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Am Fam Physician. 2001;63(6):1174

Patients with congestive heart failure typically have an initial period of asymptomatic left ventricular (LV) dysfunction followed by a period of mild to moderate symptomatic disease and eventually progress to advanced, end-stage heart failure. Prognosis at each stage is improved by treatment with angiotensin-converting enzyme (ACE) inhibitors. The use of ACE inhibitors is cost-effective because the rate of hospitalization at every disease stage is decreased. Despite the recommendations for use of ACE inhibitors in patients with LV dysfunction, actual use is suboptimal.

Kermani and associates looked at the medical records of a series of hospitalized patients with objective findings of LV dysfunction but no evidence of current or prior congestive heart failure. Follow-up was performed up to 12 months after the index admission. LV dysfunction was considered present when documented by LV ejection fractions on echocardiography of 40 percent or less. Patients with a history of congestive heart failure were excluded. All patients included in the chart review were reevaluated at six months and one year after discharge by further medical record review and telephone contact.

Of the 107 patients admitted who met the criteria during the study period, 51 (48 percent) did not receive ACE inhibitor treatment, 34 (32 percent) were newly started on an ACE inhibitor regimen and 20 (19 percent) were continued on a previously established ACE inhibitor regimen. Of the patients treated with ACE inhibitor therapy, a subtherapeutic dosage, defined as less than 50 percent of dosages shown to be effective in clinical trials (see accompanying table), was given on discharge to 67 percent of patients receiving treatment. During the one-year follow-up period, lack of use of an ACE inhibitor was the only variable predictive of death or readmission.

ACE inhibitorDosage (mg per day)

The authors conclude that despite significant supporting data, only about one half of patients hospitalized and found to meet the criteria for asymptomatic LV dysfunction were receiving ACE inhibitors at the time of discharge. Involvement of a cardiologist seemed to increase the likelihood of ACE inhibitor use, but subtherapeutic dosing is a common problem. The absence of ACE inhibitor use in this population was strongly predictive of the adverse outcomes of rehospitalization or death.

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