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Gelaye AT, Seid MA, Baffa LD. Angiotensin-Converting Enzyme Inhibitor Dose Optimization and Its Associated Factors at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, Ethiopia. Vasc Health Risk Manag 2022; 18:481-493. [PMID: 35832662 PMCID: PMC9272845 DOI: 10.2147/vhrm.s363051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/08/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Angiotensin-converting enzyme inhibitors dose optimizations (ACEIs) are essential to boost the treatment outcome in heart failure patients (HF) with reduced ejection fraction. Therefore, the main purpose of this study was to evaluate dose optimization and associated factors of ACEIs among HF patients. METHOD An institutional-based retrospective study was conducted on 256 study participants from May 20 to August 30, 2020 in ambulatory care clinic at Felege Hiwot Comprehensive Specialized Hospital. A systematic random sampling method was carried out to select study participants. Data were collected from the patient interview and the review of medical records. Epidata and SPSS version 22 were used for data entry and analysis. A bivariate logistic regression analysis was done to determine the association of independent variables with a dose optimization of ACEIs. RESULTS The mean age of the subjects in the study was 53.82 years with a standard deviation (SD) of 17.067 and more than half of (60.9%) the patients were unable to read and write. Among participants who were receiving ACEIs, only 30.6% were taking an optimal dose. Age ≥65 years (AOR 5.04 (2.81-12.56)) and a dose of furosemide ≥40 mg (AOR, 2.62 (1.28-16.74)) were significantly associated with the suboptimal dose of ACEIs. CONCLUSION Only one-third of patients received the optimum dose of ACEIs. Older age and dose of furosemide greater >40 mg were significantly associated with suboptimal dosing of ACEIs. Therefore, more attention must be given to older patients with HF in order to optimize the dose of ACEIs administered.
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Affiliation(s)
- Abebech Tewabe Gelaye
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia,Correspondence: Abebech Tewabe Gelaye, Email
| | - Mohammed Assen Seid
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Lemlem Daniel Baffa
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Schjødt I, Liljeroos M, Larsen P, Johnsen SP, Strömberg A, Løgstrup BB. Risk factors for hospital readmission in adult patients with heart failure with reduced ejection fraction: a systematic review. JBI Evid Synth 2020; 18:1641-1700. [PMID: 32898362 DOI: 10.11124/jbisrir-d-19-00203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review was to identify and synthesize evidence on risk factors associated with hospital readmission within the first year after heart failure hospitalization among patients with heart failure with reduced left ventricular ejection fraction. INTRODUCTION Heart failure is associated with a high risk of hospital readmission. Readmissions are associated with higher mortality and health care costs. It is a high health care priority to identify vulnerable patients with heart failure who may potentially benefit from targeted personalized care interventions aiming to reduce readmissions. INCLUSION CRITERIA This review considered studies including adult patients who had heart failure with a reduced left ventricular ejection fraction ≤ 40% who were discharged after a heart failure hospitalization. The authors included studies with experimental and observational designs evaluating risk factors for i) all-cause hospital readmission, ii) heart failure hospital readmission, and iii) composite outcomes within seven, 15, 30, 60, 90, 180, and 365 days after hospital discharge. Composite outcomes included end points where all-cause readmission and/or heart failure readmission were part of a defined end point (i.e. all-cause readmission or mortality; heart failure readmission or mortality; cardiovascular readmission; cardiovascular readmission or mortality; and readmission, mortality, or cardiac transplant). Studies reporting all-cause readmission and/or heart failure readmission as a primary outcome, secondary outcome, or part of a composite outcome were included. METHODS PubMed, Embase, CINAHL, Cochrane CENTRAL, PsycINFO, OpenGrey, MedNar, DART-Europe, ProQuest Dissertations and Theses, and the Grey Literature Report in Public Health were searched to find both published and unpublished studies in English, Swedish, Norwegian, or Danish from 2000 to June 2018. Study selection, critical appraisal, data extraction, and data synthesis followed the JBI approach for systematic reviews. Statistical pooling was not possible due to clinical and methodological heterogeneity of the studies included and the lack of risk factors reported more than once. A narrative summary of the findings was performed. RESULTS Fifty-two studies, including one randomized controlled trial and 51 cohort studies with a total of 128,186 participants, were included. Risk factors for readmission were reported for 30-day outcome in 16 studies, 60-day in three studies, 90-day in 15 studies, 180-day in 12 studies, and 365-day outcome in 15 studies. Based on multivariable analyses from 43 cohort studies and results from one randomized controlled trial, the authors identified several factors associated with higher risk of all-cause readmission, heart failure readmission, and composite outcomes (e.g. readmission or death) within 30, 60, 90, 180, and 365 days after discharge for a heart failure hospitalization. CONCLUSIONS This review provides a comprehensive overview of factors associated with a clinical outcome after a heart failure hospitalization in patients with heart failure with left ventricular ejection fraction ≤ 40%. Owing to the heterogeneity of variables investigated and the lack of comparability of findings, the clinical impact of the identified risk factors remains uncertain. This review highlights research gaps and the need for a standardized way to define and measure all-cause readmission, heart failure readmission, and composite end points in clinical research to improve study quality and enable comparison of findings between studies.
