Heart failure management: why evidence does not influence clinical practice

Heart failure treatment has developed rapidly over the last decade and now may include preventive measures against worsening heart failure in addition to existing symptomatic therapy. Novel developments include angiotensin-co nverting enzyme (ACE) inhibition, beta-blockade and aldosterone antagonism, which have dramatically improved morbidity and mortality. In particular, A CE inhibition has been proven to have this potential in a vast array of pat ients with asymptomatic left ventricular dysfunction and/or heart failure. As ACE inhibitors have been known for this for quite a while, one would exp ect many if not all patients to be on adequate ACE inhibition. This, unfort unately, is not the case. Although it very much depends on the category of physician involved, the overall prescription rate probably varies between 3 0% and 50%. Most heart failure patients are under the care of the general p ractitioner. Recent surveys in different Western European countries indicat e that between 25% and 45% of patients receive ACE inhibition, mostly at lo wer dosages than those recommended on the basis of available data from larg e, controlled studies on the effect of these agents in heart failure. There are many reasons for this evident lack of translating evidence-based medic ine into clinical practice. However, concern about early side-effects in a situation where immediate symptomatic benefit is usually not apparent may b e an important factor. In particular, the physician is concerned about hypotension, renal dysfunct ion and hyperkalaemia. Although there is ample evidence from large trials t hat these should not be of major concern provided the administration is ade quate, this is not the common perception. Also, cough is often a reason why ACE inhibition is discontinued quickly, perhaps in a situation where this adverse event may occur from the underlying disease rather than the medicat ion. Obviously, education is warranted. Two large European projects are in progr ess to document the (lack of) knowledge: the Improvement Programme On Evalu ation And Management Of Heart Failure [IMPROVEMENT] in general physicians, and Study group on Heart failure Awareness and Perception in Europe [SHAPE] in all physicians working in the field of heart failure, as well as the ge neral population and health care authorities with the aim of improving this subsequently. Nevertheless, concern will remain and blood pressure effects may remain imp ortant factors. In this regard, first-dose effects differ between ACE inhib itors and should be taken into account. First-dose hypotension has been rep orted with captopril, enalapril, lisinopril and quinapril. In contrast, per indopril has no untoward effect on blood pressure or on renal function desp ite adequate ACE inhibition, even in elderly heart failure patients who are commonly considered more at risk than the younger patient. Besides adequate titration and administration of ACE inhibition, the choice of an ACE inhibitor that lacks adverse effects such as first-dose hypotens ion and does not affect renal function may help in overcoming current conce rn about the use of ACE inhibitors for heart failure in clinical practice.