Are elderly people with the HOPE criteria prescribed angiotensin-converting enzyme inhibitors?

Abstract

JRAAS 2004;5:26 It is now almost four years since the publication of the Hypertension Outcomes Prevention Evaluation (HOPE) study which showed that ramipril caused a significant reduction in death and cardiovascular events compared with placebo in a high-risk elderly population. Although the HOPE study led to the widespread use of angiotensin-converting enzyme (ACE) inhibitors, there is little information on how it has affected prescribing in elderly patients who happen to meet the HOPE criteria. We investigated whether patients in our Medicine for the Elderly outpatient service were prescribed ACE inhibitors (ACE-I) inline with the HOPE recommendations. We conducted a case note survey of 526 patients attending Medicine for the Elderly day hospital and outpatient clinics in Dundee, Scotland. Patients with a diagnosis of chronic heart failure or asymptomatic left ventricular systolic dysfunction were excluded, as were patients with a documented contraindication to ACE-Is, leaving 205/526 (39%) patients with at least one of the HOPE criteria. Only 68/205 (33.2%) had been prescribed an ACE-I. Therefore, we found a low rate of prescription of ACE-I to elderly patients who fit the HOPE criteria for risk of cardiovascular events. The characteristics of those prescribed ACE-Is and those not prescribed ACE-Is are shown in Table 1. Being prescribed an ACE-I was significantly more likely if the patient was younger, if they had diabetes + another risk factor for cardiovascular disease, or if they had more than one HOPE indication. ACE-Is were infrequently prescribed to patients with ischaemic heart disease unless they had had a myocardial infarction.We speculate that the most likely explanation may be that geriatricians and GPs have not acted on the HOPE results because the main HOPE outcomes are seen to be of less relevance to frail, older people with disability. Many clinicians caring for older people are considerably more interested in interventions and treatments with the potential to improve physical function and limit dependency, than in drugs which may affect mortality. It seems probable that until trials like HOPE are undertaken with outcomes which are more clinically relevant to disabled older people, there will be an understandable reluctance to apply the HOPE results to all elderly patients.