Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals

doi:10.1016/S0002-9149(97)89177-1

The American Journal of Cardiology

Volume 77, Issue 10, 15 April 1996, Pages 832-838

https://doi.org/10.1016/S0002-9149(97)89177-1 Get rights and content

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 far 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.

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Cited by (134)

Prescribing patterns of evidence-based heart failure pharmacotherapy and outcomes in the ASIAN-HF registry: a cohort study
2018, The Lancet Global Health
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), β blockers, and mineralocorticoid receptor antagonists (MRAs) are of proven benefit and are recommended by guidelines for management of patients with heart failure and reduced ejection fraction (HFrEF). We aimed to examine the first prospective multinational data from Asia on prescribing patterns of guideline-directed medical therapies and analyse its effect on outcomes.
In the prospective multinational ASIAN-HF registry (with enrolment from 46 centres in 11 countries in Asia), we enrolled patients aged 18 years or older, with symptomatic heart failure (stage C, with at least one episode of decompensated heart failure in the past 6 months that resulted in admission to hospital or was treated in an outpatient clinic) and left ventricular systolic dysfunction (ejection fraction ≤40% on baseline echocardiography, consistent with 2016 European Society of Cardiology guidelines). We excluded patients with heart failure caused by severe valvular heart disease, life-threatening comorbidity with a life expectancy of less than 1 year, who were unable or unwilling to give consent, or who had concurrent participation in a clinical trial. Patients were followed up for 3 years for the outcomes of death and cause-specific admittance to hospital. Primary outcomes were uptake of guideline-directed medical therapies (as proportions) by therapeutic class, achieved doses as proportions of guideline-recommended doses, and their association with 1-year composite outcome of all-cause death or admittance to hospital because of heart failure. This study is registered with ClinicalTrials.gov, number NCT01633398.
Between Oct 1, 2012, and Dec 31, 2015, we enrolled 5276 patients with HFrEF (mean age 59·6 years [SD 13·2], 77% men, body-mass index 24·9 kg/m² [5·1], 33% New York Heart Association class III or IV). Follow-up data were available for 4544 (90%) of 5061 eligible patients taking medication for heart failure, with median follow-up of 417 days (IQR 214–735). ACE inhibitors or ARBs were prescribed to 3868 (77%) of 5005 patients, β blockers to 3975 (79%) of 5061, and MRAs to 2998 (58%) of 5205, with substantial regional variation. Guideline-recommended dose was achieved in only 17% of cases for ACE inhibitors or ARB, 13% for β blockers, and 29% for MRAs. Country (all three drug classes), increasing body-mass index (ACE inhibitors or ARBs and MRAs), and in-patient recruitment (ACE inhibitors or ARBs and β blockers) were associated with attainment of guideline-recommended dose (all p<0·05). When adjusted for indication bias, increasing drug doses, from low dose (1–<25% of guideline-recommended dose) upwards were associated with lower hazards of a 1-year composite outcome for ACE inhibitors or ARBs and β blockers compared with non-users. The lowest adjusted hazards were in the group that attained guideline-recommended doses above 50% (hazard ratio [HR] 0·54, 95% CI 0·50–0·58 for ACE inhibitors or ARBs [50–99·9%]; HR 0·47, 0·46–0·50 for β blockers, and HR 0·77, 0·72–0·81 for MRAs [≥100%]).
Guideline-directed medical therapies at recommended doses are underutilised in patients with HFrEF. Improved uptake and uptitration of guideline-directed medical therapies are needed for better patient outcomes.
National Medical Research Council (Singapore), A*STAR Biomedical Research Council ATTRaCT program, Boston Scientific Investigator Sponsored Research program, and Bayer.
Prescribing trends for management of congestive heart failure from 2002 to 2004
2013, Research in Social and Administrative Pharmacy
The incidence and prevalence of the patients diagnosed with congestive heart failure (CHF) continues to grow in the United States. The use of prescription drugs is a vital part of the management of CHF, and pharmacological regimens may vary among patients.
To examine the CHF prescription trends in the United States and to determine present prescribing patterns.
National Ambulatory Medical Care Survey and both divisions (outpatient and emergency department) of the National Hospital Ambulatory Medical Care Survey from 2002 to 2004 were used to acquire the appropriate data. All analyses used weighted data to represent national estimates. The unit of analysis was individual patient visits. Analysis of the data was accomplished using SPSS 14.0.2 and Stata/SE 9.2 statistical programs.
During the 3 study years, 24,213,096 weighted visits were associated with a diagnosis of CHF. More than half (56.2%) of the study population were female; over 75% of the subjects were older than 65 years. Over one-quarter (27.3%; 6,618,208 visits) of CHF-related visits were not associated with being prescribed a CHF-related medication. Loop diuretics were the most commonly used medication (35%). Cardiovascular specialists (odds ratio [OR] = 5.28; 95% confidence interval [CI]: 1.82-15.3; P = .002), general/family practice physicians (OR = 4.5, 95% CI: 1.69-12.0; P = .003), and internal medicine physicians (OR = 3.85, 95% CI: 1.39-10.7; P = .010) were more likely to prescribe CHF-related medication compared with other medical specialties. CHF patients who reside in the Northeast were more likely to receive CHF-related medications than other regions (Midwest OR = 0.24; South OR = 0.20; West OR = 0.23; P < .05) of United States.
