Prescribing ACE inhibitors to in-patients is important, but outpatients need ongoing support

Use of angiotensin-converting enzyme (ACE) inhibitors by heart failure patients drops sharply within a month after they go home from the hospital and then continues to decline, according to a new study in the June 2, 2004 issue of the Journal of the American College of Cardiology.

“Although we expected that the rate of long-term use would go down over time, we were surprised at the magnitude to which it did,” said Javed Butler, MD, MPH, FACC from Vanderbilt University in Nashville, Tenn. “Do not assume that just because the science is out, and we know that ACE inhibitors are good for these patients, that we actually are prescribing them; and even if we do prescribe them, do not assume that the patients are regularly taking them.”

The researchers called for efforts to both raise the proportion of heart failure patients who leave the hospital with ACE inhibitors and then help them continue to fill their prescriptions after they get home.

“Systems improvements like computerized order entry systems on the part of hospitals, or even a simple checklist on patients’ charts by the physicians to prescribe or ask patients about their use, may help increase the adherence with these medications. We clearly need effective intervention implementation to improve upon their use,” Dr. Butler said.

In the first study of its type to track heart failure patients over time, the researchers reviewed data on 1,059 heart failure patients who were enrolled in both Medicare and the Tennessee Medicaid (TennCare) program at the time of their hospitalization. Patients who are enrolled in both programs are covered for both hospitalization and outpatient medications. Federal and state records allowed the researchers to collect clinical information and track prescription use.

Among patients with depressed ejection fraction (one form of heart failure), 67 percent were discharged with ACE inhibitor medications. Four out of five of these patients filled an ACE inhibitor prescription within 30 days after discharge. After a year, only two-thirds of patients discharged with ACE inhibitors were still filling their prescriptions.

Among all heart failure patients (including those with preserved ejection fraction), 55 percent left the hospital with ACE inhibitors. Of that group, 77 percent filled a prescription within 30 days and 63 percent were still filling prescriptions a year after discharge.

Despite the decline in prescription use, leaving the hospital with ACE inhibitor medication was still very important, according to this study. Among patients who did not receive a discharge order for ACE inhibitors, only about one in eight filled a prescription within 30 days.

Although this study didn’t look at why prescription use declines, Dr. Butler said there are probably several reasons heart failure patients either don’t receive or fail to use ACE inhibitor prescriptions.

“The theoretical reasons are many, including not realizing the importance of long-term use by patients and stopping medicines when they feel good, costs, problems of coping with multiple diseases and lack of support, multiple prescriptions, side effects, and intolerance. From a provider perspective challenges include dealing with multiple problems in a short clinic visit and forgetting about writing prescriptions, especially for a condition which may be asymptomatic, and lack of experience or self-efficacy on part of the physician,” Dr. Butler said.

He said more studies are needed on how to develop effective interventions to increase long-term ACE inhibitor use by heart failure patients.

Edward P. Havranek, MD, FACC from the Denver Health Medical Center and the University of Colorado Health Sciences Center in Denver, who was not connected with this study, said the researchers made innovative use of publicly available data. He said their results highlight the importance of hospital practice to getting patients started off right.

“What happens in the hospital is a major predictor of what happens after a patient leaves the hospital. Patients who get the right medications at discharge are likely to be on the right medications a year later, and those who don't get the right medications at discharge frequently don't wind up on them over the ensuing year. This suggests that continued efforts to ensure high quality care for hospitalized patients does make a difference in the long run,” Dr. Havranek said.

Paul G. Shekelle, MD, PhD, with the Greater Los Angeles Veterans Affairs Health Center in California, who also was not part of the research team, said the study provides important documentation of substantial declines in the use of ACE inhibitors over time.

“Most quality of care monitoring assesses the prescription of these medications during a hospitalization or at discharge. This paper indicates that reliance on only this mechanism will leave many people at risk, and therefore additional quality monitoring that incorporates an outpatient perspective is also important,” Dr. Shekelle said.

The American College of Cardiology, a 29,000-member nonprofit professional medical society and teaching institution, is dedicated to fostering optimal cardiovascular care and disease prevention through professional education, promotion of research, leadership in the development of standards and guidelines, and the formulation of health care policy.

http://www.acc.org