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Re: Left ventricular systolic dysfunction, ACE inhibitors and heart failure mortality

Dear Editor

We read with interest the article by Nielsen et al.[1] One of the interesting findings of that study is the rather low rates of ACE inhibitor use (16% and 8% respectively for hospitalized and community dwelling heart failure patients, and 1.7% for patients with heart disease but no heart failure). The fact that the study was done conducted between 1993 and 1996 partly explains these low rates. However, survival benefit of ACE inhibitors in heart failure patients with left ventricular systolic dysfunction was well known by the early 1990’s.[2] In addition, the lack of distinction between systolic and diastolic heart failure also likely have diluted the rate of ACE inhibitor use. Assuming that about half of the hospitalized and 20% of the community dwelling heart failure patients have systolic heart failure, and all ACE inhibitors were used in these patients (which was likely not the case), not all eligible heart failure patients were receiving this life saving drug.

Presence of systolic dysfunction and lack of use of ACE inhibitors are independently associated with increased mortality in heart failure patients.[3] Once a clinical diagnosis of heart failure is made, the single most important evaluation is the left ventricular systolic function evaluation, preferably by an echocardiogram.[4] The authors’ conclusion that echocardiography should be restricted to heart failure patients with significant risk of death is in contradiction to the recommendation by heart failure guidelines.[4,5] Once the diagnosis of systolic heart failure is established, ACE inhibitors should be prescribed to all such patients unless an absolute contraindication such as past history of allergy or angioedema exists. Most general practitioners should also be able to initiate a beta blocker. General practitioners unfamiliar or uncomfortable with use of beta blockers in systolic heart failure should refer patients to cardiologists. Systolic heart failure patients with angina or sudden worsening of symptoms who are eligible and willing candidates for revascularization should also be referred for cardiac catheterization and coronary angiography.

Reference

(1) Wendelboe Nielsen O, Hilden J, McDonagh T, Fischer Hansen J. Survival differences between heart failure in general practices and in hospitals. Heart 2003; 89:1298-1302.

(2) Williams J, Bristow M, Fowler M, et al. Guidelines for the Evaluation and Management of Heart Failure: Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 1995; 92:2764-84.

(3) Ahmed A, Roseman JM, Duxbury AS, Allman RM, DeLong JF. Correlates and outcomes of preserved left ventricular systolic function among older adults hospitalized with heart failure. Am Heart J 2002; 144:365-72.

(4) Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2001; 38:2101-13.

(5) Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001; 22:1527-60.