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Nicholas L. Smith, PhD, MPH; Bruce M. Psaty, MD, PhD; Bertram Pitt, MD; Rekha Garg, MD, MS; John S. Gottdiener, MD; Susan R. Heckbert, MD, PhD

Arch Intern Med. 1998;158:1074-1080.

Background  Evidence from clinical trials in the past decade has consistently shown that angiotensin-converting enzyme (ACE) inhibitors reduce morbidity and mortality in patients with congestive heart failure (CHF). The extent to which clinical practice has adopted ACE inhibitor therapy is unknown.

Methods  The Cardiovascular Health Study is a prospective observational study of 5201 community-dwelling adults aged 65 years and older. Prevalent CHF cases were identified on study entry (from June 10, 1989, through May 31, 1990) and incident CHF cases were identified throughout 5 years of follow-up. Medication data were collected from annual medication inventories. The percentage of patients with CHF using ACE inhibitors was calculated at each annual examination. Temporal trends in CHF treatment with ACE inhibitors between June 10, 1989, through May 31, 1990, and June 1, 1994, through May 31, 1995, were analyzed.

Results  Use of ACE inhibitors to treat CHF increased slightly over time among prevalent cases at each annual examination: 26% of prevalent CHF cases were treated in 1989-1990 compared with 36% of prevalent cases in 1994-1995. This 10% increase was statistically significant (P<.01). Participants with low ejection fractions were 2 times more likely to be treated with ACE inhibitors than were those with normal ejection fraction and this tendency did not change over time. Among cases newly diagnosed in the year before the 1990-1991 examination, 42% were using ACE inhibitors; among those newly diagnosed in the year before 1994-1995, 40% were using ACE inhibitors. This 2% decrease was not statistically significant (P=.68).

Conclusion  These findings suggest that, while the medical management of CHF with ACE inhibitors has increased modestly over time in prevalent cases, these drugs may still be underused, especially among incident cases.

From the Departments of Medicine (Drs Smith and Psaty), Epidemiology (Drs Psaty and Heckbert), and Health Services (Dr Psaty), University of Washington, Seattle; Department of Cardiology, University of Michigan, Ann Arbor (Dr Pitt); Merck-Medco Managed Care Inc, Montvale, NJ (Dr Garg); and Department of Cardiology, Georgetown University Medical Center, Washington, DC (Dr Gottdiener).

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