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Angiotensin Converting Enzyme (ACE) Inhibitors and Heart Failure

The Consequences of Underprescribing

  • Review Article
  • Consequences of Underprescribing ACE Inhibitors
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Abstract

Heart failure (HF) is a common and expensive cardiovascular disease, in economic terms as well as in lives lost. Angiotensin converting enzyme (ACE) inhibitors have been shown to significantly reduce mortality and hospitalisation in HF. However, recent surveys show that the prescription rate of ACE inhibitors for HF is far below what is considered to be optimal. Furthermore, prescribed dosages are usually lower than those recommended based on evidence from clinical trials.

This article estimates the consequences, both economic and human, of underprescribing ACE inhibitors in patients with HF. The indication for prescribing an ACE inhibitor varies, and clinical trials have included different categories of patients; it is inappropriate to assess costs in all eligible patients without taking these factors into account. Therefore, we analysed the data with respect to 4 different groups: (i) asymptomatic left ventricular systolic dysfunction (LVSD)–an early stage leading to chronic HF; (ii) chronic HF; and post–myocardial infarction (MI) LVSD differentiated into (iii) post-MI asymptomatic LVSD and (iv) post-MI chronic HF. We also estimated the cost effectiveness of adding an ACE inhibitor to the treatment of patients with HF for whom an ACE inhibitor is not currently prescribed.

If only patient populations in which large trials have shown a significant effect of ACE inhibition on mortality are included in the analysis (i.e. excluding asymptomatic patients with LVSD), increasing the number of Swedish patients receiving an ACE inhibitor could save in excess of 3700 lives each year, in addition to reducing the annual number of hospitalisations by 8400. The additional cost would be 101.5 million Swedish kronor (SEK), a cost per life saved of SEK27 200. Chronic HF is the most cost-effective patient population to treat, generating cost savings under certain assumptions. A further 6700 hospitalisations can be avoided should the use of ACE inhibitors be extended to asymptomatic patients with LVSD. Increasing dosages to those used in the large clinical trials may generate additional savings in lives and hospitalisations.

In conclusion, the use of ACE inhibitors in HF and LVSD has clearly been proven to be cost effective, and compares favourably with the cost effectiveness of treating hypertension or hypercholesterolaemia. At present, however, ACE inhibitors are not optimally utilised.Given the increasingly constrained resources for healthcare, every effort should be made to increase the use of cost-effective treatments, such as ACE inhibitors in chronic HF and post-MI LVSD.

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References

  1. Kannel WB, Ho K, Thom T. Changing epidemiological features of cardiac failure. Br Heart J 1994; 72: 3S–9S

    Google Scholar 

  2. Läkemedelsverket (The Medical Products Agency). Treatment of heart failure: recommendations from the group. In: Pharmacological treatment of heart failure. Uppsala: Läkemedelsverket, 1993

    Google Scholar 

  3. Erhardt L, Caidahl K, Eriksson H, et al. Hjärtsvikt (heart failure). SoS-report 1994: 3. Stockholm: The Swedish National Board of Health and Welfare, 1994

    Google Scholar 

  4. Stevenson LW, Fowler MB, Schroeder JS, et al. Poor survival of patients with idiopathic cardiomyopathy considered too well for transplantation. Am J Med 1987; 83: 871–6

    PubMed  CAS  Google Scholar 

  5. Andersson F, Rydén-Bergsten T. The health care costs of heart failure in Sweden. J Intern Med. In press

  6. O’Connell JB, Bristow MR. Economic impact of heart failure in the United States: time for a different approach. J Heart Lung Transplant 1994; 13: 107S–12S

    Google Scholar 

  7. McMurray J, Hart W, Rhodes G. An evaluation of the cost of heart failure to the National Health Service in the UK. Br J Med Econ 1993; 6: 99–110

    Google Scholar 

  8. Parmley WW. Cost-effective management of heart failure. Clin Cardiol 1996; 19: 240–2

    PubMed  CAS  Google Scholar 

  9. Studies of Left Ventricular Dysfunction (SOLVD) Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293–302

    Google Scholar 

  10. CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med 1987; 316: 1429–35

    Google Scholar 

  11. Garg R, Yusuf S. Overview of randomised trials of angiotensin converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA 1995; 273: 1450–6

