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More appropriate use of medications could improve outcomes of heart failure patients

Management of heart failure has advanced substantially with effective revascularization procedures and improved cardiac remodeling with angiotensin-converting enzyme (ACE) inhibitors. However, many clinicians still underuse ACE inhibitors and overuse calcium antagonists in patients with significant cardiac dysfunction. They also use this less-than-ideal approach in managing heart failure among urban blacks, who are at high risk for uncontrolled hypertension and hospitalization for heart failure, according to a study supported in part by the Agency for Health Care Policy and Research (HS07400). It shows that physicians used suboptimal dosing with ACE inhibitors for a group of urban patients—most of whom were black—who were hospitalized for heart failure, and the physicians inappropriately used calcium antagonists for 56 percent of the patients.

More appropriate use of these medications and better control of hypertension could improve the outcomes of heart failure patients, according to the study, which was conducted by researchers from the Morehouse School of Medicine and Morehouse's MEDTEP Minority Research Center. The researchers identified the clinical correlates of recurrent hospitalizations for heart failure in 1,200 patients (94 percent were black; 51 percent were women; mean age 64 years) who were admitted to the hospital for heart failure during 1995. Of these patients, 98 percent had a history of systemic hypertension, and 55 percent had uncontrolled hypertension. Sixty-five percent of patients were on ACE inhibitors (for example, enalapril and captopril), 51 percent were on calcium antagonists (for example, diltiazem and nifedipine), and 8 percent were on beta blockers.

Heart failure patients with severe left ventricular (LV) dysfunction on calcium antagonists had a 28 percent increase in hospitalization during the 12-month study period and twice the risk of hospitalization as patients with severe LV dysfunction not on calcium antagonists. ACE inhibitors, the diuretic furosemide, and beta blocker treatments were not associated with a higher hospitalization rate, but treatment with calcium antagonists, alpha blockers, and the vasodilator hydralazine did increase the likelihood of hospitalization.

For details, see "Gender differences and practice implications of risk factors for frequent hospitalization for heart failure in an urban center serving predominantly African-American patients," by Elizabeth O. Ofili, M.D., M.P.H., Robert Mayberry, M.P.H., Ph.D., Ernest Alema-Mensah, Ph.D., and others, in the May 1, 1999, American Journal of Cardiology 83, pp. 1350-1355.

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