Age-related underutilization of angiotensin-converting enzyme inhibitors in older hospitalized heart failure patients.

ABSTRACT

Background. The extent to which age plays a role in the underutilization of angiotensin-converting enzyme (ACE) inhibitors in heart failure patients has not been well studied.

Methods. We studied age-related variation in the use of ACE inhibitors in older Medicare beneficiaries discharged alive in Alabama with a diagnosis of heart failure with left ventricular systolic dysfunction.

Results. A total of 285 patients had a mean age [+ or -] SD of 78 [+ or -] 6.9 years; 59% were female and 21% were African American. Of the 285 patients, 181 (63%) were prescribed ACE inhibitors at discharge. Therapy with ACE inhibitors was initiated in 47% of the patients. Compared with patients 65 to 74 years, those 85 years and older had lower odds of receiving ACE inhibitors at discharge. Among patients not admitted on an ACE inhibitor, those 85 years and older also had lower odds of ACE inhibitor therapy being initiated.

Conclusion. The overall rate of ACE inhibitor use was low, and age of 85 years and older was independently associated with lower use and initiation of ACE inhibitors. Opportunities remain to increase the use of ACE inhibitors in older patients with heart failure.

**********

IN 1995, heart failure was documented as the principal discharge diagnosis in 872,000 hospitalizations. Of these admissions, 698,000 (80%) were patients 65 years and older, of which 26% were 85 years and older. (1,2) In 1993, 42,000 patients died from heart failure, and another 219,000 deaths were secondarily associated with heart failure. (3) The majority of these deaths were in persons 65 years and older. (4)

In the late 1980s, several large-scale randomized controlled trials have shown survival benefits of using ACE inhibitors in patients with heart failure associated with left ventricular systolic dysfunction. (5,6) In the early 1990s, the Agency for Healthcare Research and Quality (AI-IRQ, formerly the AHCPR) and the American College of Cardiology/American Heart Association published heart failure guidelines that recommended use of ACE inhibitors for all heart failure patients with systolic dysfunction. (7,8)

Studies have documented underutilization of ACE inhibitors in older heart failure patients (9-14); however, the association between age and underutilization of these life-saving drugs has not been well studied. Since persons 85 years and older are the fastest growing segment of the US population, (15) the number of heart failure patients in that age group is expected to increase in the coming decades. (3,16) We studied the association between age and the underutilization of ACE inhibitors in older Medicare beneficiaries discharged from Alabama hospitals with a diagnosis of heart failure associated with left ventricular systolic dysfunction.

METHODS

General Design

This study is a secondary analysis of the baseline data set of a heart failure quality-improvement project by the Alabama Quality Assurance Foundation (AQAF). Data were collected through retrospective medical record review.

Subjects and Data Collection

Subjects were hospitalized Medicare beneficiaries 65 years and older who were discharged alive between January and December 1994 with a principal discharge diagnosis of heart failure. All patients had documented left ventricular systolic dysfunction, and none had contraindications to the use of ACE inhibitors.

The details of the subject selection and data collection processes have been described elsewhere. (12,17) Briefly, patients with heart failure were identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 428 or 402.91. The diagnosis of heart failure was verified during chart abstraction and later confirmed using diagnostic criteria described elsewhere. (17) In addition to the various demographic and clinical variables, (17) data were also collected on preadmission and discharge medications.

Outcome Measure

The primary outcomes of the study were use of ACE inhibitors at discharge, in all patients and in the subset of patients without preadmission use of ACE inhibitors (initiation of ACE inhibitors). These ACE inhibitors included captopril, enalapril, lisinopril, benazepril, quinapril, ramipril, and fosinopril. Patients were eligible for ACE inhibitor therapy if they were discharged alive with documented left ventricular systolic dysfunction and had no contraindication to ACE inhibitor use. Left ventricular ejection fraction of less than 40% or a description of moderately or severely impaired left ventricular function, measured by contrast left ventriculography, multiple gated acquisition radionuclide left ventriculography, or echocardiography during the index hospitalization or before, was considered left ventricular systolic dysfunction. Contraindications to the use of ACE inhibitors were defined as intolerance to ACE inhibitors, severe aortic stenosis, or bilateral renal artery stenosis. Intolerance to ACE in hibitors was defined as the development of cough, hypotension, hyperkalemia, deteriorating renal function, or angioneurotic edema during any previous use of the drug.

