Pharmacologic Management of Heart Failure and Left Ventricular Systolic Dysfunction

Heart failure (HF) is associated with substantial morbidity and mortality; it is a primary or secondary cause of death for approximately 250,000 people per year in the United States. According to the 2002 Heart and Stroke Statistical Update (www.americanheart.org), HF was the first-listed diagnosis for 962,000 hospitalizations in 1999, and it is the most common diagnosis among hospital patients age 65 and older. In fact, 20 percent of all hospitalizations in this age group carry a primary or secondary diagnosis of HF. Over 3 million outpatient office visits each year are related to this illness. In 1998 alone, the estimated annual direct cost due to HF was $18.8 billion. A series of studies has established that angiotensin-converting enzyme inhibitors (ACE inhibitors) and beta-adrenergic blocking agents (beta-blockers) provide life-saving benefits in patients with HF and left ventricular systolic dysfunction. However, most of the patients enrolled in such studies have been white males. Thus, a clinical question that is repeatedly asked is whether the mortality benefit reported in these clinical trials is also achieved for particular subpopulations, such as women, people of other races, and patients with various comorbidities such as diabetes mellitus or renal insufficiency. Since few of the randomized trials enrolled enough women, blacks, or patients with comorbidities to have sufficient statistical power to support conclusions based on subgroup analysis, this question is appropriate for meta-analysis. In addition, because the clinical trial data support a mortality benefit for patients with asymptomatic left ventricular dysfunction, it is natural to question both the cost-effectiveness of such treatment and that of screening asymptomatic patients for left ventricular dysfunction. These clinical and policy questions form the basis for this report.