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Affiliation(s)
- Inge Schjødt
- 1Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark 2Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden 3Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden 4Health Sciences Research Center, University College Lillebælt, Odense, Denmark 5Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark 6Department of Cardiology, Linköping University Hospital, Linköping, Sweden 7Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Atey TM, Teklay T, Asgedom SW, Mezgebe HB, Teklay G, Kahssay M. Treatment optimization of angiotensin converting enzyme inhibitors and associated factors in Ayder Comprehensive Specialized Hospital: a cross-sectional study. BMC Res Notes 2018; 11:209. [PMID: 29592815 PMCID: PMC5875017 DOI: 10.1186/s13104-017-2820-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 09/30/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors have morbidity and mortality benefits in heart failure. Failure to optimize treatment using these medications increases hospitalizations, worsens signs and symptoms of heart failure, and reduces the overall treatment outcome. Therefore, the main purpose of this study was to assess the practice of treatment optimization of these medications and associated factors. RESULTS A hospital-based cross-sectional study was conducted on 61 ambulatory heart failure patients, recruited using a convenience sampling technique, from February 25 to May 24, 2016 at the cardiology clinic of Ayder Comprehensive Specialized Hospital. Descriptive, inferential and Kaplan-Meier 'tolerability' analyses were employed. All patients were taking only enalapril as part of their angiotensin converting enzyme inhibitor treatment. According to the 2013 American College of Cardiology/American Heart Association guideline, about fourth-fifth (80.3%) of the patients were tolerating to the hypotensive effect of enalapril. The dose of enalapril was timely titrated (every 2-4 weeks) and was optimized for only 11.5 and 27.8% of the patients, respectively. Considering the tolerance, timely titration, and dose optimization, only 3.3% of the overall enalapril treatment was optimized. Multivariate regression results showed that the odds of having timely titration of enalapril for patients who were taking enalapril and calcium channel blockers were almost 20 times [adjusted odds ratio (AOR) = 21.68, 95% confidence interval (CI) 1.23-383.16, p < 0.036] more compared to patients who were taking enalapril and β-blockers. A Log Rank Chi Square result showed a 19.42 magnitude of better toleration of enalapril (p < 0.001) for patients who were taking enalapril for more than 1 year compared to less than a year. CONCLUSION This study provides a platform for assessment of the treatment optimization practice of enalapril, which remains the pressing priority and found to be poor in the ambulatory setting, despite a better tolerability to the hypotensive effect of enalapril. We call for greater momentum of efforts by health care providers in optimizing the treatment practice to benchmark with other optimization practices.