Analysis

SPSS for Windows, Release 10.0.0 (18) was used to analyze the data. Patients were stratified into age 65 to 74 years, 75 to 84 years, and 85 years and older. We compared baseline demographics and admission characteristics of the patients along the age categories, and tested statistical significance using Pearson's chi-square and the Student t test. We compared the use of ACE inhibitors by the age categories for all patients, and stratified by preadmission ACE inhibitor use. Statistical significance was tested using Pearson's chi-square tests. Using logistic regression analyses, we estimated the odds ratios (ORs) with 95% confidence intervals (CIs) for both use and initiation of ACE inhibitors in patients aged 75 to 84 years and those 85 years and older, compared with those aged 65 to 74 years. We also repeated these analyses, using age as a continuous variable.

Using multiple logistic regression models, we adjusted for age of 75 to 84 years and age of 85 years and older (reference age, 65 to 74 years), sex (female), and race (African American). In the next step, we entered nursing-home admission, incidence of heart failure, hypertension, diabetes, coronary artery disease, cardiomyopathy, preadmission use of ACE inhibitors, and care by a cardiologist. Systolic blood pressure level (mm Hg) and serum creatinine level (mg/dL) were entered as continuous variables. Serum potassium level was entered as a categorical variable ([greater than or equal to]5.5 mEq/L) due to correlation between serum creatinine and potassium levels (Pearson correlation coefficient 0.22; P<.001). We entered the admitting hospital as a dummy variable, using the hospital with the lowest rate of ACE inhibitor use as the reference. In the final step, we adjusted for the admission symptoms of dyspnea at rest, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and lower-extremity edema. Pre admission use of ACE inhibitors was dropped from the model for initiation of ACE inhibitor therapy. The variables were selected based on their significant association in the bivariate analyses and known clinical significance. We used the Hosmer-Lemeshow goodness-of-fit test to evaluate the overall fit of the model. (19) A two-tailed [alpha] of < .05 was used to determine statistical significance.

RESULTS

Of the 1,090 older heart failure patients, left ventricular function was known in 557 patients (88%), and 324 (58%) had left ventricular systolic dysfunction. Of these 324 patients, 285 (88%) were without contraindication to the use of ACE inhibitors and were discharged alive; they were considered ideal candidates for ACE inhibitor therapy. Of these 285, 181 (63%) were prescribed ACE inhibitors at discharge, while 72 (47%) of the 155 patients who were not taking ACE inhibitors before admission received the drug.

Patient Characteristics

Mean age of the subjects [+ or -] SD was 78 [+ or -] 6.9 years, with a range of 65 to 96 years. Of the 285 patients eligible for ACE inhibitor therapy, 102 (36%) were aged 65 to 74 years, 124 (43%) were aged 75 to 84 years, and 59 (21%) were [greater than or equal to]85 years. Half of the patients were female, and 21% were African American. Compared with the younger age category, there were more women in the older age categories and fewer older patients were cared for by cardiologists (Table 1). Older patients were less likely than younger ones to present with orthopnea and paroxysmal nocturnal dyspnea and also less likely to have radiologic evidence of pulmonary edema (Table 2).

Use of A CE Inhibitors

Angiotensin-converting enzyme inhibitors were prescribed at time of discharge to 66% of patients aged 65 to 74 years, 64% of those aged 75 to 84 years, and 59% of those aged 85 years and older. These differences were not statistically significant (Fig 1). Among patients who were not receiving preadmission ACE inhibitors, 51% of patients aged 65 to 74 years, 47% of those aged 75 to 84 years, and 37% of those aged 85 years and older were prescribed the drug at time of discharge (P = .477).

