McDermott M M, Lee P, Mehta S, Gheorghiade M
Division of General Internal Medicine, Northwestern University Medical School, Chicago, Illinois, USA.
Clin Cardiol. 1998 Apr;21(4):261-8. doi: 10.1002/clc.4960210406.
Among hospitalized patients with heart failure, we describe characteristics associated with prescription of angiotensin-converting enzyme (ACE) inhibitors in the doses recommended by clinical practice guidelines. We also describe the impact of ACE inhibitor prescriptions, increases in ACE inhibitor dose, and nonpharmacologic educational interventions on readmission-free survival rates.
We hypothesize that care by a cardiologist physician and higher mean arterial blood pressure on admission are associated with receipt of optimal ACE inhibitor doses. We hypothesize that receipt of an ACE inhibitor at discharge and an increase in ACE inhibitor dose during hospitalization are associated with superior readmission-free survival.
Between January 1, 1992, and December 31, 1993, medical records were reviewed for consecutively hospitalized patients with a principal diagnosis of heart failure at an academic medical center. Documented instructions and medications prescribed at discharge were abstracted. Deaths and readmissions through December 31, 1994, were identified with the National Death Index and the study institution's administrative data base, respectively.
During 1992 and 1993, 387 patients were discharged alive from hospitalization for heart failure. Among patients discharged on enalapril or captopril, 18% received doses recommended by heart failure clinical practice guidelines. Patients discharged on a recommended ACE inhibitor dose were more likely to be African-American and had lower sodium levels and higher mean arterial pressures than patients discharged on lower ACE inhibitor doses. In survival analyses, an increase in ACE inhibitor dose was associated with improved readmission-free survival, independent of left ventricular systolic function type. Receipt of an ACE inhibitor at discharge was also associated with superior readmission-free survival, while nonpharmacologic educational instructions were not associated with improved outcomes.
Interventions are needed to improve the frequency with which ACE inhibitors are prescribed at recommended doses to hospitalized patients with heart failure. We conclude that among these patients, receipt of an ACE inhibitor at discharge and an increase in ACE inhibitor dose during hospitalization are each associated with measurable effects on readmission-free survival, while provision of educational instructions as currently practiced is not associated with better outcomes.
在住院的心力衰竭患者中，我们描述与按照临床实践指南推荐剂量使用血管紧张素转换酶（ACE）抑制剂处方相关的特征。我们还描述了ACE抑制剂处方、ACE抑制剂剂量增加以及非药物教育干预对无再入院生存率的影响。
我们假设由心脏病专家进行治疗以及入院时较高的平均动脉血压与接受最佳ACE抑制剂剂量相关。我们假设出院时接受ACE抑制剂治疗以及住院期间ACE抑制剂剂量增加与更好的无再入院生存率相关。
在1992年1月1日至1993年12月31日期间，对一家学术医疗中心连续住院的主要诊断为心力衰竭的患者的病历进行回顾。提取出院时记录的医嘱和所开药物。分别通过国家死亡指数和研究机构的行政数据库确定截至1994年12月31日的死亡和再入院情况。
在1992年和1993年期间，387例心力衰竭患者出院时存活。在出院时使用依那普利或卡托普利的患者中，18%接受了心力衰竭临床实践指南推荐的剂量。与出院时接受较低ACE抑制剂剂量的患者相比，出院时接受推荐ACE抑制剂剂量的患者更可能是非裔美国人，钠水平较低且平均动脉压较高。在生存分析中，ACE抑制剂剂量增加与改善的无再入院生存率相关，与左心室收缩功能类型无关。出院时接受ACE抑制剂治疗也与更好的无再入院生存率相关，而非药物教育指导与改善结局无关。
需要采取干预措施来提高向住院心力衰竭患者按推荐剂量开具ACE抑制剂的频率。我们得出结论，在这些患者中，出院时接受ACE抑制剂治疗以及住院期间ACE抑制剂剂量增加均与对无再入院生存率有可测量的影响相关，而目前实施的提供教育指导与更好的结局无关。
