Letter Regarding Article by Masoudi et al, “National Patterns of Use and Effectiveness of Angiotensin-Converting Enzyme Inhibitors in Older Patients With Heart Failure and Left Ventricular Systolic Dysfunction”
To the Editor:
We read with great interest the article by Masoudi et al,1 in which “a stubborn, persistent gap between ideal practice and actual use of ACE inhibitors for heart failure” was shown. The editorial by Mark Hlatky2 also stimulated our reflections.
The gap between ideal and practical use in the cardiovascular field and other fields of medicine may have various explanations. Data have shown that the “real patient” is different from the “trial patient”; in fact the latter, even if old, is usually in good general condition, without comorbidities and cognitive and physical impairments. This patient may be considered a “robust” or an “intermediate” subject.3 In the real world, however, many patients are frail, with severe comorbidities, polypharmacy, cognitive or physical disabilities, and reduced life expectancy. Many doctors involved in treating frail patients have the perception that certain drugs may not be useful. We must give scientific basis to this perception. This is true in particular for angiotensin-converting enzyme inhibitors and β-blockers, the benefits of which are not immediate for patients.
As observed with the underuse of warfarin in the prophylaxis of thromboembolism in atrial fibrillation in older adult patients,4 we believe that the gap between actual and ideal clinical management may be not an index of malpractice.5 Cardiovascular professional societies should address practice guidelines not only for the robust patient but also for the frail patient with reduced life expectancy, and should choose survival and symptoms as outcomes of treatment in robust patients, but only symptoms in the frailest group of patients.
In conclusion, we believe that cardiovascular societies should classify the different typology of older adult patients (eg, robust versus intermediate versus physical and cognitively disabled versus end-stage or dying), allowing physicians to select different therapeutic goals according to life expectancy. In this way, it will be possible to reduce in the single patient the gap between actual and ideal clinical management.
Masoudi FA, Rathore SS, Wang Y, Havranek EP, Curtis JP, Foody JM, Krumholz HM. National patterns of use and effectiveness of angiotensin-converting enzyme inhibitors in older patients with heart failure and left ventricular systolic dysfunction. Circulation. 2004; 110: 724–731.
Hlatky MA. Underuse of evidence-based therapies. Circulation. 2004; 110: 644–645.
Dr Sabatini and colleagues raise important issues in the care of older patients with heart failure. It may be difficult to apply existing evidence to these patients because few resemble those enrolled in clinical trials,1 many have competing comorbidities,2 and treatment goals may vary. Nonetheless, our study3 assessed patterns of use of angiotensin-converting enzyme (ACE) inhibitors in a “real-world” older adult population characterized by these treatment challenges.
We studied only patients with no physician-documented reason—including frailty, patient preference, or physician judgment—to justify withholding ACE inhibitors.3 Given the exclusive focus on ideal candidates and the assessment of the use of ARBs as alternatives, we maintain that the treatment rates documented in our study demonstrate the persistent need for efforts to improve care.
Although polypharmacy complicates the treatment of older patients with heart failure, it is sobering to recognize that the gaps in ACE inhibitor prescription occur in the context of the frequent use of potentially harmful drugs, which emphasizes the importance of the routine review of the complex regimens of these patients. Practitioners should focus on maximizing the use of drugs with likely benefits, reconsidering those providing marginal benefits, and discontinuing potentially harmful agents.
Finally, advanced age, frailty, or comorbidity alone should not obviate the consideration of ACE inhibitor therapy. There is growing evidence demonstrating the effectiveness of guideline-recommended treatment in frail older patients with cardiovascular diseases.3,4 Furthermore, although some patients may prefer quality over quantity of life, ACE inhibitors may still be important to realizing these alternative treatment goals.
Although we support the development of a robust evidence base for the care of the growing number of older people with cardiovascular disease, we believe that it would be difficult and potentially inappropriate to create a typology of older patients. Given the complexities of caring for older people with heart failure, however, healthcare providers should provide individualized care that is sensitive to patient preferences and therapeutic goals.