Non-adherence with ACE inhibitor treatment is common in heart failure and can be detected by routine serum ACE activity assays

Abstract

Objective: To assess whether serum angiotensin converting enzyme (ACE) activity during routine clinical practice accurately reflects patient adherence to ACE inhibitor treatment for chronic heart failure (CHF).

Design: Retrospective assessment of ACE inhibitor adherence and serum ACE activity measurements.

Setting: Teaching hospital outpatient department

Patients and interventions: During 1994-95, serum ACE was measured in 73 CHF patients who were routinely attending the heart failure clinic at Ninewells Hospital. At the same time, the medicines monitoring unit collected data on whether and when prescriptions for ACE inhibitors were redeemed at community pharmacies, which enabled each patient's adherence over a prolonged period to be assessed.

Main outcome measures: Routine collected serum ACE measurements were correlated with measured adherence with ACE inhibitor treatment.

Results: In total, 18% of CHF patients appeared to exhibit < 70% adherence with their ACE inhibitor treatment with 34% exhibiting less than 85% adherence and 58% exhibiting < 100% adherence. A serum ACE activity of > 12 u/l gave 91% positive predictive accuracy that the patient was < 100% adherent with their ACE inhibitor treatment. At the other extreme, a serum ACE < 6.5 u/l gave 81% positive predictive accuracy that the patient was > 85% adherent with ACE inhibitor treatment.

Conclusions: Non-adherence with ACE inhibitor treatment was found to be common in patients with CHF. The simple, inexpensive test of serum ACE activity can be used in CHF patients to identify many, although not all, non-adherent patients so that adherence enhancing strategies can be targeted towards them. Further work is clearly required to explore the precise clinical use of this promising test.

Figure 1

Overall level of adherence with ACE inhibitor treatment in CHF patients (two high ones omitted for clarity).

Figure 2

Relation between serum ACE activity measurements and adherence with ACE inhibitor treatment in CHF patients. Linear correlation r = −0.30, p = 0.011, although the relation is really curvilinear.