Medline ® Abstract for Reference 49
of 'Prognosis of heart failure'
Impact of angiotensin-converting enzyme inhibitor underdosing on rehospitalization rates in congestive heart failure.
Luzier AB, Forrest A, Adelman M, Hawari FI, Schentag JJ, Izzo JL Jr
Am J Cardiol. 1998;82(4):465.
In a retrospective, cohort design, clinical usage of digoxin, diuretic, and angiotensin-converting enzyme (ACE) inhibitor was assessed in all patients readmitted over a 36-month period for congestive heart failure (CHF) diagnostic-related group (DRG) 127. ACE inhibitor dose-response analysis used the discharge dose of ACE inhibitor, converted to enalapril-equivalent doses and adjusted for renal function. Principal end points were time-to-readmission and 90-day readmission rate. Of 314 total patients, digoxin was used in 72%, diuretic in 86%, and 67% received an ACE inhibitor. Only 22% of those on an ACE inhibitor received currently recommended doses of enalapril>or = 20 mg/day or equivalent, whereas 41% received enalapril<or = 5 mg/day. Time-to-readmission was increased by an ACE inhibitor (p = 0.002) but not digoxin or diuretic. An ACE inhibitor was the principal covariate of 90-day readmission rate (p<0.05). The readmission rate was not reduced with daily ACE inhibitor doses of<or = 5 mg enalapril, whereas daily doses of>or = 10 mg enalapril reduced 90-day readmission rates by 28% compared to those receiving diuretic or digoxin therapy (p<0.05). Using a dynamic model, the dose required to achieve 90% to 95% of the theoretical maximum ACE inhibitor effect exceeded 100 mg enalapril daily. Thus, CHF readmission rates are lower whendaily ACE inhibitor doses exceed 5 mg enalapril or the equivalent daily, but are unaffected by digoxin or diuretic. Modeled maximum ACE inhibitor benefits require doses 8- to 10-fold higher than current usage patterns.
School of Pharmacy, State University of New York at Buffalo, Millard Fillmore Health System, USA.