ACE Inhibitors for Older Patients with Heart Failure: A Review of Evidence, Practice Patterns and Challenges

Heart failure is predominantly a condition of the elderly and is associated with substantial mortality, morbidity and functional limitation. In clinical trials of patients with left ventricular systolic dysfunction (LVSD), angiotensin-converting enzyme (ACE) inhibitors reduce the burden of heart failure. Clinical trials, however, have largely excluded older persons. This paper reviews the evidence for efficacy and effectiveness of ACE inhibitors, current patterns of use of these important agents and the challenges of prescribing ACE inhibitors for older patients with heart failure. The existing literature indicates that (1) despite a relative paucity of data from randomized controlled trials, observational studies suggest that the elderly with LVSD are as likely to benefit from ACE inhibitors as younger patients; (2) ACE inhibitors are underused in older persons despite guideline recommendations, and (3) the older population presents specific challenges in applying the clinical evidence supporting ACE inhibitors, including polypharmacy, cognitive impairment and other common comorbid conditions. Nevertheless, the judicious use of ACE inhibitors in eligible older patients will likely improve health outcomes.