    PubMed  CAS  Google Scholar 

  12. Linn WD. Angiotensin-converting enzyme inhibitors in left ventricular dysfunction. Pharmacotherapy 1996; 16 Suppl. 2: 50S–8S

    PubMed  CAS  Google Scholar 

  13. Cohn JN, Johnson G, Ziesch S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991; 325: 293–302

    Google Scholar 

  14. Pfeffer MA, Braunwald E, Moyé LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the survival and ventricular enlargement trial. N Engl J Med 1992; 327: 669–77

    PubMed  CAS  Google Scholar 

  15. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. Lancet 1993; 342: 821–8

    Google Scholar 

  16. ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group. A randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58,050 patients with suspected acute myocardial infarction. Lancet 1995; 345: 669–85

    Google Scholar 

  17. The SOLVD investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992; 327: 685–91

    Google Scholar 

  18. Køber L, Torp-Pedersen C, Carlsen JE, et al. A clinical trial of the angiotensin-converting enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 1995; 333: 1670–6

    PubMed  Google Scholar 

  19. Hall AS, Murray GD, Ball S, AIRE Study Investigators. Follow-up study of patients randomly allocated ramipril or placebo for heart failure after acute myocardial infarction: AIRE extension (AIREX) study. Lancet 1997; 349: 1493–7

    PubMed  CAS  Google Scholar 

  20. LePen C, Lilliu H, Keller T, et al. The economics of TRACE: a cost-effectiveness analysis of trandolapril in postinfarction patients with left ventricular dysfunction. Pharmacoeconomics 1998; 14: 49–58

    Google Scholar 

  21. McMurray J, Davie A. The pharmacoeconomics of ACE inhibitors in chronic heart failure. Pharmacoeconomics 1996; 9: 188–97

    PubMed  CAS  Google Scholar 

  22. Szucs TD. Pharmacoeconomics of angiotensin converting enzyme inhibitors in heart failure. Am J Hypertens 1997; 10: 272S–9S

    PubMed  CAS  Google Scholar 

  23. van Hout B, Wielink G, Bonsel GJ, et al. Effects of ACE inhibitors on heart failure in The Netherlands: a pharmacoeconomic model. Pharmacoeconomics 1993; 3: 387–97

    PubMed  Google Scholar 

  24. Paul SD, Kuntz KM, Eagle KA, et al. Costs and effectiveness of angiotensin converting enzyme inhibition in patients with congestive heart failure. Arch Intern Med 1994; 154: 1143–9

    PubMed  CAS  Google Scholar 

  25. Tsevat J, Duke D, Goldman L, et al. Cost-effectiveness of captopril therapy after myocardial infraction. J Am Coll Cardiol 1995; 26: 914–9

    PubMed  CAS  Google Scholar 

  26. Scott WG, Scott HM. Heart failure: a decision analytic analysis of New Zealand data using the published results of the SOLVD treatment trial. Pharmacoeconomics 1996; 9: 156–67

    PubMed  CAS  Google Scholar 

  27. Michel BC, Al MJ, Remme WJ, et al. Economic aspects of treatment with captopril for patients with asymptomatic left ventricular dysfunction in The Netherlands. Eur Heart J 1996; 17: 731–40

    PubMed  CAS  Google Scholar 

  28. Erhardt L, Ball S, Andersson F, et al. Cost-effectiveness in treatment of heart failure with ramipril: a Swedish substudy of the AIRE study. Pharmacoeconomics 1997; 12: 256–66

    PubMed  CAS  Google Scholar 

  29. Goldman L, Benjamin ST, Cook EF, et al. Costs and effectiveness of routine therapy with long-term beta-adrenergic antagonists after acute myocardial infarction. N Engl J Med 1988; 319: 152–7

    PubMed  CAS  Google Scholar 

  30. Franzosi MG, Maggioni, Santoro E, et al. Cost-effectiveness analysis of early lisinopril use in patients with acute myocardial infarction: results from GISSI-3 trial. Pharmacoeconomics 1998; 13: 337–46

    PubMed  CAS  Google Scholar 

  31. Hummel S, Piercy J, Wright R, et al. An economic analysis of the Survival and Ventricular Enlargement (SAVE) study: application to the United Kingdom. Pharmacoeconomics 1997; 12: 182–92

    PubMed  CAS  Google Scholar 

  32. Glick H, Cook J, Pitt B, et al. The cost and benefits of enalapril therapy in post-MI patients with asymptomatic left ventricular dysfunction [abstract]. Circulation 1995; 92: 510