Captopril (n = 74, 26%) and enalapril (n = 65, 23%) were the two most commonly used ACE inhibitors. The mean dose of captopril [+ or -] SD was 57.3 mg [+ or -] 78.6 mg per day, and the most commonly prescribed dosage (in 44% of patients) was 12.5 mg 2 or 3 times per day (Fig 2). Thirty percent of the patients discharged with prescriptions for captopril received a dosage of 75 mg per day or higher. The mean dose of enalapril [+ or -] SD was 10.9 [+ or -] 12.5 mg per day, and the most commonly prescribed dose (in 45% of patients) was 10 mg per day (Fig 2). Sixty-five percent of the patients receiving enalapril received a dosage of 10 mg or more per day.

Results of Bivariate Analyses

Compared with patients 65 to 74 years of age, those 85 years and older discharged with heart failure associated with left ventricular systolic dysfunction and without contraindication to ACE inhibitor therapy had 24% lower odds of receiving the drug, which was not statistically significant (Table 3). Preadmission use of an ACE inhibitor was strongly associated with discharge use of the drug (OR = 5.98; 95% CI = 3.40-10.51). Patients with cardiomyopathy and women also had higher odds of being prescribed ACE inhibitors at the time of hospital discharge. Each mm Hg increase in the admission systolic blood pressure level was associated with a 1% increase in the odds of receiving ACE inhibitors at discharge, while each mg/dL increase in the serum creatinine level was associated with a 43% decrease in the use of the drug. Patients with a serum potassium level 5.5 mEq/L or higher had lower odds of receiving ACE inhibitors (OR = 0.30; 95% CI = 0.11-0.83). Those with diabetes had slightly higher odds of receiving ACE inhibitors (OR = 1.70; 95% CI = 0.94.3.04), but it was not statistically significant.

Results of Multivariate ate Analyses

Patients 85 years and older had 56% lower odds of being prescribed ACE inhibitors at the time of hospital discharge (OR = 0.44; 95% CI = 0.18-1.08), which bordered on statistical significance (Table 3). Preadmission use of ACE inhibitors had the strongest independent association with discharge use of the drug (OR = 10.05; 95% CI = 4.91-20.59). Patients cared for by a cardiologist had double the odds of being prescribed ACE inhibitors at the time of discharge. Admission systolic blood pressure level and serum creatinine level remained independently associated with use of ACE inhibitors at discharge. There were no significant differences between the observed and expected number of events (chi-square = 3.25 with 8 degrees of freedom), suggesting a reasonable fit of the multivariate logistic regression model (Hosmer-Lemeshow goodness-of-fit test, P = .92). The expected number of events in most groups exceeded 5, and only 1 of the groups had an expected value of less than 1.

Initiation of ACE Inhibitor Therapy

On bivariate analysis, patients with cardiomyopathy had higher odds of being initiated on ACE inhibitor therapy than those without (Table 4). Although there was a trend toward older patients having lower odds of receiving ACE inhibitors, the associations were not statistically significant.

On multivariate analyses, age of 85 years and older was independently associated with 64% lower odds of being initiated on ACE inhibitor therapy before discharge (OR = 0.36; 95% CI = 0.13-0.99). Admission systolic blood pressure level and serum creatinine level were independently associated with initiation of ACE inhibitor therapy (Table 4). The Hosmer-Lemeshow goodness-of-fit chi-square was 2.15 (P= .98), suggesting a reasonable fit of the data to the model.

DISCUSSION

We have shown that the overall rate of ACE inhibitor use was low in older, hospitalized, heart failure patients who had left ventricular systolic dysfunction and had no contraindications to the use of those drugs. We have also shown that there was an age-related decrease in the utilization of ACE inhibitors. The decrease in use and initiation of ACE inhibitor therapy was particularly low in patients 85 years and older. These findings have important public health implications. Since the number of persons 85 years and older is increasing at the fastest rate of any age group in the United States, the number of heart failure patients in that age group will also grow remarkably over the next several decades. To provide quality care to patients with heart failure, we will need to provide quality care to these patients, particularly those who are the oldest old (85 years and older). To develop interventions to improve quality of care, it is important to study and understand the age-related biases associated with th e underutilization of life-saving drugs in these patients.