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Affiliation(s)
- Tesfay Mehari Atey
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Tsegay Teklay
- School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Solomon Weldegebreal Asgedom
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Haftay Berhane Mezgebe
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Gebrehiwot Teklay
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray Ethiopia
| | - Molla Kahssay
- School of Public Health, College of Health Sciences, Semera University, Semera, Afar Ethiopia
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Khan MS, Fonarow GC, Ahmed A, Greene SJ, Vaduganathan M, Khan H, Marti C, Gheorghiade M, Butler J. Dose of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers and Outcomes in Heart Failure. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.003956. [DOI: 10.1161/circheartfailure.117.003956] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 07/03/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Muhammad Shahzeb Khan
- From the John H. Stroger Jr Hospital of Cook County, Chicago, IL (M.S.K.); University of California Los Angeles (G.C.F.); Veterans Affairs Medical Center and George Washington University, DC (A.A.); Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V.); Emory University, Atlanta, GA (H.K.); University of Georgia, Athens (C.M.); Northwestern University Feinberg School of
| | - Gregg C. Fonarow
- From the John H. Stroger Jr Hospital of Cook County, Chicago, IL (M.S.K.); University of California Los Angeles (G.C.F.); Veterans Affairs Medical Center and George Washington University, DC (A.A.); Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V.); Emory University, Atlanta, GA (H.K.); University of Georgia, Athens (C.M.); Northwestern University Feinberg School of
| | - Ali Ahmed
- From the John H. Stroger Jr Hospital of Cook County, Chicago, IL (M.S.K.); University of California Los Angeles (G.C.F.); Veterans Affairs Medical Center and George Washington University, DC (A.A.); Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V.); Emory University, Atlanta, GA (H.K.); University of Georgia, Athens (C.M.); Northwestern University Feinberg School of
| | - Stephen J. Greene
- From the John H. Stroger Jr Hospital of Cook County, Chicago, IL (M.S.K.); University of California Los Angeles (G.C.F.); Veterans Affairs Medical Center and George Washington University, DC (A.A.); Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V.); Emory University, Atlanta, GA (H.K.); University of Georgia, Athens (C.M.); Northwestern University Feinberg School of
| | - Muthiah Vaduganathan
- From the John H. Stroger Jr Hospital of Cook County, Chicago, IL (M.S.K.); University of California Los Angeles (G.C.F.); Veterans Affairs Medical Center and George Washington University, DC (A.A.); Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V.); Emory University, Atlanta, GA (H.K.); University of Georgia, Athens (C.M.); Northwestern University Feinberg School of
| | - Hassan Khan
- From the John H. Stroger Jr Hospital of Cook County, Chicago, IL (M.S.K.); University of California Los Angeles (G.C.F.); Veterans Affairs Medical Center and George Washington University, DC (A.A.); Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V.); Emory University, Atlanta, GA (H.K.); University of Georgia, Athens (C.M.); Northwestern University Feinberg School of
| | - Catherine Marti
- From the John H. Stroger Jr Hospital of Cook County, Chicago, IL (M.S.K.); University of California Los Angeles (G.C.F.); Veterans Affairs Medical Center and George Washington University, DC (A.A.); Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V.); Emory University, Atlanta, GA (H.K.); University of Georgia, Athens (C.M.); Northwestern University Feinberg School of
| | - Mihai Gheorghiade
- From the John H. Stroger Jr Hospital of Cook County, Chicago, IL (M.S.K.); University of California Los Angeles (G.C.F.); Veterans Affairs Medical Center and George Washington University, DC (A.A.); Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V.); Emory University, Atlanta, GA (H.K.); University of Georgia, Athens (C.M.); Northwestern University Feinberg School of
| | - Javed Butler
- From the John H. Stroger Jr Hospital of Cook County, Chicago, IL (M.S.K.); University of California Los Angeles (G.C.F.); Veterans Affairs Medical Center and George Washington University, DC (A.A.); Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G.); Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V.); Emory University, Atlanta, GA (H.K.); University of Georgia, Athens (C.M.); Northwestern University Feinberg School of
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Grall S, Biere L, Le Nezet M, Bouvier JM, Lucas-Chauvelon P, Richard C, Abi-Khalil W, Delepine S, Prunier F, Furber A. Relationship between beta-blocker and angiotensin-converting enzyme inhibitor dose and clinical outcome following acute myocardial infarction. Circ J 2015; 79:632-40. [PMID: 25746548 DOI: 10.1253/circj.cj-14-0633] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Benefit of β-blockers (BB) and angiotensin-converting-enzyme inhibitors (ACEI) on mortality following acute myocardial infarction (MI) is well demonstrated. This study assessed the impact of BB and ACEI doses administered following ST-elevation MI on mortality and outcome up to 1 year. METHODS AND RESULTS: The French prospective observational cohort "RIMA" included 1,461 MI patients. Dosing of BB and ACEI given at 24 h and at time of discharge was assessed as follows: no treatment; <50% of target dose; or ≥50% of target dose. For in-hospital mortality, after MI, the use of BB in the first 24 h, but not ACEI, was associated with significantly lower event rate on multivariate analysis (OR, 5.78; 95% CI: 2.62-12.76, P<0.001). In contrast at 1 year, use of higher doses of ACEI, but not BB, was associated with significantly lower CV mortality, readmission for heart failure and the composite of CV mortality and readmission for heart failure (HR, 2.65; 95% CI: 1.32-5.31, P=0.006 for absence of ACEI at discharge). CONCLUSIONS Prescription of BB in the first 24 h was independently associated with a lower in-hospital mortality following MI. There appeared to be a significant dose effect on outcome with regard to <50% vs. ≥50% of target dose, which requires confirmation in further large-scale clinical studies.
