Content provided in partnership with

Health Care Industry

Use of angiotensin-converting enzyme inhibitors in elderly patients with heart failure

Age and Ageing, May, 1998 by Shaun O'Keeffe, Gill Harvey, Michael Lye

Introduction

Treatment with angiotensin-converting enzyme (ACE) inhibitors improves symptoms and survival of patients with chronic heart failure [1]. The incidence and prevalence of chronic heart failure increase exponentially with increasing age [2]. The results of the large randomized treatment trials indicate that treatment with ACE inhibitors benefits elderly patients with heart failure and asymptomatic left ventricular dysfunction [3-6]. Indeed, the absolute reductions in mortality and hospitalizations for heart failure brought about by ACE inhibitors may be greatest in elderly patients [1].

Most Popular Articles in Health: Fuel your workout: exercisers who eat before they work out have more energy ...; Soothe a dry, itchy scalp: 5 easy expert solutions; Cocktails and calories: Beer, wine and liquor calories can really add up. ...; The sour truth about apple cider vinegar - evaluation of therapeutic use; The, six best supplements you've never heard of: these secret weapons can ...; More »

Studies suggest that ACE inhibitors are under-used in patients with heart failure in the UK [7, 8]. Also, many patients taking ACE inhibitors are prescribed a dosage which is less than that shown to be effective in clinical trials [7, 9]. Elderly patients are less likely to receive ACE inhibitors after heart failure than young patients [7, 10]. One possible explanation is that elderly patients are more likely to have contraindications to, or experience adverse effects from, ACE inhibitors. An alternative explanation is that, while the benefits of ACE inhibitor therapy are best established in heart failure patients with systolic dysfunction on echocardiography or radionuclide testing [1], a high proportion of elderly heart failure patients have normal systolic function [11]. However, studies show that echocardiography is performed in only 30-60% of inpatients with heart failure in the UK and there is some evidence that older patients are least likely to undergo this investigation [7, 8, 12, 13].

The aim of the present study was to assess the use of ACE inhibitors in elderly heart failure patients discharged from all acute geriatric units in Mersey region, with particular reference to the performance of echocardiography and the presence or absence of left ventricular systolic dysfunction.

Methods

Ten consecutive case notes of patients discharged from hospital in 1995 with a diagnosis of heart failure in the discharge summary were assessed for each of the 31 consultants in geriatric medicine working in 12 acute hospitals in the region. Case notes were retrieved and assessed by a specially trained pharmacy audit assistant; the consultants had no influence on the selection of case notes. Patient characteristics, laboratory and other tests and drug usage were recorded for each patient using a standardized assessment form.

Echocardiography reports were obtained for all patients who had undergone this investigation. For this study, left ventricular systolic dysfunction was defined by an ejection fraction less than 0.45 or, where measurement of ejection fraction was not reported, by the presence of a global impairment of left ventricular contraction. Valvular disease was recorded if the echocardiographer or cardiologist described valvular regurgitation or stenosis as `significant', `probably significant' or `moderate to severe'.

Continuous data were examined with Student's t-tests (unpaired) and categorical data by [chi square] tests. Stepwise logistic regression was used to determine the independent predictors of dichotomous outcomes. Age, sex and cardiac diagnoses were included in all analyses. Discharge values for plasma creatinine, urea, sodium and potassium concentrations were also entered into the models examining ACE inhibitor use in different patient groups.

Determinants of the dose of ACE inhibitor were examined by stepwise multiple regression analysis. We followed the procedure of Clark and Coats and standardized the dose of each ACE inhibitor to a proportion of the lowest target dose for that agent which had been shown to improve mortality: These were: captopril 25mg twice daily, lisinopril 10mg daily, enalapril 10mg twice daily and ramipril 5 mg twice daily [13].

Results

Complete data were obtained for 310 patients. The median age of these patients was 82 years (range 68-94) and there were 106 men and 204 women. Despite the diagnosis in the discharge summary; three patients were judged not to have heart failure based on consultant comments in the case notes. Two of these patients probably had gravitational oedema and one had dyspnoea secondary to chronic obstructive airways disease. These patients are excluded from subsequent analyses. Of the remaining 307 patients, 124 were newly diagnosed as having heart failure and 181 had had a diagnosis of heart failure established before the index admission.

Of the 307 patients, 121 (39%) had undergone echocardiography either during their index hospital stay (88) or previously (33); no patient had had radionuclide scanning or left ventriculography performed. In a stepwise logistic regression analysis including all demographic, clinical and laboratory data, only patient age [odds ratio (OR) 0.94, confidence interval (CI) 0.90-0.97] was an independent predictor of performance of echocardiography. However, the proportion of heart failure patients in different hospitals who had echocardiography ranged from 7 to 67% while use of echocardiography by different consultants varied from 5 to 75%. There were no significant differences in patient demographics, clinical or laboratory data to account for these findings.

Health Care Industry

Use of angiotensin-converting enzyme inhibitors in elderly patients with heart failure

Age and Ageing, May, 1998 by Shaun O'Keeffe, Gill Harvey, Michael Lye

Find Research Guides for:

Find Featured Titles for: Home & Garden

Most Popular Articles in Health

Most Popular Publications in Health