Skip to main content
SpringerLink
Log in

Do ACE Inhibitors/Angiotensin II Type 1 Receptor Antagonists Reduce Hospitalisations in Older Patients with Heart Failure?

A Propensity Analysis

  • Original Research Article
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Background

Randomised controlled trials have shown a reduced risk of heart failure (HF) hospitalisation among users of ACE inhibitors (ACEIs) or angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]), but these results have limited generalisability. Some observational studies have also demonstrated reductions in hospitalisation but are potentially affected by non-random treatment selection.

Objective

To assess the effect of ACEI/ARB therapy on all-cause and HF-related hospitalisations among older adults using a propensity model to adjust for treatment-selection bias and focusing on consistent medication use as the exposure of interest.

Methods

A retrospective cohort study of continuously enrolled, older (age ≥60 years) Kansas Medicaid beneficiaries with HF, using data from May 1999 to April 2000. A propensity analysis was used to identify a comparison group of untreated persons that were otherwise clinically similar to treated persons. The effect of regular ACEI/ARB use on hospitalisations was estimated using multivariable logistic regression models. The HF sample included 887 subjects, of whom 235 (27%) received regular ACEI/ARB therapy. To be considered a regular user of ACEI/ARB therapy (‘treated’), we required evidence that a subject obtained at least 80% of their intended daily supply. The main outcome measure was the effect of regular ACEI/ARB use on all-cause and HF-related hospitalisations.

Results

Treated subjects were matched against an equal number of untreated persons, for a final sample of 470 persons. The mean age of both treated and untreated subjects was 81 years. Regular ACEI/ARB use did not alter the adjusted odds ratio (AOR) of all-cause hospitalisation (AOR = 1.04, 95% CI 0.71, 1.52), which occurred in 40% of the sample, or the odds of an HF-related hospitalisation (AOR =1.01, 95% CI 0.65, 1.57), which occurred in 22.6% of both groups.

Conclusion

Although randomised controlled trials have shown that ACEI/ARB treatment is associated with reduced hospitalisations in patients with HF, this benefit was not observed in our study. Further study of ACEI/ARB outcomes is needed in a larger sample of older subjects with HF.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Table I
Table II
Table III
Table IV

Similar content being viewed by others

References

  1. American Heart Association. Heart disease and stroke statistics: 2004 update. Dallas (TX): American Heart Association, 2003

    Google Scholar 

  2. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2001; 38: 2101–13

    Article  PubMed  CAS  Google Scholar 

  3. SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992; 327: 685–91

    Article  Google Scholar 

  4. Cohn JN, Archibald DG, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991; 325: 303–10

    Article  PubMed  CAS  Google Scholar 

  5. SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293–302

    Article  Google Scholar 

  6. CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med 1987; 316: 1429–35

    Article  Google Scholar 

  7. CHARM Investigators and Committees. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet 2003; 362(9386): 777–81

    Article  Google Scholar 

  8. Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA 1995; 273: 1450–6

    Article  PubMed  CAS  Google Scholar 

  9. Lee VC, Rhew DC, Dylan M, et al. Meta-analysis: angiotensin-receptor blockers in chronic heart failure and high-risk acute myocardial infarction. Ann Intern Med 2004; 141: 693–704

    PubMed  CAS  Google Scholar 

  10. Buch P, Soren R, Steen Z, et al. The long-term impact of the angiotensin-converting enzyme inhibitor trandolapril on mortality and hospital admissions in patients with left ventricular dysfunction after a myocardial infarction: follow-up to 12 years. Eur Heart J 2005; 26: 145–52

    Article  PubMed  CAS  Google Scholar 

  11. Abarca J, Malone DC, Armstrong EP, et al. Angiotensin-converting enzyme inhibitor therapy in patients with heart failure enrolled in a managed care organization: effect on costs and probability of hospitalization. Pharmacotherapy 2004; 24(3): 351–7

    Article  PubMed  CAS  Google Scholar 

  12. Krumholz HM, Parent EM, Tu N, et al. Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. Arch Intern Med 1997; 157: 99–104

    Article  PubMed  CAS  Google Scholar 

  13. Weintraub WS, Kawabata H, Tran M, et al. Cost of heart failure in patients receiving beta-blockers and angiotensin-converting enzyme inhibitors. Clin Drug Invest 2004; 24(5): 255–65