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Affiliation(s)
- Sylvain Grall
- Laboratoire Cardioprotection, Remodelage et Thrombose, University of Angers, L'UNAM University and Cardiology Department, University Hospital of Angers
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Luo J, Xu H, Chen KJ. Potential benefits of Chinese Herbal Medicine for elderly patients with cardiovascular diseases. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2014; 10:305-9. [PMID: 24454321 PMCID: PMC3888910 DOI: 10.3969/j.issn.1671-5411.2013.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 12/11/2013] [Accepted: 12/13/2013] [Indexed: 01/17/2023]
Abstract
Chinese Herbal Medicine (CHM), as the most common form of traditional Chinese medicine (TCM), has been playing an important role in the treatment of elderly cardiovascular diseases (CVDs) in China. In this paper, we briefly discuss on the potential benefits of CHM for elderly patients with CVDs. Initially, we summarize the characteristics of CVDs in the elderly, the present treatment of CVDs in the elderly, and the clinical applications of CHM for CVDs. Secondly, in addition to introducing the features of CHM, we discuss the differences between CHM and Western medicine. Lastly, the potential benefits of CHM are presented. We came to a conclusion that as mutual complementary, Western medicine and TCM together shall benefit the elderly patients with CVDs.
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Affiliation(s)
- Jing Luo
- Graduate school, Beijing University of Chinese Medicine, Beijing 100029, China
| | - Hao Xu
- Cardiovascular Diseases Centre, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Ke-Ji Chen
- Cardiovascular Diseases Centre, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
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Kazi D, Deswal A. Role and Optimal Dosing of Angiotensin-Converting Enzyme Inhibitors in Heart Failure. Cardiol Clin 2008; 26:1-14, v. [DOI: 10.1016/j.ccl.2007.12.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Dobre D, van Veldhuisen DJ, DeJongste MJL, van Sonderen E, Klungel OH, Sanderman R, Ranchor AV, Haaijer-Ruskamp FM. The contribution of observational studies to the knowledge of drug effectiveness in heart failure. Br J Clin Pharmacol 2007; 64:406-14. [PMID: 17764473 PMCID: PMC2048548 DOI: 10.1111/j.1365-2125.2007.03010.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIMS Randomized controlled trials (RCTs) are the golden standard for the assessment of drug efficacy. Little is known about the add-on value of observational studies in heart failure (HF). We aimed to assess the contribution of observational studies to actual knowledge regarding the effectiveness of angiotensin-converting enzyme inhibitors (ACEI), and beta-blockers (BB) in HF. METHODS Observational studies that assessed the effectiveness of ACEI and BB in HF were identified by searching Medline, Embase, Cochrane Database (1990-2005) and the bibliographies of published articles. Cohort, case-control and time-series analysis studies were considered for inclusion. Studies with <100 patients and those who did not perform a multivariate analysis were excluded. RESULTS A total of 23 cohort studies met the inclusion criteria. Studies of ACEI and BB showed a decrease in mortality with drug use in elderly patients with a broad range of ejection fraction (EF), and in those with depressed EF. Additionally, they showed a decrease in mortality in patients with renal insufficiency. The effect of ACEI and BB in HF with preserved EF was not clear, although last evidence suggests a potential benefit. Low-dose ACEI and BB may have beneficial effects. Target doses of ACEI seemed superior to low doses, but there was no clear dose-response relationship. CONCLUSIONS Observational studies in HF validate the effectiveness of ACEI and BB in populations underrepresented or excluded from RCTs. Observational studies of drug effectiveness provide relevant additional information for clinical practice.
