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Survival Benefits of Angiotensin-Converting Enzyme Inhibitors in Older Heart Failure Patients with Perceived Contraindications


  • The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the CMS, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.

  • An abstract based on the preliminary results of this study was presented at the 5th Scientific Meeting of the Heart Failure Society of America in Washington, DC, September 2001.

Address correspondence to Dr. Ali Ahmed, 1530 3rd Ave South, CH-19, Suite 219, Birmingham AL 35294-2041. E-mail:


OBJECTIVES: To determine the association between angiotensin-converting enzyme (ACE) inhibitor therapy and survival of older heart failure patients with conditions perceived by physicians as contraindications to ACE inhibitors.

SETTING: Hospital.

DESIGN: Retrospective follow-up study.

PARTICIPANTS: Hospitalized older heart failure patients with systolic blood pressure of 90 mmHg or less, serum creatinine of 2.5 mg/dL or more, serum potassium of 5.5 mmol/L or more, or severe aortic stenosis.

MEASUREMENTS: One-year postdischarge mortality (with and without adjustment for various patient and care characteristics). Logistic regression analyses were used to estimate the effect of the perceived contraindications on subsequent use of ACE inhibitors. Using Cox proportional hazards models, crude and adjusted hazard ratios (HRs) of 1-year mortality with 95% confidence intervals (CIs) were estimated for patients discharged on ACE inhibitors and compared with those without. HRs were estimated for all patients and were repeated after stratifying patients based on the presence of perceived contraindications to ACE inhibitor use.

RESULTS: Of the 295 subjects, 52 (18%) had conditions perceived as contraindications, 186 (63%) received ACE inhibitors, and 107 (40%) died within 1 year of discharge. Presence of a perceived contraindication was independently associated with underutilization of ACE inhibitors on discharge (adjusted OR = 0.35, 95% CI = 0.17–0.71). ACE inhibitor prescription at discharge was associated with lower 1-year mortality overall (HR = 0.58, 95% CI = 0.40–0.85) and for the groups of patients with (HR = 0.34, 95% CI = 0.14–0.81) and without (HR = 0.66, 95% CI = 0.42–1.02) perceived contraindications.

CONCLUSIONS: ACE inhibitor use was associated with a significant survival benefit in this cohort of hospitalized older heart failure patients with perceived contraindications.