Prevalence of ACE-inhibitor use in diabetic hypertensives in hypertension speciality clinic: a quality assurance review

Renin Angiotensin Aldosterone (RAA) inhibition has been shown to have beneficial effects in diabetics. We chose to evaluate the usefulness of drugs that block the RAA Axis including ACE inhibitors (ACEIs) and the Angiotensin Receptor Blockers (ARBs) in a Hypeternsion Speciality Clinic. Charts of 437 Consecutive patients seen at the Rush University Hypertension Center from September, 1998 to February, 2000 were evaluated for blood pressure control and treatment regimen. The Rush University Hypertension Center is comprised of 4 physicians, 3 of whom are certified Clinical Hypertension Specialists. Physicians based their treatment strategies on current guidelines. No specific clinical pathway was used and no drug regimen was mandated. Twenty (20%) of the total patients (N=86) were Type II diabetics, 47% were male, there mean age was 61 ± 12 years. The mean blood pressure upon initial presentation to clinic was 156 ± 24/ 89 ± 12 mm Hg and was reduced to 137 ± 16/ 78 ± 10 mm Hg after at least one year of enrolment in the clinic. ACEIs and ARBs were included in the regimen of 76% diabetic patients compared to 43% of non-diabetics. Twenty four (24%) of the diabetics were not treated with ACE inhibitors or Angiotensin Receptor Blockers. In 9/21 (43%) of the patients the failure to use these drugs was due to Side effects like cough (4), angioedema (2), hyperkalemia (1), dizziness (1), and increased creatinine (1). Additionally, physicians elected non-ACEI/ARB regimens in seven patients with already controlled BP. Four patients refused addition of medications to their current regimen, and no reason existed for only one patient. These results indicate that pharmacologic blockade of the RAA System was used in 76% of diabetics, and that contraindication for such therapy was present in 43% of those who did not recieve it. Quality assurance surveys should recognize that not all diabetics will recieve angiotensin antagonists because of existing contraindications and patient preferences.