More than half of the older heart failure patients in our study who were not taking ACE inhibitors before admission also did not receive the drug at the time of discharge. These were patients who had documented left ventricular systolic dysfunction and no contraindication to the use of ACE inhibitor therapy. Hypotension, renal insufficiency, and hyperkalemia are perceived as contraindications to ACE inhibitor therapy by many physicians and are known to be associated with underutilization of ACE inhibitors. (10,20-23) It is possible that the physicians caring for these patients also perceived these conditions as contraindications to ACE inhibitor use. In our study, each mg/dL increase in admission serum creatinine level was associated with about 50% lower odds of ACE inhibitor initiation. Compared with patients aged 65 to 74 years, however, those 85 years and older had similar serum creatinine levels, suggesting that the lower rate of initiation of ACE inhibitor therapy in this age group was not because of th eir higher serum creatinine levels. Similarly, higher admission systolic blood pressure level or presence of cardiomyopathy was associated with initiation of ACE inhibitor therapy; however, patients 85 years and older were not likely to have lower admission systolic blood pressure level or more cardiomyopathy in our study. Still, only 37% of patients 85 years and older were initiated on an ACE inhibitor. After adjustment for obvious confounding variables, age of 85 years and older was independently associated with a 64% reduction in the odds of initiation of ACE inhibitors in our study.

Because of the retrospective nature of our study, we were not able to identify the causes of the overall and age-related underutilization in the initiation of this life-saving drug; however, it is clear from our study that preadmission use of ACE inhibitors was the strongest predictor of discharge use of the drug. Among the 217 patients with known history of heart failure, 120 (55%) were taking ACE inhibitors before admission. This overall rate of preadmission use of ACE inhibitors among patients with a known history of heart failure was higher than the rate of initiation of the drug (47%). It is possible that some of these patients will be initiated on ACE inhibitors during a follow-up office visit. This suggests the importance of longitudinal follow-up, including both inpatient and outpatient care, in designing future studies to evaluate and improve quality of care in patients with heart failure. Interestingly, there was no age-related variation in the preadmission use of the drug (Table 1), and the findin gs in our study cannot be explained by any age-related variation in the preadmission use of ACE inhibitors.

The result of our study is consistent with the finding by the investigators of the 10 Large State Peer Review Organization Consortium, who were also able to show an age-related variation in the use of ACE inhibitors. (10) When age was entered into the analysis as a continuous variable, we found that for every year older after age 65 years, the patient's odds of receiving ACE inhibitors at discharge were 3% lower (OR = 0.97; 95% CI = 0.93-1.02). The direction and magnitude of this association in our study is similar to that found by the investigators of the 10 Large State Peer Review Organization Consortium (OR = 0.99) (10); however, the latter study was able to show a more precise relationship (95% CI = 0.98-0.99) because of their larger sample size (N = 6,885). Other investigators have not found any age-related variation in the discharge use of ACE inhibitors. (24,25)

The evidence for use of ACE inhibitors in patients with heart failure associated with left ventricular systolic dysfunction is overwhelming. Although most large-scale, randomized, controlled trials of ACE inhibitors in heart failure excluded patients 85 years and older, subsequent studies have shown the survival benefit of ACE inhibitors in older patients. (26,27) Several national guidelines for care of patients with heart failure have recommended their use. (7,8,28,31) The National Heart Failure Project of the Health Care Financing Administration has also identified the need for improvement in the utilization of ACE inhibitors in heart failure patients. (32)

Several limitations of our study need to be acknowledged. Because of the retrospective nature of our study, we were not able to assess patients' functional status and patient, family, and physician preferences. Functional status is often considered in the management of older patients. Although we are not aware of any contraindication to the use of ACE inhibitors in frail older patients with functional limitations, existence of such bias is likely to underestimate ACE inhibitor use in that population. It is also unlikely that patients or their family members would have declined life-saving therapy with ACE inhibitors. Our data suggest that there was an age-related bias against referral to cardiologists (both on outpatient and inpatient bases), and other similar biases cannot be ruled out. Although the study year partly explains the overall low rate of ACE inhibitor use, we do not believe it explains the age-related variations we observed. During 1998 to 1999, the rate of ACE inhibitor use in Alabama was 62%, which is comparable to the overall rate in our study. (33)

In conclusion, we observed an overall under-utilization of ACE inhibitor use in patients with left ventricular systolic dysfunction. We also observed a remarkably low rate of initiation of ACE inhibitor therapy and a significant age-related variation in the initiation of ACE inhibitor therapy. With the aging of the population in the United States, especially the growing number of people 85 years and older, the number of heart failure patients 85 years and older is also increasing. It is important that health-care providers caring for heart failure patients recognize the relationship between changing population demographics and the prevalence of heart failure. Improvement in the quality of care for patients with heart failure must involve improvement in the quality of care for patients 85 years and older.

