Interleukin‐6–174 G/C Promoter Gene Polymorphism C Allele Reduces Alzheimer's Disease Risk

JAGS 51:572–583, 2003 © 2003 by the American Geriatrics Society 0002-8614/03/$15.00 AGE AND SEX DO NOT BIAS THE USE OF ANGIOTENSIN-CONVERTING ENZYME INHIBITORS IN ACUTE MYOCARDIAL INFARCTION AND CONGESTIVE HEART FAILURE To the Editor: Age and sex do not bias the use of angiotensin-converting enzyme (ACE) inhibitors in acute myocardial infarction (AMI) and congestive heart failure (CHF). For older patients with CHF and AMI, there is ample evidence in the literature for the efficacy of ACE inhibitors in improving long-term survival and decreasing overall mortality from cardiovascular death. 1 Although most research does not exclude older people from the use of ACE inhibitors, 2,3 there are some studies suggesting that patients aged 70 and older are being denied this form of therapy (particularly in CHF) when no clear contraindications exist. 4,5 Evidence for the underuse of ACE inhibitors by sex is less clear. 6–8 ACE inhibitors offer a myriad of benefits, even in the older population with AMI and CHF. 9 A study was undertaken to determine whether patients are being denied the use of ACE inhibitors for AMI and CHF alone or in combination because of age and sex bias, because data analyzed earlier by the research team found that, in clinical practice, older patients were less likely to receive the most-effective therapy after AMI and less likely to be referred for specialist investigations. 9 The setting was a district general hospital in London, United Kingdom. Participants included all patients admitted between April 1, 1996, and March 31, 1997, with a diagnosis of AMI or CHF alone or in combination in whom no contraindications existed for ACE inhibitor use. 10 After exclusion, 669 such patients were identified (male:female 355:314) and followed for 1 year, until March 31, 1998. Data were collected and analyzed retrospectively from patients’ medical notes using International Classification of Diseases coding. A medical practitioner then validated the data. Good concordance was obtained at 80%. Statistical analysis used chi-square and chi-square trend tests to compare discrete variables. Interactions between potentially predictive variables were tested using logistic regression analysis. Of the 669 patients, 208 had CHF (31%), 131 had AMI (20%), and 330 had AMI with CHF (49%). Of the 208 patients with CHF, 122 (58.7%) received ACE inhibitors (65.1% 75 and 54.4% 75; 61.6% male and 56% female). Of the 131 patients with AMI, 53 (40.5%) received an ACE inhibitor (40.7% 75 and 40% 75; 37.0% male and 46% female). Three hundred thirty pa tients had a combination of AMI and CHF, of which 169 (51.2%) received an ACE inhibitor (51.2% 75 and 50.3% 75, 50.3% male and 52.3% female) (Table 1). Patients aged 75 and older were just as likely as their younger counterparts to receive an ACE inhibitor for CHF or AMI alone or in combination. Male patients were as likely as female patients to receive ACE inhibitors. Patients were more likely to receive an ACE inhibitor if they had a combination of AMI and CHF (51.2%) than if they had AMI alone (40.5%), regardless of age or sex ( P .03), but ACE inhibitors were generally underused for all conditions (fewer than half of the patients), particularly AMI (40.5%). Although ACE inhibitors were underused in this study, particularly with AMI, no age or sex discrimination was demonstrated, as also found in some later studies. 6–8 This finding is in contrast to the results obtained by Ganz et al . , 9 who noted older age as a significant independent negative correlate of use of ACE inhibitors in CHF and data from Haveranek et al., 4 who reported not only underuse in older patients, but also increased mortality as a result of this policy. With the availability of evidence for ACE inhibitor use in older people, it is surprising that only 40% to 60% of patients who could benefit from ACE inhibitors received treatment in this study. The results of this study possibly reflects clinical practice in the United Kingdom some 4 to 5 years ago but certainly indicates the need to undertake more investigative work to demonstrate whether this is truly the case and if so whether practice has improved since. In addition, a comparative study between the United States and the United Kingdom of the use of ACE inhibitors in the older population with AMI and CHF at the time of this study and currently should prove interesting material, because recent studies suggest that there could be room for improvement in the care of older people in general. 11