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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR23

Angiotensin converting enzyme inhibitors and congestive cardiac failure: the pharmacist as facilitator

By P. McLean and D. Campbell*

Introduction Besides improving symptoms and quality of life, angiotensin converting enzyme (ACE) inhibitors have been shown to improve prognosis in congestive cardiac failure (CCF) of any severity.1,2,3 Despite overwhelming evidence of their effectiveness and the publicity of study findings, many experts believe that ACE inhibitors are used in few patients4 and at suboptimal doses.5,6
By using the pharmacist as facilitator, this pilot study aimed to maximise therapeutic outcomes of patients with confirmed CCF. This was carried out by operationalising the initiation and dosage titration of ACE inhibitors by an appropriate multidisciplinary team within a primary care setting. Additionally, it aimed to establish this as a simple model for others to replicate, thereby driving and stimulating best practice and further development of the pharmacy profession.

Method Within a selected general medical practice, patients with potential CCF (currently treated with loop diuretics, but not ACE inhibitors) were identified and their notes reviewed to determine any confirmatory diagnosis or contraindication to ACE inhibitor therapy.
Suitable candidates had blood pressure and blood sample (for urea and electrolytes) measurements organised and an appointment for an echocardiogram (Echo) examination arranged. The confirmatory Echo indicated whether treatment with an ACE inhibitor was appropriate. Where necessary, perindopril was initiated with subsequent titration of dose.
Close monitoring took place over the next few months, via recording of patient progress in terms of biochemistry, indicators for renal function, side effects and blood pressure. It was therefore ensured that patients reached the correct maintenance dosage of perindopril (4mg daily) or, if not, the maximum dose that they could tolerate. If the Echo highlighted any problem other than CCF, then this was managed by the GP or the local consultant cardiologist, depending upon its complexity.

Focal points

  • ACE inhibitors improve symptoms, quality of life and prognosis in all grades of congestive cardiac failure (CCF)
  • ACE inhibitors are still used in too few CCF patients and at sub-optimal doses
  • The initiation and dosage titration of ACE inhibitors can be operationalised with the primary care setting
  • By using a multidisciplinary approach, with the pharmacist as facilitator, therapeutic outcomes for CCF patients can be improved
  • This model could be replicated on a larger basis to improve the care of patients with CCF

Results Forty-five patients (mean age 71 years; age range 43-86 years) were studied.
Of the six patients (mean age 71.5 years, range 52-80 years) initiated on perindopril, four (66.7 per cent) successfully attained the recommended maintenance dose. Reasons for non-attainment were patient withdrawal from the pilot (despite advice to the contrary) and a GP deciding to stop perindopril because of "side effects".

Table 1

Discussion Fewer patients than anticipated were suitable for ACE inhibitor therapy under the main care of the pharmacist. However, numerous other conditions were diagnosed by the Echo examination (Table 1). Indeed, only six patients (13 per cent) required treatment with perindopril. For these patients (with confirmed CCF), careful initiation and dosage titration of perindopril, coupled with close monitoring of renal function, blood pressure and side effects ensured that four patients (66.7 per cent) reached the recommended maintenance dosage of 4mg daily.
Current evidence suggests that ACE inhibitors should be prescribed (in combination with loop diuretics in most cases) to all patients with CCF and titrated to the recommended maintenance dose. Thus by using the pharmacist as facilitator, or a catalyst for change, as was carried out in this pilot study, therapeutic outcomes have been maximised to the greatest possible degree for patients included.
In addition, the pilot has aided the development of a simple model which can be adapted by others for use on a larger scale. This will further develop the pharmacy profession and improve the care of patients with CCF.

City Hospitals Sunderland NHS trust; *North Durham health care trust

References

1. CONSENSUS trial study group. Effects of enalapril on mortality in severe congestive heart failure. N Eng J Med 1987;316:1429-39.
2. Cohn JN, Johnson G, Zieshe S et al A comparison of enalapril with hydralazine - isosorbide dinitrate in the treatment of chronic congestive heart failure. N Eng J Med 1991;325:303-10.
3. The SOLVD investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fraction and congestive heart failure. N Eng J Med 1991;325:293-302.
4. Clarke KW, Gray D, Hampton JR. Evidence of inadequate investigation and treatment of patients with heart failure. Br Heart J 1994;71:584-7.
5. Packer M, Poole-Wilson PA, Armstrong PW et al. Comparative effects of low and high doses of the angiotensin converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. Circulation 1999;100:2312-18.
6. Luzier AB, Ditusa L. Underutilisation of angiotensin converting enzyme inhibitors in heart failure. Pharmacotherapy 19:1296-1307.