    Google Scholar 

  33. Szucs T, Berger K, Schulte-Hillen J, et al. Die Wirtschaftlichkeit von Captopril nachMyokardinfarkt. Med Klin 1996; 91: 112–8

    CAS  Google Scholar 

  34. McMurray JJV, McGuire A, Davie AP, et al. Cost-effectiveness of different ACE inhibitor treatment scenarios post-myocardial infarction. Eur Heart J 1997; 18: 1411–5

    PubMed  CAS  Google Scholar 

  35. Bart BA, Gattis WA, Diem SJ, et al. Reasons for underuse of angiotensin-converting enzyme inhibitors in patients with heart failure and left ventricular dysfunction. Am J Cardiol 1997; 79: 1118–20

    PubMed  CAS  Google Scholar 

  36. Barron HV, Michaels AP, Maynard C, et al. Use of angiotensin converting enzyme inhibitors at discharge in patients with acute myocardial infarction in the Unites States: data from the National Registry of Myocardial Infarction 2. J Am Coll Cardiol 1998; 32: 360–7

    PubMed  CAS  Google Scholar 

  37. Bleske BE, Cornish LA, Erickson SR, et al. Evaluation of ACE inhibitor therapy for congestive heart failure in an outpatient setting. J Pharm Technol 1998; 14: 7–11

    CAS  Google Scholar 

  38. Bourassa MG, Gurne O, Bangdiwala SI, et al. Natural history and patterns of current practice in heart failure. J Am Coll Cardiol 1993; 22: 14S–9S

    Google Scholar 

  39. Bown Luzier A, Forest A, Adelman M, et al. Impact of angiotensin-converting enzyme inhibitor underdosing on rehospitalization rates in congestive heart failure. Am J Cardiol 1998; 82: 465–9

    Google Scholar 

  40. Campbell NC, Thain J, Deans HG, et al. Secondary prevention in coronary heart disease: baseline survey of provision in general practice. BMJ 1998; 3: 1430–4

    Google Scholar 

  41. Chin MH, Friedmann PD, Cassel CK, et al. Differences in generalist and specialist physicians’ knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure. J Gen Intern Med 1997; 12: 523–30

    PubMed  CAS  Google Scholar 

  42. Chin MH, Goldman L. Factors contributing to the hospitalisation of patients with congestive heart failure. Am J Public Health 1997; 87: 643–8

    PubMed  CAS  Google Scholar 

  43. Chin MH, Wang JC, Zhang JX, et al. Utilization and dosing of angiotensin-converting enzyme inhibitors for heart failure: effect of physician specialty and patient characteristics. J Gen Intern Med 1997; 12: 563–6

    PubMed  CAS  Google Scholar 

  44. Chodoff B, Bischof RO, Nash DB, et al. The AHCPR gudielines on heart failure: comparison of family medicine and an internal medicine practice with the guidelines and educational intervention to modify behavior. Clin Perform Qual Health Care 1996; 4: 179–85

    PubMed  CAS  Google Scholar 

  45. Clark AL, Coats AJS. Severity of heart failure and dosage of angiotensin converting enzyme inhibitors. BMJ 1995; 310: 973–4

    PubMed  CAS  Google Scholar 

  46. Clarke KW, Gray D, Hampton JR. Evidence of inadequate investigation and treatment of patients with heart failure. Br Heart J 1994; 71: 584–7

    PubMed  CAS  Google Scholar 

  47. Croft JB, Giles WH, Roegner RH, et al. Pharmacologic management of heart failure among older adults by office-based physicians in the United States. J Fam Pract 1997; 44: 382–90

    PubMed  CAS  Google Scholar 

  48. Clinical Quality Improvement Network Investigators. Mortality risk and patterns of practice in 4,606 acute care patients with congestive heart failure: the relative importance of age, sex, and medical therapy. Arch Intern Med 1996; 156: 1669–73

    Google Scholar 

  49. Cody RJ. Management of refractory congestive heart failure. Am J Cardiol 1992; 4: 141–9

    Google Scholar 

  50. Deedwania PC. Under-utilization of evidence-based therapy in heart failure: an opportunity to deal a winning hand with ace up your sleeve. Arch Intern Med 1997; 157: 2409–12

