Underutilization of Ace Inhibitors in Older Persons

Daniel Forman and co-authors demonstrated an under-utilization of ACE inhibitors in an older nursing home cohort in the United States.1 The reasons for such underprescription are complex but unsurprising. In the UK, there seems to be reluctance among physicians to investigate older patients with heart failure and to treat systolic dysfunction appropriately with ACE inhibitors.2 It is likely that many older patients with heart failure in the UK do not receive an ACE inhibitor because of lack of access to objective assessments of left ventricular function in the first instance. However, in this US study, treatment with ACE inhibitors is still disappointingly low at only 35% of patients despite confirmed objective evidence of impaired left ventricular function. Possible additional reasons for low levels of ACE inhibitors use include concerns about the small numbers of frail older patients included in the SOLVD study.3 The mortality benefits demonstrated may not apply to frail older patients with impaired renal function, and the higher likelihood of associated postural hypotension may also be deterring clinicians from initiating treatment. In a nursing home setting where access to objective assessment of left ventricular function by radionuclide ventriculography is likely to be limited, objective assessments of left ventricular function may be possible using portable echocardiography.4 If wider use of ACE inhibitors in frail older patients is to be advocated, then more trial evidence is required that demonstrates benefit in terms of quality of life and activities of daily living measurements.5 These end-points are more meaningful in a frail older population than mortality data alone. We are currently evaluating the impact of the ACE inhibitor perindopril on quality of life measures, cognition, and 6-minute walking distance. Useful effect on these end points would augment the case for a more widespread use of ACE inhibitors in nursing home residents with systolic dysfunction.