Disclaimer: The analyses upon which this publication is based were performed under Contract Number 500-96-P60, en tided "Utilization and Quality Control Peer Review Organization for the State of Alabama," sponsored by the Center for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration), Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.

The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the CMS, which has encouraged identification of quality-improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to us concerning experience in engaging with issues presented are welcomed.

FIGURE 1

Percentage of patients receiving ACE inhibitors (ACEI) at discharge by
age category.

                     65-74Y  75-84Y  85+Y

All Patients
 (n=285)             66%     64%     59%
 (p=0.720)

In Patients with
 Preadmission ACEI
 (n=130)             83%     84%     85%
 (p=0.969)

In Patients without
 Preadmission ACEI
 (n=155)             51%     47%     37%
 (p=0.477)

Note: Table made from bar graph
Dose of Captopril (mg/day)


  5.00
  6.26
 12.50   8
 13.00
 18.75   7
 25.00  20
 37.50  22
 50.00   9
 75.00  19
100.00   5
150.00
225.00
300.00
600.00

Note: Table made from bar graph
FIGURE 2

Doses of ACE inhibitors used during discharge (mg/day).

Dose of enalapril (mg/day)


 2.00
 2.50  17
 5.00  18
 7.50   3
10.00  45
15.00
20.00   8
30.00
40.00   3
90.00

Note: Table made from bar graph
TABLE 1

Patient Characteristics by Age Category


                               All     65-74 Yrs  75-84 Yrs
                            (N = 285)  (N = 102)  (N = 124)

Sex
   Female                   143 (50%)  39 (38%)   62 (50%)

Race
   African American          59 (21%)  24 (24%)   25 (20%)

Historical features
   Heart failure            217 (76%)  84 (82%)   93 (75%)

Admission medications
   ACE inhibitors           130 (46%)  47 (46%)   56 (45%)
   Digoxin                  156 (55%)  58 (57%)   65 (52%)
   Diuretics                 87 (30%)  34 (33%)   34 (27%)

Comorbidities
   Coronary artery disease   80 (28%)  33 (32%)   31 (25%)
   Cardiomyopathy            78 (27%)  29 (28%)   31 (25%)
   Arrhythmias              108 (38%)  33 (34%)   54 (44%)
   Hypertension              48 (17%)  17 (17%)   16 (13%)
   Diabetes                  72 (25%)  33 (32%)   31 (25%)

Care by cardiologist
   By admission              53 (19%)  27 (27%)   19 (15%)
   By consultation          130 (46%)  47 (46%)   64 (52%)

                            [greater than or
                            equal to] 85 Yrs
                                (N = 59)      P Value

Sex
   Female                       42 (71%)       <.001

Race
   African American             10 (17%)        .599

Historical features
   Heart failure                40 (68%)        .105

Admission medications
   ACE inhibitors               27 (46%)        .99
   Digoxin                      33 (56%)        .783
   Diuretics                    19 (32%)        .6

Comorbidities
   Coronary artery disease      16 (27%)        .465
   Cardiomyopathy               18 (31%)        .704
   Arrhythmias                  19 (32%)        .217
   Hypertension                 15 (25%)        .107
   Diabetes                      8 (14%)        .03

Care by cardiologist
   By admission                  7 (13%)        .007
   By consultation              19 (35%)        .007
TABLE 2

Admission characteristics by Age Category


                                   All                65-74 Yrs
                                (N = 285)             (N = 102)

