Determinants of angiotensin-converting enzyme inhibitor prescription in severe heart failure with left ventricular systolic dysfunction: The EPICAL study

• Published in: The American heart journal 2000-04, Vol.139 (4), p.624-631
• Main Authors: Echemann, M., Zannad, F., Briançon, S., Juillière, Y., Mertès, P.M., Virion, J.M., Villemot, J.P., EPICAL Investigators
• Format: Article
• Language: English
• Subjects: Aged; Angiotensin-Converting Enzyme Inhibitors - administration & dosage; Angiotensin-Converting Enzyme Inhibitors - adverse effects; Biological and medical sciences; Cardiovascular system; Chronic Disease; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Prescriptions - statistics & numerical data; Drug Utilization - statistics & numerical data; Female; France; Heart Failure - diagnosis; Heart Failure - drug therapy; Humans; Kidney Function Tests; Male; Medical sciences; Middle Aged; Miscellaneous; Pharmacology. Drug treatments; Prospective Studies; Systole - drug effects; Ventricular Dysfunction, Left - diagnosis; Ventricular Dysfunction, Left - drug therapy
• ISSN: 0002-8703; 1097-6744
• DOI: 10.1016/S0002-8703(00)90039-5

Background Angiotensin-converting enzyme (ACE) inhibitors have been demonstrated to reduce morbidity and mortality rates in patients with heart failure with left ventricular systolic dysfunction. Nevertheless, these drugs are underutilized in current practice and prescribed at doses below those usually recommended. The aim of this work was to identify the social, demographic, laboratory, clinical, and therapeutic factors associated with nonprescription of ACE inhibitors and/or their prescription at doses below those recommended in the treatment of severe long-term congestive heart failure (CHF). Methods and Results An epidemiologic observational study, EPICAL (EPidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine), studied 417 patients with severe CHF surviving after the index hospitalization. Multivariate logistic regression determined the factors associated with ACE inhibitor nonprescription and with their prescription at lower-than-recommended doses. ACE inhibitors were taken by 75% of the patients but 38% took lower-than-recommended doses. Factors shown to be associated with nonprescription included patients >65 years of age with renal impairment (odds ratio 19.5, confidence interval [Cl] 7.9–48.0), nonsinus cardiac rhythm (odds ratio 2.0, Cl 1.2–3.2), and prescription of potassium-sparing diuretics (odds ratio 2.4, Cl 1.2–4.7). Renal impairment was the single most important factor associated with prescription of lower-than-recommended doses, particularly in elderly patients. Conclusions Our results underline the need for optimal and better use of ACE inhibitor therapy. CHF treatment guidelines must be more uniformly applied by all physicians caring for patients with heart failure.