Can treatment with angiotensin-converting enzyme inhibitors in elderly patients with moderate to severe chronic heart failure be improved by a nurse-monitored structured care program? A randomized controlled trial

doi:10.1067/mhl.2003.5

Heart & Lung

Volume 32, Issue 1, January–February 2003, Pages 3-9

https://doi.org/10.1067/mhl.2003.5 Get rights and content

Abstract

Objective: The purpose of this study was to examine whether a nurse-monitored structured care program resulted in a more effective use of angiotensin-converting enzyme (ACE) inhibitors in elderly patients compared with standard care in patients with chronic heart failure (CHF). Methods: Hospitalized patients were screened to identify individuals with CHF, age more than 65 years, New York Heart Association classification III to IV, and no contraindications to ACE inhibitor treatment. One hundred forty-five patients were randomized to a nurse-monitored structured care program that included uptitration of enalapril to a target dose of 10 mg twice a day or to standard care. Six-month follow-up data were collected. Results: The mean age of the randomized patients was 81 years. Although the proportion of patients treated with an ACE inhibitor did not differ between structured care (70%) and standard care (64%), the number of patients with the target ACE inhibitor dose was significantly higher in the structured care group (26% versus 11% in the standard care group; P <.018). Treatment had to be discontinued in 26% of the patients because of adverse effects. Conclusion: The patients in this study were older than in previous intervention studies and had considerable comorbidity and reduced tolerance for ACE inhibitors. ACE inhibitor treatment was underused but improved with the structured care program, although achieved treatment levels were below those in the large intervention trials in patients with CHF. (Heart Lung® 2003;32:3-9.)

Section snippets

Methods

The study was conducted at the Sahlgrenska University Hospital/Sahlgrenska, which is both a secondary care and a tertiary hospital. Most patients from the catchment area in need of acute hospital care for CHF are treated in the internal medicine wards. The ethics committee at Sahlgrenska University Hospital approved the study protocol.

Results

During the study period (6 months), there were 1124 admissions to the Department of Medicine and the screened wards with CHF as a diagnosis (International Classification of Diseases 9, diagnosis 428). The mean age of these patients discharged from internal medicine wards was 79 years, and 93% of the patients were more than 65 years old. Although we screened 1058 patients, only 160 patients were included. The main reasons for exclusions were communication problems (27%), Boston criteria less

Discussion

With a nurse-monitored outpatient program and carefully prepared routines for uptitration of ACE inhibitors, we succeeded in instituting such treatment in 70% of the patients at the end of the follow-up period. This was only marginally better than in the standard care group (64%). However, the special care program at study closure resulted in a larger proportion of patients on the target dose and higher dose levels overall explained by a more consistent start and uptitration of ACE inhibitor

Acknowledgements

We appreciate all help from our colleagues Lisbeth Carlsson, Rachel Vessby, Ing-Marie Forsell, Gunnel Pettersson, Agneta Hallén, Urban Lindblom, Torbjörn Almgren, and Lena Bokemark. We also express our gratitude to Professor Karl Swedberg for his comments on the final manuscript.

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Pharmacist- and Nurse-Led Medical Optimization in Heart Failure: A Systematic Review and Meta-Analysis
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Traditional approaches to guideline-directed medical therapy (GDMT) management often lead to delayed initiation and titration of therapies in patients with heart failure. This study sought to characterize alternative models of care involving nonphysician provider-led GDMT interventions and their associations with therapy use and clinical outcomes.
We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing nonphysician provider-led GDMT initiation and/or uptitration interventions vs usual physician care (PROSPERO ID: CRD42022334661). We queried PubMed, Embase, the Cochrane Library, and the World Health Organization International Clinical Trial Registry Platform for peer-reviewed studies from database inception to July 31, 2022. In the meta-analysis, we used RCT data only and leveraged random-effects models to estimate pooled outcomes. Primary outcomes were GDMT initiation and titration to target dosages by therapeutic class. Secondary outcomes included all-cause mortality and HF hospitalizations.
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Pharmacist- and nurse-led interventions for GDMT initiation and/or uptitration improved guideline concordance. Further research evaluating newer therapies and titration strategies integrated with pharmacist- and/or nurse-based care may be valuable.
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^*: Supported by grants from the Swedish Medical Research Council, Hjärt-och lungsjukas riksförbund, and Merck, Sharp & Dohme.

^**: Reprint requests: Inger Ekman, The Sahlgrenska Academy at Göteborg University, Faculty of Health and Caring Sciences, Institute of Nursing, Box 457 405 30, Göteborg, Sweden.

^*: 0147-9563/2003/$30.00 + 0

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Issues in Cardiovascular NursingCan treatment with angiotensin-converting enzyme inhibitors in elderly patients with moderate to severe chronic heart failure be improved by a nurse-monitored structured care program? A randomized controlled trial*,**,*

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgements

Am J Cardiol

J Chronic Dis

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Effects of enalapril on mortality in severe congestive heart failure

N Engl J Med

Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions

N Engl J Med

Issues in Cardiovascular Nursing
Can treatment with angiotensin-converting enzyme inhibitors in elderly patients with moderate to severe chronic heart failure be improved by a nurse-monitored structured care program? A randomized controlled trial*,**,*