Journals of Gerontology Series A: Biological Sciences and Medical Sciences Large Type Edition
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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 57:M398-M400 (2002)
© 2002 The Gerontological Society of America

Underutilization of Aspirin, Beta Blockers, Angiotensin-Converting Enzyme Inhibitors, and Lipid-Lowering Drugs and Overutilization of Calcium Channel Blockers in Older Persons With Coronary Artery Disease in an Academic Nursing Home

Subrato Ghosha, Valerie Ziesmera and Wilbert S. Aronowa,b

a Department of Medicine, Divisions of Geriatrics, Westchester Medical Center/New York Medical College, Valhalla
b Department of Medicine, Divisions of Cardiology, Westchester Medical Center/New York Medical College, Valhalla

Wilbert S. Aronow, CMD, Cardiology Division, New York Medical College, 23 Pebble Way, New Rochelle, NY 10804 E-mail: WSAronow{at}aol.com.


   Abstract
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 Abstract
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Background. We report the prevalence of use of aspirin, beta blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers, statins, and calcium channel blockers in older persons with coronary artery disease (CAD) in an academic nursing home.

Methods. We investigated the prevalence of use of aspirin, beta blockers, ACE inhibitors or angiotensin II type 1 receptor blockers, lipid-lowering drugs, and calcium channel blockers in older persons with a mean age of 77 ± 9 years, in an academic nursing home with documented CAD and no contraindications to the use of aspirin, beta blockers, ACE inhibitors or angiotensin II type 1 receptor blockers, and lipid-lowering drugs.

Results. CAD was documented in 77 of 255 persons (30%). Of 77 persons with CAD, 48 persons (62%) were treated with aspirin, 45 persons (58%) with ACE inhibitors or angiotensin II type 1 receptor blockers, 44 persons (57%) with beta blockers, 21 persons (27%) with calcium channel blockers, and 16 persons (21%) with statins. Of the 61 persons with CAD not treated with statins, serum low-density lipoprotein (LDL) cholesterol was measured in only 22 persons (36%) and was increased in 14 of the 22 persons (64%).

Conclusions. These data show underutilization of aspirin, beta blockers, ACE inhibitors, lipid-lowering drugs, and measurement of serum LDL cholesterol and overutilization of calcium channel blockers in older persons with CAD in an academic nursing home.

OLDER persons with coronary artery disease (CAD) should be treated with aspirin, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, and statins if necessary to reduce the serum low-density lipoprotein (LDL) cholesterol to <100 mg/dl (1)(2). The American Heart Association/American College of Cardiology guidelines also state that there are no Class I indications for the use of calcium channel blockers in treating persons with CAD (3). We are reporting data from an analysis of charts from all persons aged 59 years or older currently residing in an academic nursing home affiliated with Westchester Medical Center/New York Medical College investigating the prevalence of use of aspirin, beta blockers, ACE inhibitors or angiotensin II type 1 receptor blockers, lipid-lowering drugs, and calcium channel blockers in persons with documented CAD and no contraindications to the use of aspirin, beta blockers, ACE inhibitors or angiotensin II type 1 receptor blockers, and lipid-lowering drugs.


   Methods
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 Abstract
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Results
 Discussion
 References
 
All charts of persons aged 59 years or older currently residing in an academic nursing home affiliated with Westchester Medical Center/New York Medical College were analyzed by two geriatrics fellows according to a protocol designed by WS Aronow. The study population included 96 men and 159 women with a mean age of 77 ± 9 years (range 59 to 100 years).


   Results
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 Abstract
 Methods
 Results
Discussion
 References
 
CAD was documented in 77 of 255 persons (30%) with no contraindications to the use of aspirin, beta blockers, ACE inhibitors or angiotensin II type 1 receptor blockers, and lipid-lowering drugs. Of the 77 persons with CAD, 12 persons had prior coronary artery bypass graft surgery, two persons had prior percutaneous transluminal coronary angioplasty, three persons had coronary angiographic evidence of significant CAD without coronary revascularization, 58 persons had a documented myocardial infarction, and two persons had typical angina pectoris without prior myocardial infarction.

Table 1 shows the prevalence of use of aspirin, beta blockers, ACE inhibitors or angiotensin II type 1 receptor blockers, statins, and calcium channel blockers in older persons with CAD currently residing in an academic nursing home. None of the 49 postmenopausal women (0%) with CAD were receiving hormonal therapy. Of the 61 persons with CAD not treated with statins, only 22 persons (36%) had measurements of serum LDL cholesterol. Fourteen of these 22 persons (64%) had elevation of serum LDL cholesterol that needed treatment with lipid-lowering drug therapy.


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  		Table 1. Prevalence of Use of Aspirin, Beta Blockers, Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Type 1 Receptor Blockers, Statins, and Calcium Channel Blockers in 77 Older Persons With Coronary Artery Disease

 

   Discussion
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 Abstract
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Aspirin is underutilized in older persons with CAD (4)(5)(6) and was administered to only 62% of older persons with CAD in the present study. Beta blockers are underutilized in older persons wth CAD (7)(8)(9)(10) and were administered to only 57% of older persons with CAD in the present study. ACE inhibitors or angiotensin II type 1 receptor blockers (if intolerant to ACE inhibitors) are underutilized in older persons with CAD (11)(12) and were administered to only 58% of older persons with CAD in the present study. Lipid-lowering drugs are also underutilized in older persons with CAD (13)(14)(15) and were administered to only 21% of persons with CAD in the present study.