Symptoms
 Dyspnea at rest                258 (91%)              97 (95%)
 Dyspnea on exertion             97 (34%)              38 (37%)
 Orthopnea                      127 (45%)              55 (54%)
 PND *                           82 (29%)              38 (37%)
 Fatigue                         22 (8%)                6 (6%)
 Leg swelling                   167 (59%)              66 (65%)

Physical Signs
 Pulse (beats per minute)    96 ([+ or -] 22)      96 ([+ or -] 22)
 Systolic BP + (mm Hg)      146 ([+ or -] 29)     144 ([+ or -] 27)
 Third heart sound               71 (25%)              28 (28%)
 JVD **                         138 (48%)              49 (48%)
 Pulmonary rales                198 (70%)              72 (71%)
 PMI ++ displaced                33 (12%)              16 (16%)

Laboratory values
 BUN (ss) (mg/dL)          28.7 ([+ or -] 17.5)  25.6 ([+ or -] 15.6)
 Serum creatinine (mg/dL)    1.6 ([+ or -] 1)    1.6 ([+ or -] 1.11)
 Serum sodium (mEq/L)       139 ([+ or -] 5.3)    139 ([+ or -] 4.8)
 Serum potassium (mEq/L)   4.3 ([+ or -] 0.66)   4.2 ([+ or -] 0.71)

Chest radiograph
 Pulmonary edema                 95 (33%)              35 (34%)

                                                   [greater than or
                                75-84 Yrs          equal to] 85 Yrs
                                 (N =124)              (N = 59)

Symptoms
 Dyspnea at rest                111 (90%)              50 (85%)
 Dyspnea on exertion             43 (35%)              16 (27%)
 Orthopnea                       50 (40%)              22 (37%)
 PND *                           33 (27%)              11 (19%)
 Fatigue                         12 (10%)               4 (7%)
 Leg swelling                    70 (57%)              31 (53%)

Physical Signs
 Pulse (beats per minute)    95 ([+ or -] 22)      97 ([+ or -] 23)
 Systolic BP + (mm Hg)      146 ([+ or -] 30)     149 ([+ or -] 29)
 Third heart sound               31 (25%)              12 (20%)
 JVD **                          59 (48%)              30 (51%)
 Pulmonary rales                 89 (72%)              37 (63%)
 PMI ++ displaced                13 (11%)               4 (7%)

Laboratory values
 BUN (ss) (mg/dL)          29.5 ([+ or -] 17.3)  30.9 ([+ or -] 20.9)
 Serum creatinine (mg/dL)  1.6 ([+ or -] 1.16)   1.7 ([+ or -] 0.78)
 Serum sodium (mEq/L)       139 ([+ or -] 4.6)    138 ([+ or -] 7.3)
 Serum potassium (mEq/L)   4.2 ([+ or -] 0.57)   4.6 ([+ or -] 0.70)

Chest radiograph
 Pulmonary edema                 50 (40%)              10 (17%)



                           P Value

Symptoms
 Dyspnea at rest            .085
 Dyspnea on exertion        .417
 Orthopnea                  .056
 PND *                      .033
 Fatigue                    .542
 Leg swelling               .26

Physical Signs
 Pulse (beats per minute)   .823
 Systolic BP + (mm Hg)      .485
 Third heart sound          .603
 JVD **                     .914
 Pulmonary rales            .440
 PMI ++ displaced           .207

Laboratory values
 BUN (ss) (mg/dL)           .276
 Serum creatinine (mg/dL)   .98
 Serum sodium (mEq/L)       .509
 Serum potassium (mEq/L)    .003

Chest radiograph
 Pulmonary edema            .007

* Paroxysmal nocuturnal dyspnea.

+ Blood pressure.

** Jugular venous distension.

++ Point of maximum impulse.

