ACE inhibitors, higher awareness drive CHF mortality rate down

CDC says greater physician awareness reduces deaths further

Heart failure is a killer. There’s no doubt about it. And there’s no doubt that it is the fastest-growing diagnosis leading to hospitalization.

But recent figures from the Centers for Disease Control and Prevention in Atlanta show the stranglehold of the disease is loosening, just a little.

Mortality attributed to heart failure in patients 65 and older declined from 116.9 per 100,000 standard population in 1988 to 107.6 in 1995, an annual average decline of about 1.1%.

The decreased death rate was most striking for African-Americans: 3% per year for men and 2.2% per year for women. Mortality among white men decreased by 1.7% per year and for white women, .5% per year.

The study "suggests improved survival for older adults with heart failure or misdiagnosis of the underlying cause of death among adults with heart failure," according to the CDC narrative published in the Aug. 13 issue of Mortality and Morbidity Weekly Report.

Experts have varying theories on the causes. Janet Croft, PhD, cardiac epidemiologist for the CDC’s cardiovascular health unit, offers four possible factors:

1. There is an increased use of angiotensin-converting enzyme (ACE) inhibitors.

2. Patients with high blood pressure are being treated with cholesterol lowering drugs, therefore they are not deteriorating to CHF.

3. Patients who have had myocardial infarctions (MIs) are managing their heart disease better and, therefore, are not developing CHF.

4. There could be changes in the means of reporting on death certificates.

The bottom line, Croft says, "Physicians need to be familiar with clinical guidelines in treating heart failure."

Most heart patients (78%) are likely to see a family practitioner, general practitioner, or internist, she adds, and statistics show those physicians are less likely to prescribe ACE inhibitors than cardiologists.

"Obviously cardiologists know about ACE inhibitors and their value," she says. "Perhaps the message hasn’t gotten down to the family practitioners, general practitioners, and internists."

But with 4.9 million Americans living with CHF, 400,000 new cases diagnosed each year, and 20% of heart attack victims expected to be disabled by CHF within six years of their MIs, Croft challenges physicians to contain the disease.

An American Heart Association (AHA) spokesman says the outlook is improving for CHF patients in view of new methods of identifying those at high risk, better treatment of patients with MIs, and the availability of more effective drug treatments.

Croft concedes the declining death rate from CHF could be connected to changes in reporting methods. "We always have to consider that." Plus, the declining death rate among black men may be due, in part, to physicians coding more accurately, she adds.

But Croft says she disagrees with the theory that lifestyle changes may account for the reduced mortality. "CDC data show no improvement in exercise or diet, although there has been some decline in smoking."

K. Lance Gould, MD, professor of medicine at the University of Texas Medical School’s division of cardiology in Houston, says he couldn’t disagree more.

Gould, author of Heal Your Heart: How You Can Prevent or Reverse Heart Disease, says Americans are doing a good job of reducing risk factors through "better diets and less smoking," although "there are still large numbers of overweight people."

Drastic eating changes are needed

He particularly castigates the food industry for its marketing strategies that contribute to obesity. "Go to Europe, and you’ll see that [in this country], portions are twice the size," Gould says. He urges physicians not only to encourage low-fat diets for their patients, but also to encourage patients to consume low-carbohydrate, low-calorie diets.

He says heart failure is a "complicated social issue" among black men and attributes the declining CHF death rate to "greater awareness of the risk factors and a greater determination among black men to eat right and stay lean." Gould adds that physicians need to engage in "better risk factor management, including the use of cholesterol-lowering drugs."

He challenges health care professionals to pay more attention to cholesterol levels, which he believes are "grossly undertreated," and adds that data show 50% of all bypass patients are not on cholesterol-lowering drugs. "That’s crazy," Gould states.

Alan Wasserman, MD, chairman of the Department of Medicine at George Washington University in Washington, DC, says he believes longevity is directly tied to more effective medical therapy. "The use of ACE inhibitors has revolutionized treatment in the last three or four years," he says. "We really got the word out that everyone with poor left ventricular function should be on ACE inhibitors."

He echoes the "need for primary care physicians to make an impact" by providing aggressive therapy for CHF patients. Most common therapies — diuretics, digoxin, and ACE inhibitors — can be managed by primary care physicians, Wasserman says, "but there are advanced therapies that can be applied, like beta blockers that need to be used carefully and slowly."

"Most generalists are not comfortable with that, so they need to realize when patients need other therapies and they need to refer," he concludes.

For more information, contact Janet Croft, PhD, Cardiac Epidemiologist, Centers for Disease Control and Prevention, Atlanta. Telephone: (770) 488-5528.