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Affiliation(s)
- Daniela Dobre
- Northern Centre for Healthcare Research, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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Angiotensin-Converting Enzyme Inhibitors. Hypertension 2007. [DOI: 10.1016/b978-1-4160-3053-9.50026-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Nucifora G, Albanese MC, De Biaggio P, Caliandro D, Gregori D, Goss P, Miani D, Fresco C, Rossi P, Bulfoni A, Fioretti PM. Lack of improvement of clinical outcomes by a low-cost, hospital-based heart failure management programme. J Cardiovasc Med (Hagerstown) 2006; 7:614-22. [PMID: 16858241 DOI: 10.2459/01.jcm.0000237910.34000.58] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Heart failure (HF) is a major health problem resulting in a high financial burden for the healthcare system. Many previous HF management programmes reduced adverse clinical outcomes and costs, but they usually involved several professional figures as well as huge investments, requiring resources and budgets not often available in our healthcare system. We evaluated the effects of our HF management programme, which included patient education and regular outpatient contact with the HF team, on re-hospitalisation and death, optimising the few resources already available at our hospital. METHODS Two hundred consecutive patients admitted to the internal medicine department with a diagnosis of HF were randomised to the intervention group (nurse-led education programme, facilitated telephone communication and follow-up visits with an internist at 15 days, 1 and 6 months) or to the usual care group (follow-up by their primary care physician). The primary endpoints were all-cause readmissions and all-cause deaths during the 6-month post-discharge period. RESULTS There were 81 all-cause hospital readmissions in the intervention group and 82 in the control group (P = NS). Fourteen patients (14%) in the intervention group and eight patients (8%) in the control group died during the study period (P = NS). Unplanned outpatient visits were less frequent in the intervention group than in the control group (39 [28%] versus 99 [72%], P < 0.001). CONCLUSIONS The present low-cost HF management programme reduced unplanned outpatient visits but proved ineffective in reducing subsequent readmissions and in improving clinical status. More intense follow-up monitoring and more resources are needed to achieve better results.
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Affiliation(s)
- Gaetano Nucifora
- Cardiology Unit, Cardiopulmonary Science Department, S. Maria della Misericordia Hospital, Udine, Italy.
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Tsikouris JP, Cox CD, Simoni JS, Seifert CF, Peek MC, Meyerrose GE. Lack of effect on coronary atherosclerotic disease biomarkers with modest dosing of an angiotensin-converting enzyme inhibitor, angiotensin II type-1 receptor blocker, and the combination. Coron Artery Dis 2006; 17:439-45. [PMID: 16845252 DOI: 10.1097/00019501-200608000-00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers, used alone or in combination, have been shown to improve outcomes in certain populations, primarily when administered in high doses. For stable coronary atherosclerotic disease, however, the relative physiologic effect of these therapies is unclear. Furthermore, because of the notorious subtarget dosing of such agents in clinical practice, we explored the influence of a modest dosing of an angiotensin-converting enzyme inhibitor, angiotensin II type 1 receptor blockers, and the combination on common biologic markers of coronary atherosclerotic disease. METHODS This randomized, cross-over study enrolled stable coronary atherosclerotic disease patients (n=20), each receiving three treatments: candesartan 16 mg daily, ramipril 5 mg daily, and candesartan 8 mg plus ramipril 2.5 mg daily. Treatments were administered for 2 weeks with a 2-week washout. Blood samples were collected before and after each treatment. Markers of endothelial function, fibrinolytic balance, and vascular inflammation were measured. RESULTS No significant differences were observed in the pretreatment concentrations of angiotensin-converting enzyme or of any measured biologic marker. Relative to pretreatment levels, candesartan alone was the only therapy to exhibit an action on any measured biomarker--a trend toward increased nitric oxide concentrations (P=0.054). Otherwise, no effects on biologic markers were observed with the treatments. CONCLUSION This study of various methods of the renin-angiotensin system inhibition in stable coronary atherosclerotic disease patients demonstrates negligible effects of a modest dosing of ramipril and the combination of ramipril plus candesartan on common biologic markers of coronary atherosclerotic disease. Candesartan at modest doses may favorably influence endothelial function. Overall, however, the results indicate that the commonly practiced subtarget dosing of such treatments provides little, if any, benefit pertaining to key physiologic components of coronary atherosclerotic disease.
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Affiliation(s)
- James P Tsikouris
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
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Kazi D, Deswal A. Role and Optimal Dosing of Angiotensin-Converting Enzyme Inhibitor Therapy. Heart Fail Clin 2005; 1:25-37. [PMID: 17386831 DOI: 10.1016/j.hfc.2004.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Dhruv Kazi
- Baylor College of Medicine, Houston, TX 77030, USA
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Shah RR. Drug development and use in the elderly: search for the right dose and dosing regimen (Parts I and II). Br J Clin Pharmacol 2005; 58:452-69. [PMID: 15521892 PMCID: PMC1884629 DOI: 10.1111/j.1365-2125.2004.02228.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Rashmi R Shah
- Medicines and Healthcare products Regulatory Agency, Market Towers, 1 Nine Elms Lane, Vauxhall, London, UK.
