Evaluating the use of angiotensin-converting enzyme inhibitors for older nursing home residents with chronic heart failure

BACKGROUND: Despite their well noted therapeutic benefits for heart failure (HF), angiotensin-converting enzyme (ACE) inhibitors may be underprescribed and underdosed among older nursing home patients. OBJECTIVES: To assess the use of ACE inhibitor therapy in older (greater than or equal to 70 years) nursing home residents with systolic heart failure (HF). DESIGN: A cross-sectional, retrospective analysis. SETTING: Five long-term care facilities in Providence, Rhode Island. SUBJECTS: Adults aged 70 years or older with left ventricular (LV) ejection fractions less than or equal to 40%. MEASUREMENTS: New York Heart Association (NYHA) class, comorbid diseases, and cardiac medications with logistic regression analysis to clarify their bearing on the prescription of ACE inhibitors. RESULTS: Of the 819 nursing home residents who were evaluated, 119 (24 men, 95 women) fulfilled exacting entry criteria, i.e., heart failure signs/symptoms and documented LV systolic dysfunction. Forty-one of these 119 (35%) older persons were receiving ACE inhibitor therapy, predominantly in doses (less than or equal to 50 mg captopril/day or less than or equal to 5 mg enalapril/ day) less than those of proven therapeutic efficacy. Compared with older residents not receiving ACE inhibitors, those receiving ACE inhibitors included fewer with NYHA Class I HF (0 vs 21%, P = .017), more men (58 vs 28%, P less than or equal to .01), and more people with hypertension (61 vs 35%, P less than or equal to .01). In contrast, diuretics were prescribed more frequently among those not receiving ACE inhibitors (83 vs 56%, P less than or equal to .001). CONCLUSIONS: ACE inhibitors are underprescribed and underdosed among elderly nursing home patients carefully screened to include systolic KF and no contraindications to the medication. ACE inhibitors are particularly underused in those elderly with NYHA Class I HF and in those receiving diuretics.