Almost one third of eligible patients with heart failure do not receive an angiotensin-converting enzyme inhibitor (ACE-inhibitor) and they have an increased risk for death, according to an article in the August 3rd rapid access issue of Circulation.

A review of data from the Centers from Medicare and Medicaid Services’ National Heart Care Project showed that 32 percent of elderly heart failure patients were discharged from hospitals without prescriptions for ACE-inhibitors. Patients discharged without such anti-angiotensin therapy had a 14 percent greater risk of dying within a year than patients treated with ACE-inhibitors. The use of angiotensin receptor blockers, an alternative to ACE-inhibitors in some patients with heart failure, did not explain the low rates of appropriate therapy.

“The under-use of life-saving medications in patients with systolic heart failure is a pervasive problem throughout the health care community,” said Frederick Masoudi, MD, MSPH, lead author of the study. “Our study provides good evidence… to validate current guideline recommendations that all patients with systolic dysfunction should be getting ACE-inhibitors unless they have a contraindication to the use of these drugs.”

Because the authors suspected multiple factors probably contribute to under-use of ACE-inhibitors in heart failure patients, they reviewed records on 17,456 Medicare patients who had heart failure and left ventricular systolic dysfunction. The review covered two time periods: April 1998 to March 1999 and July 2000 to June 2001. All he patients were at least 65 years old (average age, 78 years), and none had contraindications to treatment with an ACE-inhibitor.

Overall, 68 percent of patients had prescriptions for ACE-inhibitors on hospital discharge. The proportion of patients treated with ACE-inhibitors was 69 percent during 1998?1999 and 67 percent between 2000 and 2001. When ACE-inhibitors and angiotensin receptor blockers were considered together, 78 percent of patients had prescriptions at hospital discharge.

Treatment with an ACE-inhibitor was associated with a lower risk of death during the first year after hospital discharge. Patients who received an ACE-inhibitor had a one-year mortality of 33 percent compared with 42 percent for patients who did not use one. After adjusting for differences in patient and provider characteristics, the prescription of an ACE-inhibitor was associated with a 14 percent lower risk of death at one year.

The study identified the benefits of ACE-inhibitors in patients underrepresented in clinical studies, or some for whom the benefits of ACE-inhibitors have been controversial, according to Masoudi. Those patients have included the very old, women, African-Americans, and patients with kidney disease and other high-risk conditions.

In an editorial accompanying the article, Mark Hlatky, MD, noted that using ACE-inhibitors to treat heart failure has reached a plateau in recent years, leaving a substantial gap between current medical practices and optimal care.

“If we’re going to get to the next stage [in ACE-inhibitor use], we have to do more than tell people ‘just do this’,” said Hlatky, professor of medicine and of health research and policy.