    PubMed  CAS  Google Scholar 

  51. Edep ME, Shah ND, Tateoi IM, et al. Differences between primary care physicians and cardiologists in the management of CHF: relationship to practice guidelines. J Am Coll Cardiol 1997; 30: 518–26

    PubMed  CAS  Google Scholar 

  52. Fleg JL, Kitzman DW, Aronow WS, et al. Physician management of patients with heart failure and normal versus decreased left ventricular systolic function. Am J Cardiol 1998; 81: 506–9

    PubMed  CAS  Google Scholar 

  53. Gattis WA, Larsen RL, Hasselblad V, et al. Is optimal angiotensin converting enzyme inhibitor dosing neglected in elderly patients with heart failure? Am Heart J 1998; 136: 43–8

    PubMed  CAS  Google Scholar 

  54. Gundersen T, Saevareid HI. Treatment with ACE inhibitors in older patients with chronic congestive heart failure. Cardiol Elderly 1995; 3: 281–3

    Google Scholar 

  55. Havranek EP, Abrams F, Stevens E, et al. Is optimal angiotensin-converting enzyme inhibitor dosing neglected in elderly patients with heart failure? Determinants of mortality in elderly patients with heart failure: the role of angiotensin-converting enzyme inhibitors. Arch Intern Med 1998; 158: 2024–8

    CAS  Google Scholar 

  56. Hillis GS, Trent RJ, Winton P, et al. Angiotensin-converting enzyme inhibitors in the management of cardiac failure: are we ignoring the evidence? Q J Med 1996; 89: 145–50

    CAS  Google Scholar 

  57. Hillis GS, Al-Mohammad A, Wood M, et al. Changing patterns of investigation and treatment of cardiac failure in hospital. Heart 1996; 76: 427–9

    PubMed  CAS  Google Scholar 

  58. Hlatky MA, Fleg JL, Hinton PC, et al. Physician practice in the management of congestive heart failure. J Am Coll Cardiol 1986; 8: 966–70

    PubMed  CAS  Google Scholar 

  59. Houghton AR, Cowley AJ. Why are angiotensin converting enzyme inhibitors underutilised in the treatment of heart failure by general practitioners? Int J Cardiol 1997; 59: 7–10

    PubMed  CAS  Google Scholar 

  60. Krumholz HM, Wang Y, Parent EM, et al. Quality of care for elderly patients with heart failure. Arch Intern Med 1997; 157: 2242–7

    PubMed  CAS  Google Scholar 

  61. Luther P, Baldus D, Beckham V, et al. Adherence to prescribed medications in elderly patients with congestive heart failure. Cardiovasc Rev Rep 1995; 16 (10): 32–34, 39-40

    Google Scholar 

  62. Mair FS, Crowley TS, Brundred PE. Prevalence, aetiology and management of heart failure in general practice. Br J Gen Pract 1996; 46: 77–9

    PubMed  CAS  Google Scholar 

  63. McDermott MM, Feinglass J, Sy J, et al. Hospitalized congestive heart failure patients with preserved versus abnormal left ventricular systolic function: clinical characteristics and drug therapy. Am J Med 1995; 99: 629–35

    PubMed  CAS  Google Scholar 

  64. McDermott MM, Lee P, Mehta S, et al. Patterns of angiotensin-converting enzyme inhibitor prescriptions, educational interventions, and outcomes among hospitalized patients with heart failure. Clin Cardiol 1998; 21: 261–8

    PubMed  CAS  Google Scholar 

  65. McGrae McDermott M, Feinglass J, Lee P, et al. Heart failure between 1986 and 1994: temporal trends in drug-prescribing practices, hospital readmissions, and survival at an academic medical center. Am Heart J 1997; 134: 901–9

    Google Scholar 

  66. Mendelson G, Aronow WS, Under-utilization of angiotensin-converting enzyme inhibitors in older patients with Q-wave anterior myocardial infarction in an academic hospital-based geriatrics practice. J Am Geriatr Soc 1998; 46: 751–2

    PubMed  CAS  Google Scholar 

  67. Missouris CG, MacGregor GA. The use of angiotensin-converting enzyme inhibitors in the treatment of heart failure in hospital practice. Postgrad Med J 1997; 73: 409–11

    PubMed  CAS  Google Scholar 

  68. O’Keefe S, Harvey G, Lye M. Use of angiotensin-converting enzyme inhibitors in elderly patients with heart failure. Age Ageing 1998; 27: 297–301

