Angiotensin-converting enzyme inhibitors, beta-blockers, and mortality in systolic heart failure.

We read with interest the study by Johnson et al. (1). We believe that one of the key findings of this study was the relatively low rates of angiotensin-converting enzyme inhibitor (ACEI) angiotensin receptor blocker (ARB) and beta-blocker (BB) use in heart failure (HF) patients discharged from the hospital within three months, at 44.3% and 20.9%, respectively, from 1999 to 2000. Furthermore, only 11.3% of these patients received both an ACEI/ARB and a BB. The inclusion in this study of HF patients with preserved left ventricular systolic function (LVSF), or diastolic HF, may partially account for the low rates of utilization of these medications. The current American College of Cardiology/American Heart Association (ACC/ AHA) HF guidelines do not have a recommendation to use either ACEI/ARB or BB in patients with diastolic HF. Lack of appropriate use of ACEI/ARB and BB in HF patients with impaired LVSF or systolic HF indicates poor quality of care and is clearly associated with poor outcomes. Although there is pathophysiological rationale for use of ACEI/ARB and BB in patients with diastolic HF (2), lack of use of these drugs in diastolic HF is neither poor quality of care nor is it associated with poor outcomes. We believe that HF quality improvement programs should focus on increasing the use of ACEI and BB in patients with systolic HF, and studies of quality and outcomes of HF care should classify patients based on their LVSF. Furthermore, ARBs are not currently recommended in systolic HF unless patients have an absolute contraindication to ACEI (2). The U.S. Centers for Medicare and Medicaid Services in its Seventh Scope of Work (2002 to 2005) identified use of ACEI, not ARB, as a quality indicator for HF care for Medicare beneficiaries (3). We also note with interest an apparent lack of survival benefit of combined use of ACEI/ARB and BB on one-year mortality as compared to therapy with ACEI/ARB alone (1). Most large randomized controlled trials of BBs in systolic HF enrolled patients who were already receiving an ACEI. These studies showed that use of a BB resulted in an additional 35% reduction in mortality in subjects receiving both drugs compared with those receiving an ACEI alone (4). The rate of BB use in patients with systolic HF is low (5), and we are concerned that the finding of lack of survival benefit of BBs in HF as shown in the study by Johnson et al. (1) might be perceived by some clinicians as evidence that results of clinical trials do not necessarily translate into real-life patients.