Published Online
on August 2, 2004

A more recent version of this article appeared on August 10, 2004

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Submitted on April 14, 2004
Revised on June 7, 2004
Accepted on June 15, 2004

National Patterns of Use and Effectiveness of Angiotensin-Converting Enzyme Inhibitors in Older Patients With Heart Failure and Left Ventricular Systolic Dysfunction

Frederick A. Masoudi MD, MSPH^*, Saif S. Rathore MPH, Yongfei Wang MS, Edward P. Havranek MD, Jeptha P. Curtis MD, JoAnne Micale Foody MD, and Harlan M. Krumholz MD

From the Department of Medicine, Denver Health Medical Center (F.A.M., E.P.H.) and the Department of Medicine, University of Colorado Health Sciences Center (F.A.M., E.P.H.), Denver, Colo; Colorado Foundation for Medical Care (F.A.M., E.P.H., H.M.K.), Aurora, Colo; the Department of Internal Medicine (S.S.R., Y.W., J.P.C., J.M.F., H.M.K.) and the Department of Epidemiology and Public Health (H.M.K.), Yale University School of Medicine, and the Center for Outcomes Research and Evaluation (H.M.K.), Yale-New Haven Hospital, New Haven, Conn.

^* To whom correspondence should be addressed. E-mail: fred.masoudi{at}uchsc.edu.

Background--Although ACE inhibitors are underprescribed for heart failure, factors associated with their use are not well described. Furthermore, the effectiveness of ACE inhibitors has been questioned in some populations, potentially contributing to underuse. Our objectives were to assess the correlates of ACE inhibitor use and the relationship between ACE inhibitor prescription and mortality in older patients with heart failure.

Methods and Results--We studied a national sample aged 65 years who had survived hospitalization for heart failure between April 1998 and March 1999 or July 2000 and June 2001, restricting the analysis to patients with left ventricular systolic dysfunction and without a documented contraindication to use of ACE inhibitors (n=17 456). Factors associated with ACE inhibitor prescription at discharge and the relationship between ACE inhibitor prescription and death within 1 year were assessed with hierarchical logistic models. Secondary analyses assessed therapeutic substitution with angiotensin receptor blockers (ARBs). ACE inhibitors were prescribed to only 68% of this ideal cohort, and 76% received either an ACE inhibitor or an ARB. Patient, physician, and hospital factors were weak predictors of prescription, except for serum creatinine (RR for 133 to 221 µmol/L=0.87, 95% CI 0.85 to 0.89; RR for 222 µmol/L=0.53, 95% CI 0.49 to 0.57 compared with 132 µmol/L). ACE inhibitor prescription was associated with lower crude 1-year mortality (33.0% versus 42.1%, P<0.001), lower risk of death after adjustment (RR 0.86, 95% CI 0.82 to 0.90), and lower mortality regardless of patient gender, age, race, or serum creatinine level.

Conclusions--ACE inhibitors were widely underprescribed despite evidence of a favorable impact on survival in a broad range of patients with heart failure. These results emphasize the importance of ongoing efforts to translate clinical trial results into practice.

Key words: heart failure • aging • risk factors • follow-up studies • mortality

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