 [P =.042], and 1.51 [P =.034], respectively). Use of metolazone was an independent predictor of total mortality (adjusted HR = 1.37, P =.016) but not of cause-specific mortality. Low angiotensin-converting enzyme inhibitor dose was an independent predictor of pump failure death (adjusted HR = 2.21, P =.0005). Unadjusted mortality risks of congestion and its treatment were additive and comparable to those of established risk factors.

CONCLUSIONS

The independent association of high diuretic doses with mortality suggests that diuretic resistance should be considered an indicator of prognosis in patients with chronic CHF. These retrospective observations do not establish harm or rule out a long-term benefit of diuretics in CHF, because selection bias may entirely explain the relation of prescribed therapy to death.

Underutilisation of ACE inhibitors in patients with congestive heart failure

Congestive heart failure (CHF) is associated with substantial morbidity and mortality, and is the only major cardiovascular disease increasing in prevalence. Despite abundant evidence to support their efficacy and cost-effectiveness, angiotensin-converting enzyme (ACE) inhibitors are sub-optimally used in patients with CHF. This paper reviews the evidence for the sub-optimal use of ACE inhibitors in patients with CHF, the factors contributing to this, and its implications for health systems. A systematic review of all articles assessing practice patterns (specifically the use of ACE inhibitors in CHF) identified by MEDLINE, search of bibliographies, and contact with content experts was undertaken. 37 studies have documented the use of ACE inhibitors in patients with CHF. Studies assessing use among all patients with CHF document 33% to 67% (median 51%) of all patients discharged from hospital and 10% to 36% (median 26%) of community dwelling patients were prescribed ACE inhibitors. Rates of ACE inhibitor use range from 43% to 90% (median of 71%) amongst those discharged from hospital having known systolic dysfunction, and from 67% to 95% (median of 86%) for those monitored in specialty clinics. Moreover, the dosages used in the 'real world' are substantially lower than those proven efficacious in randomised, controlled trials, with evaluations reporting only a minority of patients achieving target doses and/or an overall mean dose achieved to be less than one-half of the target dose. Factors predicting the use and optimal dose administration of ACE inhibitors are identified, and include variables relating to the setting (previous hospitalisation, specialty clinic follow-up), the physician (cardiology specialty versus family practitioner or general internist, board certification), the patient (increased severity of symptoms, male, younger), and the drug (lower frequency of administration). In light of the substantial evidence for reductions in morbidity and mortality, clearly, the prescription of ACE inhibitors is sub-optimal. Wide variability in ACE inhibitor use is noted, with higher rates consistently reported among patients having systolic dysfunction confirmed by an objective assessment--an apparent minority of the those having CHF. Optimisation of the prescription of proven efficacious therapies has the potential to confer a substantial reduction in the total cost of care for patients with CHF by reducing hospitalisations and lengths of hospital stays. It is likely that only multifaceted programs targeted toward the population at large will yield benefits to the healthcare system, given the widespread nature of the sub-optimal prescription of therapies proven effective in the management of patients with CHF.

Lisinopril: a review of its use in congestive heart failure

The ACE inhibitor lisinopril is a lysine derivative of enalaprilat, the active metabolite of enalapril. In patients with heart failure, maximum pharmacodynamic effects are produced 6 to 8 hours after administration of the drug and persist for 12 to 24 hours. High doses (32.5 to 35mg, administered once daily) of lisinopril in the Assessment of Treatment with Lisinopril and Survival (ATLAS) study demonstrated clinically important advantages over low doses (2.5 to 5mg, administered once daily) of the drug in the treatment of congestive heart failure. High doses of lisinopril were more effective than low doses in reducing the risk of major clinical events in patients with heart failure treated for 39 to 58 months. Compared with recipients of low doses, those receiving high doses of lisinopril had an 8% lower risk of all-cause mortality (p = 0.128), a 12% lower risk of death or hospitalisation for any reason (p = 0.002) and 24% fewer hospitalisations for heart failure (p = 0.002). These benefits were associated with significant cost savings. In short term (generally 12 weeks' duration) randomised, double-blind, parallel-group, multicentre clinical trials, lisinopril was significantly more effective than placebo and was at least as effective as captopril, enalapril, digoxin and irbesartan at improving symptomatic end-points and clinical status in patients with heart failure. Lisinopril is generally well tolerated by patients with heart failure. In controlled clinical trials, the most common adverse events occurring in recipients of the drug were dizziness, headache, hypotension and diarrhoea. Overall adverse event profiles for patients treated with high or low doses of lisinopril in the ATLAS study were similar. However, high doses of lisinopril used in the ATLAS study were associated with a higher incidence of adverse events, importantly hypotension and worsening renal function; nevertheless, these events were generally well managed by altering the dose of lisinopril or concomitant medications. Furthermore, despite the higher incidence of some adverse events with high doses of lisinopril, the frequency of treatment discontinuations because of adverse events was the same in the high and low dose groups.

CONCLUSIONS

Lisinopril (when added to diuretics and/or digoxin) provides symptomatic benefits in patients with congestive heart failure. The ATLAS study demonstrated that high doses of lisinopril significantly reduced the risk of the combined end-point of morbidity and mortality compared with low doses of the drug. Importantly, there was no clinically significant decrease in the tolerability of the drug with use of a high dose. Lisinopril is at least as effective and as well tolerated as other members of the ACE inhibitor class for the treatment of congestive heart failure.

The basics of heart failure management: are they being ignored?

BACKGROUND

Advances have been made in the medical management of congestive heart failure. However, there is concern that these changes may not be transmitted to the heart failure population in the community. Other impediments to improved prognosis, such as failure to apply non-pharmacological strategies and poor patient comprehension may also be prevalent in the community.

AIMS

The purpose of this study was to assess physician practice and patient knowledge in a heart failure population admitted to a University Hospital in Ireland.

METHODS

Patients admitted with a primary diagnosis of heart failure were studied. Estimation of ejection fraction was used to subdivide the population into heart failure with impaired and normal systolic function. Patients' course in hospital was noted with reference to management by cardiology or internal medicine, use of angiotensin-converting enzyme inhibition therapy and digoxin and application of dietary and rehabilitative services. Patient knowledge was assessed by questionnaire.

RESULTS

Eighty patients were included in this study. Two-thirds of the population had impaired systolic function. The majority of patients were managed by internal medicine physicians, and this population was older and more likely to have normal systolic function. Prescription of converting enzyme inhibitor therapy was more frequently used in cardiology-managed patients (96 vs. 70%, P<0.05). Neither group applied dietary or rehabilitative advice to a significant level. Patient comprehension was poor, especially with regard to understanding of medicine and the value of weight measurement.

CONCLUSION

The above data demonstrate a lack of use of rehabilitative and dietary services and poor patient knowledge. These deficiencies may play a role in determining outlook and may impede the expected improvement in prognosis that has been witnessed in large randomised studies.