Angiotensin-converting-enzyme inhibitors in the management of cardiac failure: are we ignoring the evidence?

Abstract

The benefits of angiotensin-converting enzyme (ACE) inhibition in the management of cardiac failure have been extensively documented. However, little is known about its impact upon the investigation and management of this condition. We assessed how patients diagnosed as having cardiac failure were investigated, which patients were treated with ACE inhibitors and with what dosages. We reviewed the case notes of all 343 patients discharged from Aberdeen Royal Infirmary 1 July-31 December 1992 with a diagnosis of cardiac failure. In addition, a questionnaire was sent to the general practitioners of the 166 patients still alive in October 1994. Only 40% of patients were discharged from hospital on ACE inhibitors. In 58.8%, the diagnosis of cardiac failure was based purely on clinical or radiological grounds. At discharge, 76.1% of patients were on lower doses of ACE inhibitors than those used in the major survival studies; with 68.9% receiving similar doses two years later. The majority of patients with heart failure are under-investigated and under-treated.

Further evidence that chronic perindopril treatment maintains neurohormonal suppression but does not lower blood pressure in chronic cardiac failure

“…Whatever the real frequency of hypotension in diuretic treated heart failure patients given an ACEI, and this appears In the present study not only was there the expected suppression of serum ACE on chronic dosing with perindoplow yet variable in controlled trials, it remains a matter of concern that fear of first dose hypotension is used as a ril, but effective suppression of angiotensin II was also maintained in all patients during the 2 month treatment common reason for physicians to withold ACEI treatment especially in elderly heart failure patients [6][7][8]. Current period.…”

“…Regardless of the relatively low incidence of symptomatic first dose hypotenaddition to diuretic therapy these drugs now dominate the management of symptomatic chronic cardiac failure of sion (1-10% by variable trial evidence; [2,3]), it remains a concern for general practitioners when they prescribe ACE whatever origin and are becoming increasingly used in asymptomatic left ventricular dysfunction. Their role has inhibitors to this patient group [6] and may explain why ACE inhibitors are underutilised in heart failure [7][8][9][10]. It is recently been extended into the management of myocardial infarction complicated by symptomatic or asymptomatic left clear that combination treatment with diuretics and ACE inhibition is important in this regard and hypoperfusion can ventricular dysfunction [1][2][3][4].…”

Evidence of Improving Prognosis in Heart Failure

“…Clearly, this observation must be speculative. Although ACE inhibitors are used widely among patients admitted to Scottish hospitals with heart failure, [13][14][15] it is also possible that other factors could account for the apparent reduction in short-and long-term case-fatality rates. One obvious explanation is a reduction in admission threshold and the consequent creation of a cohort of patients with milder disease.…”

Management of heart failure in primary health care. A retrospective study on electronic patient records in a registered population

“…The diagnosis and management of CHF is changing rapidly (3) and many practical problems occur in trying to implement and measure adherence to such recommendations in primary health care (11). A substantial proportion of CHF patients do not get the treatment they need (12,13). Knowledge concerning management of CHF is limited in Swedish primary health care, although a recent study on prescribing indicated that the use of ACE inhibitors in CHF is increasing very modestly (14).…”