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NEW YORK (Reuters Health) Aug 03 - Almost one third of patients with left ventricular systolic dysfunction (LVSD) are not prescribed an angiotensin converting enzyme (ACE) inhibitor upon hospital discharge. As a result, investigators report in the August 10th issue of Circulation: Journal of the American Heart Association, these older patients are at higher risk of dying during the following year.

To get a better picture of the extent of ACE inhibitor underuse, the factors that may be driving it, and the effects on patient survival, Dr. Frederick A. Masoudi and associates studied a national sample of 17,456 Medicare recipients age 65 years or older who were hospitalized between 1998 and 2001 for LVSD. The sample was considered an "ideal cohort" in that there were no documented contraindications to use of ACE inhibitors.

Dr. Masoudi, at the University of Colorado Health Sciences Center in Denver, and his team found that 68% of patients were prescribed an ACE inhibitor at hospital discharge. Substitution of an angiotensin receptor blocker (ARB) did not make up the difference, since only 10% received this type of drug.

The 1-year crude mortality was 42.1% among those who were not treated with an ACE inhibitor versus 33.0% for those who were.

Multivariable analysis that included patient, physician and hospital factors revealed a 14% relative reduction in 1-year mortality among those who were given an ACE inhibitor prescription at discharge. Use of an ACE inhibitor or an ARB was associated with a 17% relative reduction in mortality.

Dr. Masoudi's team notes that randomized trials typically exclude older patients or those with renal dysfunction, suggesting that physicians may hesitate to use ACE inhibitors in these patients for fear of adverse events.

Their own analysis, however, indicates lower mortality regardless of patient gender, age, race or serum creatinine level, and in fact, "older patients and those with renal insufficiency may have the most to gain from treatment."

In an editorial, Dr. Mark A Hlatky, at Stanford University School of Medicine in California, addresses the need to "close the gap between actual and ideal performance" in prescribing ACE inhibitors for heart failure. Such measures may include reminder systems for physicians, critical pathways, and other structured approaches to quality improvement.

Circulation 2004.