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Rangaswamy C, Finn JI, Koelling TM. Angiotensin-Converting Enzyme Inhibitor Use in Elderly Patients Hospitalized with Heart Failure and Left Ventricular Systolic Dysfunction. Cardiology 2005; 103:17-23. [PMID: 15528896 DOI: 10.1159/000081847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2003] [Accepted: 02/27/2004] [Indexed: 11/19/2022]
Abstract
PURPOSE Although angiotensin-converting enzyme (ACE) inhibitors are recommended for all patients with systolic heart failure, prior studies suggest that elderly cohorts are less likely to receive such therapy. The purpose of this study was to determine the age dependence of adherence to guideline-based medical care in hospitalized heart failure patients. METHODS We performed a multicenter observational cohort study including 613 patients admitted to participating hospitals with a primary diagnosis of heart failure with ejection fraction < or =40%. This cohort was divided into four age groups (group 1: <60, group 2: 60-69, group 3: 70-79, and group 4: 80 years) and adherence to guideline-based medical care was measured. RESULTS ACE inhibitors were administered to 83% of ideal heart failure patients, and this rate was similar for all age groups. Elderly patients received significantly lower ACE inhibitor dosages compared to their younger counterparts (168, 148, 125 and 117 mg captopril in groups 1, 2, 3, and 4, respectively, p=0.001). Lower creatinine clearance (p<0.001), prior residence in a long-term care facility (p=0.037), intolerance to ACE inhibitors (p=0.006), lower blood pressure (p=0.005), absence of a history of hypertension (p=0.005), and no prior heart failure hospitalizations within the past year (p=0.001) were found to be independent predictors of low ACE inhibitor dosing. CONCLUSIONS In this heart failure benchmarking project, elderly patients received guideline-based ACE inhibitor therapy at similar rates, but at lower doses, compared to their younger counterparts.
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Harder S, Fischer P, Krause-Schäfer M, Ostermann K, Helms G, Prinz H, Hahmann M, Baas H. Structure and markers of appropriateness, quality and performance of drug treatment over a 1-year period after hospital discharge in a cohort of elderly patients with cardiovascular diseases from Germany. Eur J Clin Pharmacol 2004; 60:797-805. [PMID: 15578173 DOI: 10.1007/s00228-004-0838-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2004] [Accepted: 09/06/2004] [Indexed: 11/30/2022]
Abstract
In a group of elderly patients over 65 years of age with at least two cardiovascular diagnoses requiring chronic medication (n=424), drug therapy at hospital discharge and at home thereafter was followed for a 1-year period. Two home visits took place at 3 months and 12 months after initial discharge. A median of six prescriptions had already been given at the time of discharge; this number increased slightly during ambulatory follow-up. After 1 year, about 30% of the patients had to take more than ten dosing units per day. After discharge, about 50% of all prescriptions were subject to changes in the choice of the preparation (brand-generic) or the agent used [within a class of similar agents, e.g. angiotensin converting enzyme inhibitors (ACIs)]. The prescription of some problematic agents (benzodiazepines, non-steroidal anti-inflammatory agents) increased during the ambulatory follow-up, but pivotal medications for cardiovascular indications (e.g., ACI) given at discharge were maintained. Over-the-counter (OTC) drugs-which were not part of the discharge medication-contributed to 12% of all drugs taken at V4. The majority of the prescriptions (95% of about 2,000 prescriptions surveyed at each visit) was in agreement with the drug's approval status and was appropriate in terms of absence of contraindications. At home visits, therapy with ACI or beta-blocking agents was in agreement with clinical guidelines, although under-dosing was obvious. Blood pressure control (<140/90 mmHg) was achieved in 61% of the patients at discharge and deteriorated to 45% after 1 year; international normalized ratio control in patients with oral anticoagulation also declined (control rate 57% at discharge, 46% after 1 year). Statins as secondary prevention were given at discharge in only 60% of suitable patients, declining to about 50% in ambulatory visits. Diabetic control was not present in 35% of the patients at discharge or at home. Properties of or reason for their medication could be given for the majority (70-80%) of the prescriptions; these quotations were, however, cursory and almost nothing was known about medication risks. At home visits, non-compliance was admitted for approximately 8% of the prescriptions. In conclusion, for pivotal indications, family doctors widely followed the discharge recommendations, but deficits in ambulatory prescriptions and poor performance of the medication were in part already employed at the time of discharge from the hospital. The lack of a patient's knowledge about their own medication is precarious.