    Google Scholar 

  69. Parameshwar J, Shackell MM, Richardson A, et al. Prevalence of heart failure in three general practices in north west London. Br J Gen Pract 1992; 42: 287–9

    PubMed  CAS  Google Scholar 

  70. Philbin EF. Factors determining angiotensin converting enzyme inhibitor underutilization in heart failure in a community setting. Clin Cardiol 1998; 21: 103–8

    PubMed  CAS  Google Scholar 

  71. Philbin EF, Andreaou C, Rocco TA, et al. Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals. Am J Cardiol 1996; 77: 832–9

    PubMed  CAS  Google Scholar 

  72. Philbin EF, Rocco TA. Use of angiotensin-converting enzyme inhibitors in heart failure with preserved left ventricular systolic function. Am Heart J 1997; 134: 188–95

    PubMed  CAS  Google Scholar 

  73. Rajfer SI. Perspective of the pharmaceutical industry on the development of newdrugs for heart failure. J Am Coll Cardiol 1993; 22: 198S–200S

    Google Scholar 

  74. Rich MW, Beckham V, Wittenberg C, et al. A multi-disciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995; 333: 1190–5

    PubMed  CAS  Google Scholar 

  75. Rich MW, Brooks K, Luther P. Temporal trends in pharmacology for congestive heart failure at an academic medical center: 1990-1995. Am Heart J 1998; 135: 367–72

    PubMed  CAS  Google Scholar 

  76. Simko RJ, Stanek EJ. Treatment patterns for heart failure in a primary care environment. Am J Manag Care 1997; 3: 1669–76

    PubMed  CAS  Google Scholar 

  77. Smith NL, Psaty BM, Pitt B, et al. Temporal patterns in the medical treatment of congestive heart failure with angiotensin- converting enzyme inhibitors in older adults, 1989 through 1995. Arch Intern Med 1998; 158: 1074–80

    PubMed  CAS  Google Scholar 

  78. Stafford RS, Saglam D, Blumenthal D. National patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure. Arch Intern Med 1997; 157: 2460–4

    PubMed  CAS  Google Scholar 

  79. Teo K, Montague T, Ackman M, et al. Mortality risk and patterns of practice in 4606 acute care patients with congestive heart failure: the relative importance of age, sex, and medical therapy. Arch Intern Med 1996; 156: 1669–73

    Google Scholar 

  80. The Large State Peer Review Organization Consortium. Heart failure treatment with angiotensin-converting enzyme inhibitors in hospitalized Medicare patients in 10 large states. Arch Intern Med 1997; 157: 1103–8

    Google Scholar 

  81. The SEOSI Investigators. Survey on heart failure in Italian hospital cardiology units: results of the SEOSI study. Eur Heart J 1997; 18: 1457–64

    Google Scholar 

  82. Vince JM, Rich MW, Sperry JC, et al. Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc 1990; 38: 1290–5

    Google Scholar 

  83. Young JB, Weiner DH, Yusuf S, et al. Patterns of medication use in patients with heart failure: a report from the Registry of Studies of Left Ventricular Dysfunction (SOLVD). South Med J 1995; 88: 514–23

    PubMed  CAS  Google Scholar 

  84. Information från Läkemedelsverket. Behandling av akut och kronisk hjärtsvikt: Rekommendationer [Treatment of acute and chronic heart failure: recommendations], no. 4. Uppsala: Läkemedelsverket, 1992

  85. Information från Läkemedelsverket. Nya data rörande behandling med ACE-hämmare efter hjärtinfarkt [New data regarding treatment with ACE-inhibitors after myocardial infarction], no. 5. Uppsala: Läkemedelsverket, 1993

  86. The Task Force on Heart Failure of the European Society of Cardiology. Guidelines on the diagnosis of heart failure. Eur Heart J 1995; 16: 741–51

    Google Scholar 

  87. American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure). Guidelines for the evaluation and management of heart failure. Circulation 1995; 92: 2764–84

    Google Scholar 

  88. McDonagh TA, Morrison CE, Lawrence A, et al. Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population. Lancet 1997; 50: 829–33

    Google Scholar 

  89. Statistiska Centralbyrån. Befolkningsstatistik 1996 [population statistics 1996]. Stockholm: SCB, 1997

  90. Køber L, Torp-Pedersen C, Pedersen O, et al. Importance of congestive heart failure and left ventricular systolic function on prognosis in patients with acute myocardial infarction. Am J Cardiol 1996; 78: 1124–8

