DIFFERENCES IN GENERALIST AND SPECIALIST PHYSICIANS KNOWLEDGE AND USEOF ANGIOTENSIN-CONVERTING ENZYME-INHIBITORS FOR CONGESTIVE-HEART-FAILURE

OBJECTIVE: To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with c ongestive heart failure, especially with respect to physician specialt y and clinical indication. DESIGN: Survey of a national systematic sam ple of physicians, PARTICIPANTS: Five hundred family practitioners, 50 0 general internists, and 500 cardiologists. MEASUREMENTS AND MAIN RES ULTS: Physicians' choice of medications were determined for four hypot hetical patients with left ventricular systolic dysfunction: (1) new-o nset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on dig italis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms, Amo ng the 727 eligible physicians returning surveys (adjusted response ra te 58%), approximately 90% used ACE inhibitors for patients with chron ic heart failure who were already taking digitalis and a diuretic. How ever, family practitioners and general internists chose ACE inhibitors less frequently (p less than or equal to .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72 %, general internists 76%, cardiologists 86%); asymptomatic (family pr actitioners 68%, general internists 78%, cardiologists 93%): and asymp tomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiol ogists were more likely (p less than or equal to .05) to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic bl ood pressures of 90 mm Hg or less (43% vs 15%). CONCLUSIONS: Compared with cardiologists, family practitioners and general internists probab ly underutilize ACE inhibitors, particularly among patients with decre ased ejection fraction who are either asymptomatic or post-myocardial infarction, Educational efforts should focus on these indications and emphasize the dosages demonstrated to lower mortality and morbidity in the trials.