Mortality associated with the quality of care of patients hospitalized with congestive heart failure

OBJECTIVE: This study examined the association between use of angiotensin converting enzyme inhibitors (ACEIs) and risk of death in elderly patients hospitalized with left ventricular systolic dysfunction (LVSD). DESIGN: Retrospective cohort study. SETTING: Despite evidence showing the benefit of treating LVSD with ACEI, elderly patients with LVSD are often not treated with an ACEI. Concern that the risk of ACEI treatment might exceed the benefits in elderly patients is a possible reason. STUDY PARTICIPANTS: We abstracted records from 2943 Medicare beneficiaries hospitalized for congestive heart failure in 69 hospitals in five states. The presence of LVSD was determined from recorded ejection fractions or a narrative description of ventricular function. Discharge medications and dosages were abstracted. MAIN OUTCOME MEASURES: Mortality was tracked for one year using Health Care Finance Administration MEDPRO files. RESULTS: There were 621 patients aged 65 years or older with LVSD. The mean age (SD) was 77.4 years (7.0). At discharge 79% were prescribed an ACEI and, of these, 47% were discharged at the dose recommended by clinical practice guidelines. There were 195 deaths (31.4%) during the year of follow-up. Compared with patients discharged at a recommended ACEI dose, patients not prescribed an ACEI at discharge had an adjusted hazard ratio for death (95% CI) of 1.63 (1.02, 2.60) and patients prescribed an ACEI at a less than recommended dose had a hazard ratio of 1.30 (0.86, 1.97). CONCLUSIONS: Our results show that ACEI use at discharge in elderly patients with LVSD is associated with decreased risk of death.