    PubMed  Google Scholar 

  91. Swedish National Board of Health and Welfare, Epidemiological Center. Myocardial Infarction Register 1987-1997, Stockholm

    Google Scholar 

  92. Agents acting on the renin-angiotensin system: new data on SPICE (Study of patients intolerant to converting enzyme). Heart Failure Update ‘98; 1998 Jun 23-27; Glasgow

  93. Medical Index Sweden (MIS). Bi-annual reports covering February-September and October-March, 1988-1997, Stockholm

    Google Scholar 

  94. FASS. FASS 1996. Stockholm: Linfo, 1995

    Google Scholar 

  95. Data on file. Navigare-Barometer. Heart failure Sweden, 1996/2 (survey of specialists in internal medicine and general practitioners). Kungsbacka

  96. Husten L. ATLAS shows global undertreatment of heart failure [news item]. Lancet 1998; 351: 1035

    PubMed  CAS  Google Scholar 

  97. Jackson G. High dose lisinopril is superior to low dose in heart failure [editorial]. Int J Clin Pract 1998; 52: 139

    PubMed  CAS  Google Scholar 

  98. Cleland JGF, Massie BM, Packer M, et al. Health economic benefits of treating patients with heart failure with high dose lisinopril versus low dose: the ATLAS study [abstract]. Circulation 1998; 98: I135

    Google Scholar 

  99. Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico. GISSI-3: effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction. Lancet 1994; 343: 1115–22

    Google Scholar 

  100. Swedish Drug Market (SDM). Stockholm: Läkemedelsindustriföreningen (LIF), 1997

  101. Swedish National Board of Health and Welfare, Epidemiology Center. Health care database in Sweden, Stockholm

  102. Wolfel EE. Effects of ACE inhibitor therapy on quality of life in patients with heart failure. Pharmacotherapy 1998; 18: 1323–34

    PubMed  CAS  Google Scholar 

  103. WHO MONICA Project. Myocardial Infarction and Coronary Deaths in the World Health Organization MONICA Project. Circulation 1994; 90: 583–612

    Google Scholar 

  104. Darbar D, Choy A-MJ, Lang CC, et al. Attitudes of physicians in the treatment of congestive heart failure in older adults. J Am Geriatr Soc 1995; 43: 943–4

    PubMed  CAS  Google Scholar 

  105. Colquhoun MC, Waine C, Monaghan MJ, et al. Investigation in general practice of patients with suspected heart failure: how should the essential echocardiography service be delivered [editorial]? Br Heart J 1995; 74: 335–6

    PubMed  CAS  Google Scholar 

  106. Arnau JM, Agusti A. Is aspirin underused in myocardial infarction? Pharmacoeconomics 1997; 12: 524–32

    PubMed  CAS  Google Scholar 

  107. Khong TK, Missouris CG, Murdah H, et al. The use of HMG Co-A reductase inhibitors following acute myocardial infarction in hospital practice. Postgrad Med J 1998; 74: 600–1

    PubMed  CAS  Google Scholar 

  108. Stafford RS, Singer DE. National patterns of warfarin use in atrial fibrillation. Arch Intern Med 1996; 156: 2537–41

    PubMed  CAS  Google Scholar 

  109. Lamas GA, Pfeffer MA, Hamm P, et al. Do the results of randomized clinical trials of cardiovascular drugs influence medical practice? N Engl J Med 1992; 327: 241–7

    PubMed  CAS  Google Scholar 

  110. Deedwania PC. Early intervention in patients with heart failure and left ventricular dysfunction. Med Clin North Am 1995; 79: 1191–203

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Health Economics & QoL, Astra Draco AB, PO Box 34, Lund, S-221 00, Sweden

    Fredrick Andersson

  2. Cardiology Research Unit, Malmö University Hospital, Malmö, Sweden

    Charles Cline & Leif Erhardt

  3. Department of Health Economics, Astra Hässle AB, Mölndal, Sweden

    Tina Rydén-Bergsten

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  1. Fredrick Andersson
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Andersson, F., Cline, C., Rydén-Bergsten, T. et al. Angiotensin Converting Enzyme (ACE) Inhibitors and Heart Failure. Pharmacoeconomics 15, 535–550 (1999). https://doi.org/10.2165/00019053-199915060-00002

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