Philbin E F
Cardiovascular Medicine Division, Henry Ford Hospital, Detroit, Michigan 48202, USA.
Clin Cardiol. 1998 Feb;21(2):103-8. doi: 10.1002/clc.4960210208.
Angiotensin-converting enzyme (ACE) inhibitors were underprescribed for patients with congestive heart failure (CHF) treated in the community setting in the early 1990s despite convincing evidence of benefit.
We postulated that (1) the prevalence of ACE inhibitor use has increased, and (2) prescribing biases have narrowed, as community physicians have gained additional clinical experience with these drugs for treatment of CHF.
We examined rates of ACE inhibitor use among 1,150 patients with CHF hospitalized at 10 community hospitals in 1995, evaluated determinants of ACE inhibitor prescription, and compared the results with survey data gathered among similar patients during 1992.
Compared with 1992, ACE inhibitor use prior to hospital admission was increased among all patients (42 vs. 33%, p < 0.001) and the subset with a history of CHF (53 vs. 39%, p < 0.0005). Angiotensin-converting enzyme inhibitor prescription at hospital discharge also increased among all survivors (64 vs. 51%, p < 0.00005) and the subset eligible for ACE inhibitor treatment based on clinical trial criteria (77 vs. 66%, p = 0.04). Multivariate analysis suggested no change in the prescribing biases previously observed; ACE inhibitor use was related to lower ejection fraction, lower serum creatinine, documentation of left ventricular systolic function, younger patient age, prescription of any diuretic drug, and nonprescription of alternate vasodilators and calcium blockers. In multivariate analyses, physician specialty did not predict ACE inhibitor use.
Angiotensin-converting enzyme inhibitor use among patients with CHF is increasing but remains below the 80-90% rates of drug tolerance documented in randomized clinical trials. This discrepancy is partially explained by the prevalence of renal impairment and "diastolic" heart failure in the community setting. However, age bias, use of alternative vasodilators, and substandard quality of care may also play a role.
20世纪90年代初，尽管有确凿的证据表明血管紧张素转换酶（ACE）抑制剂对社区环境中治疗的充血性心力衰竭（CHF）患者有益，但该药物的处方量却不足。
我们推测（1）ACE抑制剂的使用普及率有所提高，并且（2）随着社区医生在使用这些药物治疗CHF方面获得了更多临床经验，处方偏见已经缩小。
我们检查了1995年在10家社区医院住院的1150例CHF患者中ACE抑制剂的使用比例，评估了ACE抑制剂处方的决定因素，并将结果与1992年期间收集的类似患者的调查数据进行了比较。
与1992年相比，所有患者入院前ACE抑制剂的使用有所增加（42%对33%，p<0.001），有CHF病史的亚组患者也是如此（53%对39%，p<0.0005）。所有幸存者出院时ACE抑制剂的处方量也有所增加（64%对51%，p<0.00005），以及根据临床试验标准有资格接受ACE抑制剂治疗的亚组患者（77%对66%，p = 0.04）。多变量分析表明，先前观察到的处方偏见没有变化；ACE抑制剂的使用与较低的射血分数、较低的血清肌酐、左心室收缩功能的记录、患者年龄较小、任何利尿剂的处方以及替代血管扩张剂和钙阻滞剂的未处方有关。在多变量分析中，医生专业并不能预测ACE抑制剂的使用。
CHF患者中ACE抑制剂的使用正在增加，但仍低于随机临床试验中记录的80-90%的药物耐受性比例。这种差异部分是由于社区环境中肾功能损害和“舒张性”心力衰竭的患病率所致。然而，年龄偏见、替代血管扩张剂的使用以及护理质量不合格也可能起作用。