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Affiliation(s)
- Sebastian Harder
- Pharmazentrum Frankfurt, Institute for Clinical Pharmacology, University Hospital Frankfurt am Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany.
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Aupetit JF, Bourdariat K, Lestaevel M. [Features of the treatment of heart failure in the elderly]. Presse Med 2004; 33:1086-8. [PMID: 15523262 DOI: 10.1016/s0755-4982(04)98853-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PHARMACOLOGICAL MODIFICATIONS TO BE TAKEN INTO ACCOUNT: In elderly patients, there is a modification in the distribution columns of drugs, an alteration in glomerular filtration (doses require adaptation) and tubular function (greater sensitivity to low salt diet and diuretics), and a reduction in the hepatic elimination capacity. FOR SYSTOLIC HEART FAILURE: The choice of drugs is in practice the same as that for younger patients: diuretics, antialdosterone agents, converting enzyme inhibitors, angiotensin II receptor antagonists, beta-blockers and digitalics. FOR DIASTOLIC HEART FAILURE: The therapeutic approach combines an etiologic treatment (blood pressure, myocardial ischaemia), prevention and the rapid treatment of the decompensation factors (atrial arrhythmia), a pharmacological treatment (converting enzyme inhibitors, angiotensin II receptor antagonists, and bradycardia lowering agents). Non-pharmacological measures include dietary restrictions, regular physical exercise, and education for the patient and the family.
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Affiliation(s)
- Jean-François Aupetit
- Département de pathologie cardiovasculaire, Centre hospitalier Saint-Joseph et Saint Luc, Lyon
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18
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Rich MW. Are Angiotensin-Converting Enzyme Inhibitors Indicated for the Routine Treatment of Elderly Heart Failure Patients? J Gerontol A Biol Sci Med Sci 2004; 59:713-5. [PMID: 15304536 DOI: 10.1093/gerona/59.7.m713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
OBJECTIVE To discuss the controversy associated with the optimal dosing of angiotensin-converting enzyme (ACE) inhibitors in the management of patients with systolic heart failure; specifically, to review data related to the use of high-dose ACE inhibitors related to both neurohormonal and clinical outcomes associated with doses similar to, lower than, and higher than those used in the large, randomized clinical trials. DATA SOURCES Primary, review, and meta-analysis articles were identified by MEDLINE search (1987–September 2002) and through secondary sources. STUDY SELECTION AND DATA EXTRACTION All of the articles identified from the data sources were evaluated, and all information deemed relevant was included in this discussion. All available comparative dose trials, both prospective and retrospective, were evaluated for clinical and neurohormonal outcomes. DATA SYNTHESIS The majority of data comparing the effect of high- with low-dose ACE inhibitors on neurohormonal outcomes demonstrate dose-related reduction in various neurohormonal measurements including plasma ACE, aldosterone, atrial natriuretic peptide, B-type natriuretic peptide, and interleukin-6 levels. Clinical endpoints including New York Heart Association class and heart failure—related hospitalizations were reduced by higher doses, but a dose-related survival benefit has not been demonstrated. Differences in duration of therapy and study design may account for variability in neurohormonal and morbidity results among various studies. CONCLUSIONS Despite documented underutilization in clinical practice of doses of ACE inhibitors demonstrated in large controlled trials to improve morbidity and mortality, clinicians should attempt to reach these target doses if possible in patients with heart failure. Higher doses may improve surrogate markers for heart failure without impacting survival.
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Affiliation(s)
- David S Roffman
- School of Pharmacy, Cardiac Care Unit, University of Maryland Medical System, University of Maryland, Baltimore, MD 21201-10872, USA.
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Moser DK, Biddle MJ. Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers: what we know and current controversies. Crit Care Nurs Clin North Am 2004; 15:423-37, vii-viii. [PMID: 14717387 DOI: 10.1016/s0899-5885(02)00107-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A little more than a decade ago, management of heart failure was changed forever when a number of randomized clinical trials confirmed that a class of drugs, angiotensin-converting enzyme (ACE) inhibitors, could improve survival in patients with heart failure. The recognition that blockade of one of the neurohumoral systems activated in heart failure could improve outcomes prompted widespread testing of other neurohumoral blockers, such as beta-adrenergic blocking agents, aldosterone antagonists, and most recently, angiotensin II type 1 receptor blockers (ARBs) for the treatment of heart failure. This article describes what is known about the use of ACE inhibitors and ARBs in the management of heart failure and presents the current controversies surrounding the use of these agents.
