Letter Regarding Article by Newby et al, “Long-Term Adherence to Evidence-Based Secondary Prevention Therapies in Coronary Artery Disease”
To the Editor:
We read with interest the article by Newby et al1 regarding adherence to evidence-based secondary prevention therapies in patients with heart disease. This is an important and sobering study, highlighting the need for better use of proven therapies for patients with coronary artery disease and heart failure. We were surprised, however, at the low rate of adherence to the use of angiotensin-converting enzyme inhibitors (ACEIs) in patients with heart failure. We feel that this reported rate may be somewhat misleading. To obtain information on heart failure drug use, the database was searched for any patient “with an ejection fraction less than 40% or clinical history congestive heart failure.” Using that definition, adherence rates to ACEIs were reported as low as 51%. However, up to 50% of patients with evidence of clinical heart failure have preserved systolic function.2 There is no evidence that ACEIs mitigate the morbidity or mortality from heart failure in patients with preserved systolic function. The American College of Cardiology/American Heart Association guidelines accordingly list ACEIs as a Class IIB agent in patients with heart failure and normal systolic function.3 In a large survey of patients hospitalized with heart failure, 62% were discharged on an ACEI.4 However, when this group was assessed according to ejection fraction, 80% of those with an ejection fraction <40% were discharged on an ACEI. Therefore, we propose that had the authors1 included only patients with an ejection fraction<40% (a Class I recommendation of ACEIs), adherence rates would have been higher.
The opinions or assertions expressed herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Dr Sullenberger has received honoraria from Koss Pharmaceuticals. Dr Jezior reports no conflicts.
Newby LK, LaPointe NM, Chen AY, Kramer JM, Hammill BG, DeLong ER, Muhlbaier LH, Califf RM. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006; 113: 203–212.
Hunt SA, American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2005; 46: 1116–1143.
Komajda M, Follath F, Swedberg K, Cleland J, Aguilar JC, Cohen-Solal A, Dietz R, Gavazzi A, Van Gilst WH, Hobbs R, Korewicki J, Madeira HC, Moiseyev VS, Preda I, Widimsky J, Freemantle N, Eastaugh J, Mason J; Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. The EuroHeart Failure Survey programme: a survey on the quality of care among patients with heart failure in Europe: part 2: treatment. Eur Heart J. 2003; 24: 464–474.