Although the American Heart Association/American College of Cardiology guidelines (1) and the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (2) recommend lowering the serum LDL cholesterol in persons with CAD to below 100 mg/dL irrespective of age, serum LDL cholesterol was measured in only 22 of the 61 persons (36%) with CAD not treated with lipid-lowering drugs in the present study. Fourteen of these 22 persons (64%) had elevated serum LDL cholesterol levels that should have been treated with lipid-lowering drug therapy according to recent guidelines (1)(2).

Although the American Heart Association/American College of Cardiology guidelines state that there are no Class I indications for treating persons with CAD with calcium channel blockers (3), calcium channel blockers are overutilized in the treatment of older persons with CAD (8)(9)(16) and were administered to 27% of persons with CAD in the present study. A retrospective analysis of the use of beta blockers after myocardial infarction from 1987–1992 in a New Jersey Medicare population demonstrated that use of a calcium channel blocker instead of a beta blocker doubled the risk of mortality (8).

The data from the present study show that, despite excellent guidelines (1)(2)(3), older persons with CAD in an academic nursing home are not receiving appropriate cardiac drugs in 2001. Physician education in journal articles, nonbiased lectures, and audits with physician feedback need to be intensified to provide better medical care to older persons with CAD through the use of optimal doses of drugs found to be effective and safe by evidence-based studies.

Received January 2, 2002

Accepted January 28, 2002


   References
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 Abstract
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 Results
 Discussion
 References
 

  1. Smith SC, Jr Blair SN, Bonow RO, et al. 2001. AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update. A statement for healthcare profes-sionals from the American Heart Association and the American College of Cardiology. Circulation. 104:1577-1579. [Free Full Text]
  2. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults2001. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 285:2486-2497. [Free Full Text]
  3. Ryan TJ, Antman EM, Brooks NH, et al. 1999. 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). Circulation. 100:1016-1030. [Free Full Text]
  4. Krumholz HM, Radford MJ, Ellerbeck EF, et al. 1996. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcome. Ann Intern Med. 124:292-298. [Abstract/Free Full Text]
  5. Ganz DA, Lamas GA, Orav EJ, Goldman L, Gutierrez PR, Mangione CM, for the Pacemaker Selection in the Elderly PASE) Investigators 1999. Age-related differences in management of heart disease. A study of cardiac medication use in an elderly cohort. J Am Geriatr Soc. 47:145-150. [Medline]
  6. Aronow WS, 1998. Underutilization of aspirin in older patients with prior myocardial infarction at the time of admission to a nursing home. J Am Geriatr Soc. 46:615-616. [Medline]
  7. Rich MW, Bosner MS, Chung MK, Shen J, McKenzie JP, 1992. Is age an independent predictor of early and late mortality in patients with acute myocardial infarction?. Am J Med. 92:7-13. [Medline]
  8. Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Goldman L, 1997. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA. 277:115-121. [Abstract]
  9. Aronow WS, 1996. Prevalence of use of beta blockers and of calcium channel blockers in older patients with prior myocardial infarction at the time of admission to a nursing home. J Am Geriatr Soc. 44:1075-1077. [Medline]
  10. Mendelson G, Aronow WS, 1997. Underutilization of beta-blockers in older patients with prior myocardial infarction or coronary artery disease in an academic, hospital-based geriatrics practice. J Am Geriatr Soc. 45:1360-1361. [Medline]
  11. Krumholz HM, Vaccarino V, Ellerbeck EF, et al. 1997. Determinants of appropriate use of angiotensin-converting enzyme inhibitors after acute myocardial infarction in persons >=65 years of age. Am J Cardiol. 79:581-586. [Medline]
  12. Mendelson G, Aronow WS, 1998. Underutilization of angiotensin-converting enzyme inhibitors in older patients with Q-wave anterior myocardial infarction in an academic hospital-based geriatrics practice. J Am Geriatr Soc. 46:751-752. [Medline]
  13. Aronow WS, 1998. Underutilization of lipid-lowering drugs in older persons with prior myocardial infarction and a serum low-density lipoprotein cholesterol >=125 mg/dl. Am J Cardiol. 82:668-669. [Medline]
  14. Mendelson G, Aronow WS, 1998. Underutilization of measurement of serum low-density lipoprotein cholesterol levels and of lipid-lowering therapy in older patients with manifest atherosclerotic disease. J Am Geriatr Soc. 46:1128-1131. [Medline]
  15. Rich SE, Shah J, Rich DS, Shah R, Rich MW, 2000. Effects of age, sex, race, diagnosis-related group, and hospital setting on lipid management in patients with coronary artery disease. Am J Cardiol. 86:328-330. [Medline]
  16. Fishkind D, Paris BEC, Aronow WS, 1997. Use of digoxin, diuretics, beta blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers in older patients in an academic hospital-based geriatrics practice. J Am Geriatr Soc. 45:809-812. [Medline]



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