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Affiliation(s)
- Debra K Moser
- Department of Cardiovascular Nursing, College of Nursing, University of Kentucky, 52777 CON/HSLC Building, 760 Rose Avenue, Lexington, KY 40536-0232, USA.
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Manyemba J, Mangoni AA, Pettingale KW, Jackson SHD. Determinants of failure to prescribe target doses of angiotensin-converting enzyme inhibitors for heart failure. Eur J Heart Fail 2003; 5:693-6. [PMID: 14607209 DOI: 10.1016/s1388-9842(03)00055-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Juliet Manyemba
- Department of Health Care of the Elderly, Clinical Age Research Unit, Guy's King's and St. Thomas School of Medicine, King's College Hospital, London SE5 9PJ, UK.
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Abstract
Chronic heart failure is an epidemic disorder in the elderly population. The frequent coexistence of comorbid illnesses and psychosocial issues in older persons often makes diagnosis and management difficult. Physicians must be aware of the current diagnostic modalities and proven therapies as they apply to elderly patients in order to achieve optimal outcomes. This article reviews new approaches to the diagnosis of heart failure, and discusses the latest evidence for both pharmacologic and nonpharmacologic treatment for this condition. Multidisciplinary strategies for the management of heart failure and end-of-life care are also briefly discussed.
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Affiliation(s)
- Roger Kerzner
- Washington University School of Medicine, 660 South Euclid Avenue, Box 8086, St. Louis, MO 63110, USA
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Scott IA, Denaro CP, Flores JL, Bennett CJ, Hickey AC, Mudge AM, Atherton J. Quality of care of patients hospitalized with congestive heart failure. Intern Med J 2003; 33:140-51. [PMID: 12680979 DOI: 10.1046/j.1445-5994.2003.00362.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Congestive heart failure (CHF) is an increasingly prevalent poor-prognosis condition for which effective interventions are available. It is -therefore important to determine the extent to which patients with CHF receive appropriate care in Australian hospitals and identify ways for improving suboptimal care, if it exists. AIM To evaluate the quality of in-hospital acute care of patients with CHF using explicit quality indicators based on published guidelines. METHODS A retrospective case note review was -performed, involving 216 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between October 2000 and April 2001. Outcome measures were process-of-care quality -indicators calculated as proportions of all, or strongly -eligible (ideal), patients who received -specific interventions. RESULTS Assessment of underlying causes and acute precipitating factors was undertaken in 86% and 76% of patients, respectively, and objective evaluation of left ventricular function was performed in 62% of patients. Prophylaxis for deep venous thrombosis (DVT) was used in only 29% of ideal patients. Proportions of ideal patients receiving pharmacological treatments at discharge were: (i) angiotensin--converting enzyme inhibitors (ACEi) (82%), (ii) target doses of ACEi (61%), (iii) alternative vasodilators in patients ineligible for ACEi (20%), (iv) beta-blockers (40%) and (v) warfarin (46%). CONCLUSIONS Opportunities exist for improving quality of in-hospital care of patients with CHF, -particularly for optimal prescribing of: (i) DVT prophylaxis, (ii) ACEi, (iii) second-line vasodilators, (iv) beta-blockers and (v) warfarin. More research is needed to identify methods for improving quality of in-hospital care.
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Affiliation(s)
- I A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, and Department of Medicine, University of Queensland, Brisbane, Queensland, Australia.
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Lonn E. Dose response of ACE inhibitors: implications of the SECURE trial. CURRENT CONTROLLED TRIALS IN CARDIOVASCULAR MEDICINE 2001; 2:155-159. [PMID: 11806789 PMCID: PMC59639 DOI: 10.1186/cvm-2-4-155] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The choice of the appropriate dosage of ACE inhibitor in clinical practice is an important one. The available evidence suggests that in chronic heart failure as well as in chronic coronary artery disease, high doses of angiotensin-converting enzyme (ACE) inhibitor are more effective than low ones. The current recommended clinical approach is to target ACE inhibitor dosing regimens to be similar to those used in the clinical trials, which demonstrated mortality and morbidity benefits. When titrated appropriately, ACE inhibitors are generally well tolerated and target doses can be achieved and maintained in the majority of patients with atherosclerotic vascular disease, with or without heart failure.
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Affiliation(s)
- Eva Lonn
- McMaster University, Hamilton, Ontario, Canada.
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