Underuse of ACE Inhibitors for Congestive Heart Failure
ABSTRACT & COMMENTARY
Synopsis: Chart review of hospitalized geriatric CHF patients across 10 large states showed widespread underuse of ACE Inhibitors, with variations both by age and state of hospitalization.
Source: Large State Peer Review Organization Consortium. Arch Intern Med 1997;157:1103-1108.
The use of angiotensin-converting enzyme (ACE) inhibitors for heart failure caused by left ventricular systolic dysfunction has been a great advance in the reduction of disease progression and the rates of hospitalization and mortality. Previous studies including 1103 congestive heart failure (CHF) hospitalizations in 1988-1989 indicated that only 32% of eligible patients were prescribed ACE inhibitors.1 Multiple other studies have documented improved functional status, morbidity, and mortality with the use of ACE inhibitors when CHF is associated with an abnormal left ventricular ejection fraction.2
This study reviewed 6749 randomly selected medical records of Medicare patients hospitalized with a principal diagnosis of heart failure not due to valvular disease, endocarditis, or myocarditis for the year 7/1/93 through 6/30/94. Through a collaborative effort of 10 large state peer-review organizations with the support of the Health Care Financing Administration (HCFA), a uniform study design was created, and data were pooled and analyzed to provide a widely applicable snapshot of treatment practices in this elderly population.
Results indicate an improvement in the use of ACE inhibitors to an overall rate of 55% at hospital dischargestill far less than the desired usage. Interesting differences were seen in usage analyzed by age of the patient, with 59% usage in the 65- to 74-year-old age group and only 50% in the group aged 85 and over. Medical records were also analyzed for evidence of allergy or intolerance to the medications, but only 2.5% documented allergy and 3.5% indicated treatment was started but withdrawn during the hospitalization for any reason.
Since a low ejection fraction (EF) is an important indicator of the need for CHF treatment, charts were abstracted for this information, and it was found overall in 59% of cases, ranging from 45% in California records to 79% in New Jersey. Again, there was an age discrepancy, with 66% of younger patients (65-74 years) having EF present but only 49% of the older group (over 85 years). Overall, patients were more likely to receive ACE inhibitors if the EF was documented (59% vs 48%). If the CHF patients were narrowly selected for only those with EF less than 40% with no strict contraindications to ACE inhibitor use (such as Creatinine > 3.0 mg/dL), the number receiving this treatment rose to 73% (78% for the younger ages vs 67% for the older).
Besides the clear treatment differences based on age across all 10 states, this study also demonstrated a difference in length of stay for the CHF diagnosis, ranging from a median of four days in California and eight days in New Jersey (overall stay was 6 days). This, along with the difference in documentation of ejection fractions, continues to show regional differences in the treatment of this disease.
COMMENT BY MARY ELINA FERRIS, MD
As the leading discharge diagnosis for the elderly from acute care hospitals, heart failureits workup and treatmentis an area of great research and financial interest. The previous Digoxin and Lasix regimen has expanded to include new drugs and technologies, yet their acceptance has been slow, as shown in the above article.
In 1994, the Agency for Health Care Policy and Research issued physician treatment guidelines for heart failure from left ventricular systolic disfunction3 reflecting the widespread consensus that echocardiography should be used to measure the left ventricular ejection fraction and that ACE inhibitors should be a standard part of CHF treatment. The main contraindications that preclude ACE Inhibitor use are: 1) symptomatic hypotension, 2) serum potassium above 5.5 that can’t be reduced, and 3) intolerance or adverse reactions. Recent studies in the geriatric literature specifically support this treatment for the elderly.4,5
This study provides clinicians with useful feedback on how their performance in CHF treatment is evolving and also shows regional variations in health care which have been known in other illnesses. It reflects the new role for the HCFA-funded peer review organizations in each state, which were previously charged with random Medicare chart audits to ferret out bad practices and prosecute accordingly. Since 1993, the emphasis of their work has been shifted to a more collaborative role with providers, giving information about clinical processes and outcomes on a statewide and national level that can be used as benchmarks and as opportunities for improvement in a continuous quality improvement model.6
Finally, the clear differences in treatment and workup based on age merits more attention and has not been studied to great extent. Although it might be tempting to attribute the variation to frailty or diminished mental status, we must be alert to potential "age-bias" and not judge our patients’ need for treatment solely on their chronological age.
References
1. Young JB, et al. Patterns of medication use in patient with heart failure: A report from the Registry of Studies of Left Ventricular Dysfunction (SOLVD). South Med J 1995;88:514-523.
2. Garg R, et al. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA 1995;273:1450-1456.
3. Konstam M, et al. Heart Failure: Evaluation and Care of Patients with Left Ventricular Systolic Dysfunction. AHCPR Publication No. 94-0612. Rockville, MD: Agency for Health Care Policy and Research, June 1994; 1-21. (Available from http://www.ahcpr.gov)
4. Aronow WS. Treatment of congestive heart failure in older persons. J Am Geriatr Soc 1997;45:1252-1258.
5. Tresch DD. The clinical diagnosis of heart failure in older persons. J Am Geriatr Soc 1997;45:1128-1133.
6. Jencks SF, et al. The health care quality improvement initiative: A new approach to quality assurance in Medicare. JAMA 1992;268:900-903.
Which of the following patients with heart failure from left ventricular systolic dysfunction are not candidates for ACE inhibitor therapy?
Gemfibrozil treatment of post-CABG patients with isolated low HDL has been associated with marked reduction in subsequent clinical events despite lack of any demonstrated angiographic benefit.
a. African-American male age 82 living at home
b. Caucasian female age 65 with rheumatoid arthritis and Creatinine 2.5
c. Hispanic female age 70 with symptomatic hypotension
d. Caucasian male age 85 with ejection fraction < 40%
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.