    Article  Google Scholar 

  14. Luthi J, Lund M, Sampietro-Colom L, et al. Readmissions and the quality of care in patients hospitalized with heart failure. Int J Qual Health Care 2003; 15(5): 413–21

    Article  PubMed  Google Scholar 

  15. Gambassi G, Lapane KL, Sgadari A, et al. Effects of angiotensin-converting enzyme inhibitors and digoxin on health outcomes of very old patients with heart failure: SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology. Arch Intern Med 2000; 160(1): 53–60

    Article  PubMed  CAS  Google Scholar 

  16. Luzier AB, DiTusa L. Underutilization of ACE inhibitors in heart failure. Pharmacotherapy 1999; 19(11): 1296–307

    Article  PubMed  CAS  Google Scholar 

  17. Antonelli Incalzi R, Pedone C, Pahor M, et al. Trends in prescribing ACE-inhibitors for congestive heart failure in elderly people. Aging Clin Exp Res 2002; 14(6): 516–21

    PubMed  Google Scholar 

  18. Smith NL, Psaty BM, Pitt B, et al. Temporal patterns in the medical treatment of congestive heart failure with angiotensin-converting enzyme inhibitors in older adults, 1989 through 1995. Arch Intern Med 1998; 158(10): 1074–80

    Article  PubMed  CAS  Google Scholar 

  19. Bouvy ML, Heerdink ER, Leufkens HG, et al. Patterns of pharmacotherapy in patients hospitalized for congestive heart failure. Eur J Heart Fail 2003; 5(2): 195–200

    Article  PubMed  CAS  Google Scholar 

  20. Stafford RS, Radley DC. The underutilization of cardiac medications of proven benefit, 1990–2002. J Am Coll Cardiol 2003; 41(1): 69–72

    Article  Google Scholar 

  21. Philbin EF. Factors determining angiotensin-converting enzyme inhibitor underutilization in heart failure in a community setting. Clin Cardiol 1998; 21(2): 103–8

    Article  PubMed  CAS  Google Scholar 

  22. Hope CJ, Jingwei W, Wanzhu T, et al. Association of medication adherence, knowledge and skills with emergency department visits by adults 50 years or older with congestive heart failure. Am J Health Syst Pharm 2004; 61: 2043–9

    PubMed  Google Scholar 

  23. Michalsen A, König G, Thimme W. Preventable causative factors leading to hospital admission with decompensated heart failure. Heart 1998; 80: 437–41

    PubMed  CAS  Google Scholar 

  24. Butler J, Arbogast PG, Daugherty J, et al. Outpatient utilization of angiotensin-converting enzyme inhibitors among heart failure patients after hospital discharge. J Am Coll Cardiol 2004 Jun 2; 43(11): 2036–43

    Article  PubMed  CAS  Google Scholar 

  25. Practice Management Information Corporation (PMIC). Classification of diseases, 9th revision: clinical modification. 6th edition. Los Angeles (CA): PMIC, 2002

    Google Scholar 

  26. Ahmed A, Allman RM, Delong JF, et al. Age-related underutilization of angiotensin-converting enzyme inhibitors in older hospitalized heart failure patients. South Med J 2002; 95(7): 703–10

    PubMed  Google Scholar 

  27. Lau DT, Nau DP. Oral antihyperglycemic medication nonadherence and subsequent hospitalization among individuals with type 2 diabetes. Diabetes Care 2004; 27(9): 2149–53

    Article  PubMed  CAS  Google Scholar 

  28. Choo PW, Rand CS, Inui TS, et al. Validation of patient reports, automated pharmacy records, and pill counts with electronic monitoring of adherence to antihypertensive therapy. Med Care 1999; 37(9): 846–57

    Article  PubMed  CAS  Google Scholar 

  29. Weiden PJ, Kozma C, Grogg A, et al. Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia. Psychiatr Serv 2004; 55(8): 886–91

    Article  PubMed  Google Scholar 

  30. Granger BB, Swedberg K, Ekman I, et al. Adherence to candesartan and placebo and outcomes in chronic heart failure in the CHARM programme: double-blind, randomised, controlled clinical trial. Lancet 2005; 366(9502): 2005–11

    Article  PubMed  CAS  Google Scholar 

  31. Steiner JF, Fihn SD, Blair B, et al. Appropriate reductions in compliance among well-controlled hypertensive patients. J Clin Epidemiol 1991; 44(12): 1361–71

