Krumholz H M, Vaccarino V, Ellerbeck E F, Kiefe C, Hennen J, Kresowik T F, Gold J A, Jencks S F, Radford M J
Department of Medicine, Yale School of Medicine, New Haven, Connecticut 06520-8017, USA.
Am J Cardiol. 1997 Mar 1;79(5):581-6. doi: 10.1016/s0002-9149(96)00819-3.
We sought to determine how often angiotensin-converting enzyme (ACE) inhibitors are prescribed as a discharge medication among eligible patients > or = 65 years old with an acute myocardial infarction; to identify patient characteristics associated with the decision to prescribe ACE inhibitors; and to determine the factors associated with the decision to obtain an evaluation of left ventricular function among patients who have no contraindications to ACE inhibitors. We addressed these aims with an observational study of consecutive elderly Medicare beneficiary survivors of an acute myocardial infarction hospitalized in Alabama, Connecticut, Iowa, and Wisconsin between June 1992 and February 1993. Among the 5,453 patients without a contraindication to ACE inhibitors at discharge, 3,528 (65%) had an evaluation of left ventricular function. Of the 1,228 patients without a contraindication to ACE inhibitors who had a left ventricular ejection fraction < or = 40%, 548 (45%) were prescribed the medication at discharge. In a multivariable analysis, an increased prescribed use of ACE inhibitors at discharge was correlated with several factors, including diabetes mellitus, congestive heart failure, ventricular tachycardia, and loop diuretics as a discharge medication. Patients admitted after the publication of the Survival and Ventricular Enlargement (SAVE) trial were significantly more likely to receive ACE inhibitors, although the absolute improvement in utilization was small in the 6 months after the trial results were published. In conclusion, improving the identification of appropriate patients for ACE inhibitors and increasing the prescription of ACE inhibitors for ideal patients may provide an excellent opportunity to improve care.
我们试图确定在年龄≥65岁的急性心肌梗死合格患者中，血管紧张素转换酶（ACE）抑制剂作为出院用药的处方频率；确定与开具ACE抑制剂处方的决定相关的患者特征；并确定在无ACE抑制剂使用禁忌证的患者中，与进行左心室功能评估的决定相关的因素。我们通过对1992年6月至1993年2月期间在阿拉巴马州、康涅狄格州、爱荷华州和威斯康星州住院的急性心肌梗死老年医疗保险受益连续幸存者进行观察性研究来实现这些目标。在5453例出院时无ACE抑制剂使用禁忌证的患者中，3528例（65%）进行了左心室功能评估。在1228例无ACE抑制剂使用禁忌证且左心室射血分数≤40%的患者中，548例（45%）在出院时被开具了该药物。在多变量分析中，出院时ACE抑制剂的处方使用增加与几个因素相关，包括糖尿病、充血性心力衰竭、室性心动过速以及作为出院用药的襻利尿剂。在生存与心室扩大（SAVE）试验发表后入院的患者接受ACE抑制剂的可能性显著更高，尽管在试验结果发表后的6个月内使用率的绝对改善很小。总之，改善对适合使用ACE抑制剂患者的识别，并增加对理想患者的ACE抑制剂处方，可能为改善治疗提供绝佳机会。