There were regional and medical specialty-related variations for prescribing CHF-related medications. The results from this study suggest a need for increased awareness of the benefit of CHF-related medications in the management of CHF. The increased implementation of the CHF management guidelines would improve overall patient care.
Pharmacologic management of heart failure in the ambulatory setting
2012, Cardiovascular Therapeutics: A Companion to Braunwald's Heart Disease: Fourth Edition
β-Blocker dosing in community-based treatment of heart failure
2007, American Heart Journal
Citation Excerpt :
Furthermore, their experience suggests that a small percentage of patients with HF in the community setting may not be able to tolerate β-blockade, for whatever reason, and that these patients appear to do worse than those who can tolerate some maintenance dose of a β-blocker. Thus, the characteristics of our patients and their physicians, as well as the observed outcomes, appear consistent with previous reports of HF experience in the community setting.1-9,22 Therefore, it is reasonable to believe that the present experience is representative of the community setting of HF.
Community patients with heart failure (HF) are older, less often treated by HF specialists, and have more comorbidity than those in randomized clinical trials. These differences might affect β-blocker prescribing in HF.
To explore patterns of β-blocker prescribing for HF in the community and their association with outcomes, we determined carvedilol doses at end titration in 4113 patients from a community-based β-blocker HF registry according to physician and patient characteristics, HF severity, and rates of hospitalization and death.
Female sex, age ≥65 years, and left ventricular ejection fraction ≥35% were associated with lower β-blocker doses. Average daily dose of β-blocker was lower with worse baseline New York Heart Association class. More patients of cardiologists achieved carvedilol doses ≥25 mg twice daily, whereas in those of noncardiologists lower doses were more common. Relative risk of HF hospitalizations or all-cause death was significantly lower with higher doses of β-blocker.
β-Blocker dosing in community HF appears lower than in randomized clinical trials, especially when prescribed by noncardiologists. At all doses, patients taking the β-blocker carvedilol have a lower incidence of death and HF hospitalization than those discontinuing it, regardless of physician type in the community setting.
Nonpharmacologic Measures and Drug Compliance in Patients with Heart Failure: Data from the EuroHeart Failure Survey
2007, American Journal of Cardiology
Advice on lifestyle, diet, vaccination, and therapy are part of the standard management of heart failure (HF). However, there is little information on whether patients with HF recall receiving such recommendations and, if so, whether they report following them. We obtained information on the recall of and adherence to nonpharmacologic advice from patients enrolled in the EuroHeart Failure Survey. This article focuses on 2,331 patients who had a clinical diagnosis of HF during the index admission and attended an interview 12 weeks after discharge. Their mean age was 67 ± 12 years and 38% were women. Patients recalled receiving 4.1 ± 2.7 items of advice with higher rates in Central Europe and the Mediterranean region. Recall of dietary advice (cholesterol or fat intake, 63%; dietary salt, 60%) was higher than for some other interventions (influenza vaccination, 36%; avoidance of nonsteroidal anti-inflammatory drugs, 17%). Among those who recalled the advice, a substantial proportion indicated that they did not follow advice completely (cholesterol and fat intake, 61%; dietary salt, 63%; influenza vaccination, 75%; avoidance of nonsteroidal anti-inflammatory drugs, 80%), although few patients indicated they ignored the advice completely. Patients who recalled >4 items versus ≤4 items of advice were younger and more often received angiotensin-converting enzyme inhibitors (71% vs 62%), β-blockers (51% vs 38%), and spironolactone (25% vs 21%). In conclusion, after hospitalization for HF, many patients do not recall nonpharmacologic advice. In addition, a substantial proportion of those who recall the advice follow it incompletely. Younger age and prescription of appropriate pharmacologic treatment are associated with higher rates of recall and implementation.
Pharmacologic Management of Heart Failure in the Ambulatory Setting
2007, Cardiovascular Therapeutics: A Companion to Braunwald's Heart Disease

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^*: This work was supported in part by Grants C-011191 and C-011696 from the New York State Department of Health.

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Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals*

Am J Cardiol

J Am Coll Cardiol

Cardiol Clin

A placebo-controlled trial of refractory chronic congestive heart failure

J Am Coll Cardiol

Comparison of captopril and enalapril in patients with severe chronic heart failure

N Engl J Med

Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study

N Engl J Med

Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure

N Engl J Med

A comparison of enalapril with hydralazine-isosorbide in the treatment of chronic congestive heart failure

N Engl J Med

Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction

N Engl J Med

Role of angiotensin-converting enzyme inhibition in the management of heart failure: present and future roles

Congestive Heart Failure

Costs and effectiveness of angiotensin converting enzyme inhibition in patients with congestive heart failure

Arch Intern Med