ACE inhibitors, awareness lowers CHF mortality rate

CDC says more physician awareness reduces deaths

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.

Recent figures from the Centers for Disease Control and Prevention (CDC) in Atlanta may show the stranglehold of the disease is loosening just a little.

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

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

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, 1998 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:

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

• Patients with high blood pressure are being treated with cholesterol lowering drugs and not deteriorating to congestive heart failure (CHF).

• Patients who have had myocardial infarctions are managing their heart disease better and not developing CHF.

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

The bottom line, in Croft’s mind: 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, Croft adds, and statistics show these physicians are less likely to prescribe ACE inhibitors than cardiologists.

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

With 4.9 million Americans living with congestive heart failure, 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 spokesman said 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 changing reporting methods. "We always have to consider that," including the possibility that the declining death rate among black men may be due in part to physicians coding more accurately.

Croft scoffs at the idea 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," she says.

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

Gould, author of Heal Your Heart: How You Can Prevent or Reverse Heart Disease, thinks 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." He particularly castigates the food industry for its marketing strategies that contribute to obesity.

"Go to Europe and you’ll see that [American] portions are twice the size," he says.

Gould urges physicians not only to encourage low-fat diets for their patients, but also to encourage patients to consume low-carbohydrate, low-calorie diets.

Gould 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 [them] to eat right and stay lean."

He 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," noting data he says show that 50% of all bypass patients are not on cholesterol-lowering drugs.

"That’s crazy," Gould concludes.

Alan Wasserman, MD, chairman of the Department of Medicine at George Washington University in Washington, DC, 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," Wasserman 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."

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