Ghali J K, Giles T, Gonzales M, Horswell R, Kumar S, Lejuene A, Livaudais G F, Sarkar I C
Heart Failure Program, LSU Medical Center, Shreveport, USA.
J La State Med Soc. 1997 Dec;149(12):474-84.
Randomized clinical trails have demonstrated that angiotensin-converting enzyme (ACE) inhibitors reduce mortality, improve symptoms, and decrease hospitalization rates in congestive heart failure (CHF) patients with impaired left ventricular systolic function. Guidelines from the Agency for Healthcare Policy and Research (AHCPR) endorse the use of ACE inhibitors in eligible CHF patients and note their underutilization in practice. Randomly selected records of 1,212 Medicare CHF patients in Louisiana, discharged between July 1993 and October 1993, were reviewed. Abstracted data were used to characterize practice patterns and pertinent clinical factors influencing current ACE inhibitor utilization by practicing physicians in eligible Medicare CHF patients admitted to acute care hospitals. A total of 1,133 patients admitted were discharged alive; mean age was 77.6 years (64% female; 68% white). One third of the patients (34%) were already receiving ACE inhibitors on admission; of these, 85% were discharged on ACE inhibitors. The remaining 66% of patients were not on an ACE inhibitor on admission; only 35% of these are documented to have been placed on an ACE inhibitor(s) at discharge. Overall, a significantly large number of CHF patient charts (48%) lacked documentation of LV systolic function assessments. On multivariate logistic regression modeling, the following key clinical variables were positively related to the prescription of ACE inhibitors: low ejection fraction, dyspnea and orthopnea, normal creatinine levels, high diastolic blood pressure, cardiomegaly, and increasing age. Among patients with low ejection fraction, factors contributing to not being discharged on ACE inhibitors included: high creatinine levels, history of myocardial infarction or ischemic heart disease, renal failure, and being African American. This study documents the underutilization of ACE inhibitors in patients with impaired left ventricular systolic function. Results suggest the need for increased physician-based educational efforts concerning the use of ACE inhibitors in CHF patients, and also for increasing left ventricular systolic function assessments and documentation of findings in patient charts.
随机临床试验表明，血管紧张素转换酶（ACE）抑制剂可降低左心室收缩功能受损的充血性心力衰竭（CHF）患者的死亡率，改善症状，并降低住院率。医疗保健政策与研究机构（AHCPR）的指南认可在符合条件的CHF患者中使用ACE抑制剂，并指出其在实际应用中未得到充分利用。对1993年7月至1993年10月间在路易斯安那州出院的1212名医疗保险CHF患者的随机选择记录进行了审查。提取的数据用于描述实际应用模式以及影响在急性护理医院住院的符合条件的医疗保险CHF患者中执业医师当前使用ACE抑制剂的相关临床因素。总共1133名入院患者存活出院；平均年龄为77.6岁（64%为女性；68%为白人）。三分之一的患者（34%）入院时已在服用ACE抑制剂；其中，85%出院时仍在服用ACE抑制剂。其余66%的患者入院时未服用ACE抑制剂；这些患者中只有35%的记录显示出院时开始服用ACE抑制剂。总体而言，大量CHF患者病历（48%）缺乏左心室收缩功能评估的记录。在多变量逻辑回归模型中，以下关键临床变量与ACE抑制剂的处方呈正相关：射血分数低、呼吸困难和端坐呼吸、肌酐水平正常、舒张压高、心脏扩大以及年龄增加。在射血分数低的患者中，未在出院时使用ACE抑制剂的因素包括：肌酐水平高、心肌梗死或缺血性心脏病史、肾衰竭以及非裔美国人。这项研究记录了左心室收缩功能受损患者中ACE抑制剂的未充分利用情况。结果表明，需要加强针对医师的教育工作，以提高其对CHF患者使用ACE抑制剂的认识，同时也需要增加左心室收缩功能评估并在患者病历中记录结果。
