Chin M H, Friedmann P D, Cassel C K, Lang R M
Section of General Internal Medicine, University of Chicago (Ill) Medical Center 60637, USA.
J Gen Intern Med. 1997 Sep;12(9):523-30. doi: 10.1046/j.1525-1497.1997.07105.x.
To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication.
Survey of a national systematic sample of physicians.
Five hundred family practitioners, 500 general internists, and 500 cardiologists.
Physicians' choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p < or = .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%): and asymptomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely [p < or = .05] to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less [43% vs 15%).
Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasise the dosages demonstrated to lower mortality and morbidity in the trials.
量化充血性心力衰竭患者血管紧张素转换酶（ACE）抑制剂使用不足的程度及其决定因素，尤其关注医生专业和临床指征。
对全国医生进行系统抽样调查。
500名家庭医生、500名普通内科医生和500名心脏病专家。
针对4例左心室收缩功能障碍的假设患者确定医生的用药选择：（1）新发、有症状；（2）无症状；（3）慢性心力衰竭，正在服用洋地黄和利尿剂；（4）无症状，心肌梗死后。对于每例患者，随机对照试验已证明ACE抑制剂可降低死亡率或症状进展。在727名回复调查问卷的合格医生中（调整后回复率58%），约90%的医生为已在服用洋地黄和利尿剂的慢性心力衰竭患者使用了ACE抑制剂。然而，对于其他指征，家庭医生和普通内科医生选择ACE抑制剂的频率低于心脏病专家（p≤0.01）。每种模拟患者使用ACE抑制剂的相应比例分别为：新发、有症状（家庭医生72%，普通内科医生76%，心脏病专家86%）；无症状（家庭医生68%，普通内科医生78%，心脏病专家93%）；无症状，心肌梗死后（家庭医生58%，普通内科医生70%，心脏病专家94%）。与全科医生相比，心脏病专家更有可能（p≤0.05）将ACE抑制剂增加至目标剂量（45%对26%），并耐受收缩压90mmHg或更低（43%对15%）。
与心脏病专家相比，家庭医生和普通内科医生可能未充分使用ACE抑制剂，尤其是在射血分数降低的无症状或心肌梗死后患者中。教育工作应聚焦于这些指征，并强调在试验中已证明可降低死亡率和发病率的剂量。
