I. Gotsman et al. • Vol 10 • March 2008 214 Angiotensin-converting enzyme inhibitors are the first line of drugs in the treatment of congestive heart failure. Angiotensin receptor blockers are first-line drugs if there is intolerance to ACE-I. These classes of drugs have been shown in numerous randomized controlled trials to reduce morbidity and mortality in patients with CHF [1-4]. In addition, the combination of both drugs may have clinical benefit in appropriate patients [5]. ACE-I treatment has significantly reduced the rehospitalization rate in these patients [6,7] and is cost effective [8]. Despite the undisputed benefit of ACE-I treatment, studies suggest that the rate of ACE-I usage in heart failure patients remains low in terms of the number of patients treated and ACE-I target doses. Low (insufficient) dosages are entrenched in current practices despite clear guidelines regarding the usage and optimal dosage of ACE-I in CHF [9-11]. This has been shown to increase the morbidity and mortality rate in patients without or with insufficient ACE-I treatment as compared to patients with recommended doses of ACE-I [6-11]. Few data exist concerning the reasons for this anomaly. It could be due to side effects, the treating physician’s unawareness, or reluctance due to perceived side effects, like renal failure or hyperkalemia, or to patient non-compliance. Since regular and adequate treatment with ACE-I reduces hospitalizations for heart failure and also mortality, the objectives of this study were to investigate treatment rates of ACE-I/ARB in patients hospitalized with CHF and analyze the reasons for non-treatment. In addition, we examined clinical parameters that influenced ACE-I/ARB usage and the clinical outcome in these patients. Patients and Methods We prospectively enrolled consecutive patients with CHF admitted to an internal medicine department with a definite diagnosis of CHF not necessarily related to the hospital admission. Diagnosis of heart failure was based either on clinical symptoms and signs consistent with heart failure or reduced left ventricular function. Clinical diagnosis of CHF was based on multiple symptoms and signs consistent with heart failure: orthopnea, paroxysmal noc- turnal dyspnea, elevated jugular pulse, leg edema and enlarged heart silhouette on chest X-ray. The echocardiographic inclusion criterion was reduced left ventricular function. Classification of left ventricular function was qualitative using a visual assessment of mild, moderate or severely reduced left ventricular function. The study protocol was approved by the Hadassah-Hebrew University Medical Center Institutional Committee for Human Studies. Hospitalization evaluation Data on sociodemographic status including place of residence, ethnic background, education, background (concurrent) diseases as documented by the medical records, the causes of admission Abstract Background: Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve prognosis in congestive heart failure and are the treatment of choice in these patients. Despite this, the rates of ACE-I usage in heart failure patients remain low in clinical practice. Objectives: To evaluate the rate of ACE-I/ARB treatment in hospitalized patients with CHF, and analyze the reasons for non-treatment. Methods: We prospectively evaluated 362 consecutive patients hospitalized with CHF. Patients were evaluated for ACE-I/ARB usage at discharge and were followed for 1 year. Results: At hospital discharge 70% of the patients were prescribed ACE-I/ARB treatment. Only 69% received recommended target or sub-target dosages, proven to improve prognosis. This decreased to 63% and 59% at 6 months and 12 months of follow-up respectively, due to a shift from sub-target levels to low dosages. Justifed reasons for under-treatment were apparent in only 25% not optimally treated discharged patients and this decreased to 12% and 4% at 6 and 12 months follow-up, respectively. Common reasons for non-treatment at discharge were hyperkalemia and elevation in serum creatinine, while hypotension and cough were more prominent at follow-up. Clinical parameters associated with increased treatment rates were ischemic heart disease and the absence of chronic renal failure. Patients receiving treatment had lower hospitalization and mortality rates. Conclusions: ACE-I/ARB treatment is still underutilized in patients discharged from hospital with a diagnosis of CHF. Increasing the awareness of the importance of these drugs may increase the number of patients treated. IMAJ 2008;10:214–218 Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Patients with Congestive Heart Failure: An Observational Study of Treatment Rates and Clinical Outcome Israel Gotsman MD 1 , Shani Rubonivich MSc 2 and Tanya Azaz-Livshits PhD 3 1 Heart Institute, 2 School of Pharmacy and 3 Department of Clinical Pharmacology, Hadassah University Hospital and Hebrew University- Hadassah Medical School, Jerusalem, Israel Key words: angiotensin-converting enzyme inhibitors, utilization, congestive heart failure ACE-I = angiotensin-converting enzyme inhibitors ARB = angiotensin receptor blockers CHF = congestive heart failure Original Articles