(ss) Blood urea nitrogen.
TABLE 3

Variables Associated With Use of ACE Inhibitors in Patients With Heart
Failure and Left Ventricular Systolic Dysfunction: Crude and Adjusted
Odds Ratios (OR) and 95% Confidence Intervals (CI)

                               Crude OR         Adjusted * OR
                               (95% CI)            (95% CI)

Age 75-84 years            0.92 (0.53-1.59)    0.69 (0.36-1.39)
Age [greater than or
 equal to]85 years         0.76 (0.39-1.48)    0.44 (0.18-1.08)
Female                     2.25 (1.37-3.69)    2.60 (1.33-5.09)
African American           1.05 (0.58-1.91)    1.37 (0.62-2.03)
Preadmission use of ACE    5.98 (3.40-10.51)  10.05 (4.91-20.59)
 inhibitors
Incident heart failure     0.98 (0.56-1.73)    2.65 (1.25-5.63)
Cardiomyopathy             1.98 (1.11-3.53)    3.29 (1.57-6.87)
Systolic blood pressure    1.01 (1.002-1.02)   1.02 (1.01-1.03)
 (increase by 1 mm Hg)
Serum creatinine           0.57 (0.42-0.78)    0.60 (0.42-0.84)
 (increase by 1 mg/dL)
Serum potassium [greater   0.30 (0.11-0.83)           --
 than or equal to] 5.5 mE
Care by cardiologist       1.40 (0.85-2.31)    2.00 (1.01-3.98)

* Also adjusted for admission from nursing home, new-onset heart
failure, hypertension, diabetes, coronary artery disease, admission
symptoms of dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and lower
extremity edema, serum potassium 5.5 mEq/L or greater, and hospital
(used as dummy variable).
TABLE 4

Variables Associated With Initiation of Therapy With ACE inhibitors in
Patients With Heart Failure and Left Ventricular Systolic Dysfunction:
Crude and Adjusted Odds Ratios (OR) with 95% Confidence Intervals
(95% CI)

                             Crude OR         Adjusted * OR
                             (95% CI)            (95% CI)

Age 75-84 years          0.86 (0.42-1.75)   0.65 (0.29-1.49)
Age [greater than or     0.58 (0.24-1.41)   0.36 (0.13-0.99)
 equal to]85 years
Female                   1.60 (0.85-3.03)   1.69 (0.77-3.71)
African American         0.87 (0.40-1.91)   0.95 (0.38-2.37)
Dyspnea                  3.15 (0.83-11.93)          --
Cardiomyopathy           2.07 (1.004-4.25)  2.95 (1.27-6.84)
Systolic blood pressure  1.01 (1.001-1.03)  1.02 (1.004-1.031)
 (increase by 1 mm Hg)
Serum creatinine         0.47 (0.28-0.77)   0.51 (0.30-0.85)
 (increase by 1 mg/dL)

* Also adjusted for admission from nursing home, hypertension, diabetes,
coronary artery disease, admission symptoms of dyspnea on exertion,
orthopnea, paroxysmal nocturnal dyspnea, fatigue, and lower extremity
edema, serum potassium [greater than or equal to]5.5 mEq/L, care by
cardiologists, and hospital (used as dummy variable).

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RELATED ARTICLE: KEY POINTS

* Large-scale randomized controlled trials have shown the survival benefits of angiotensin-converting enzyme (ACE) inhibitors in patients with heart failure associated with left ventricular systolic dysfunction (LSVD).

* Since persons age 85 years of age and older are the fastest-growing segment of the US population, the number of heart failure patients in that age group is expected to increase in the coming decades.

* Of the 285 patients discharged with a diagnosis of heart failure associated with LVSD and without any contraindications to the use of ACE inhibitors, 63% were prescribed ACE inhibitors and 47% had the therapeutic regimen initiated.

* Compared with patients 65 to 74 years of age, those 85 and years and older had 56% lower odds of being discharged with a prescription for an ACE inhibitor and 66% lower odds of having the therapeutic regimen initiated.

* Opportunities remain to improve quality of care in older heart failure patients.

From the Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine, Department of Epidemiology and International Health and Department of Biostatistics, School of Public Health, Center for Aging, and Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham; Section of Geriatrics Heart Failure Clinic, and Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center; and the Alabama Quality Assurance Foundation.

Supported by a grant from the Southeast Center of Excellence in Geriatric Medicine (Ali Ahmed, MD, MPH).

Reprint requests to Ali Ahmed, MD, MPH, 1530 3rd Ave 5, CH19, Suite 219, Birmingham, AL 35294-2041.