    Article  PubMed  CAS  Google Scholar 

  32. Gilmer TP, Dolder CR, Lacro JP, et al. Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia. Am J Psychiatry 2004; 161(4): 692–9

    Article  PubMed  Google Scholar 

  33. Monane M, Bohn RL, Gurwitz JH, et al. Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race. Am J Public Health 1996; 86(12): 1805–8

    Article  PubMed  CAS  Google Scholar 

  34. Howard PA, Shireman TI, Dhingra A, et al. ACE inhibitor patterns of use in elderly Medicaid patients with heart failure. Am J Geriatr Cardiol 2002; 11: 287–94

    Article  PubMed  Google Scholar 

  35. Rochon PA, Sykora K, Bronskill SE, et al. Use of angiotensin-converting enzyme inhibitor therapy and dose-related outcomes in older adults with new heart failure in the community. J Gen Intern Med 2004; 19: 676–83

    Article  PubMed  Google Scholar 

  36. Granger CB, McMurray JJV, Yusuf S, et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting enzyme inhibitors: the CHARM-Alternative trial. Lancet 2002; 362: 772–6

    Article  Google Scholar 

  37. Peduzzi P, Concato J, Kemper E, et al. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996 Dec; 49(12): 1373–9

    Article  PubMed  CAS  Google Scholar 

  38. Delahaye F, de Gevigney G. Is the optimal dose of angiotensin-converting enzyme inhibitors in patients with congestive heart failure definitely established? J Am Coll Cardiol 2000; 36: 2096–7

    Article  PubMed  CAS  Google Scholar 

  39. Chin MH, Goldman L. Factors contributing to the hospitalization of patients with congestive heart failure. Am J Public Health 1997; 87: 643–8

    Article  PubMed  CAS  Google Scholar 

  40. Croft JB, Giles WH, Roegner RH, et al. Pharmacologic management of heart failure among older adults by office-based physicians in the United States. J Fam Pract 1997; 44(4): 382–90

    PubMed  CAS  Google Scholar 

  41. Goff Jr DC, Pandey DK, Chan FA, et al. Congestive heart failure in the United States: is there more than meets the I(CD code)? The Corpus Christi heart project. Arch Intern Med 2000; 160(2): 197–202

    Article  PubMed  Google Scholar 

  42. Hogg K, Swedberg K, McMurray J. Heart failure with preserved left ventricular systolic function. J Am Coll Cardiol 2004; 43: 317–27

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

This study was supported by a contract with the Kansas Department of Social and Rehabilitation Services. The opinions and conclusions of this study do not necessarily reflect the position or opinion of the Kansas Department of Social and Rehabilitation Services. SKR received salary support from the National Institute on Aging (K08 AG019516). The sponsor did not play a role in the design, methods, subject recruitment, data collections analysis and preparation of the study. The authors have no conflicts of interest that are directly relevant to the content of this study.

Author information

Authors and Affiliations

  1. College of Pharmacy and Broadlawns Family Health Center, University of Iowa, 1801 Hickman Road, Des Moines, Iowa, 50322, USA

    CoraLynn B. Trewet

  2. Department of Preventive Medicine and Public Health, University of Kansas, Kansas City, Kansas, USA

    Theresa I. Shireman

  3. Landon Center on Aging, Kansas City, Kansas, USA

    Theresa I. Shireman & Sally K. Rigler

  4. Department of Medicine, University of Kansas, Kansas City, Kansas, USA

    Sally K. Rigler

  5. University of Kansas School of Pharmacy, Lawrence, Kansas, USA

    Patricia A. Howard

  6. University of Kansas Medical Center, Kansas City, Kansas, USA

    Patricia A. Howard

Authors
  1. CoraLynn B. Trewet
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Theresa I. Shireman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sally K. Rigler
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Patricia A. Howard
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to CoraLynn B. Trewet.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Trewet, C.B., Shireman, T.I., Rigler, S.K. et al. Do ACE Inhibitors/Angiotensin II Type 1 Receptor Antagonists Reduce Hospitalisations in Older Patients with Heart Failure?. Drugs Aging 24, 945–955 (2007). https://doi.org/10.2165/00002512-200724110-00006

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002512-200724110-00006

Keywords

Search

Navigation