Aging Clin Exp Res (2014) 26:307–314 DOI 10.1007/s40520-014-0231-1
ORIGINAL ARTICLE
Influence of hospitalisation on the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in elderly hypertensive patients Martin Wawruch • Veronika Slezakova • Jan Murin Jan Luha • Michal Bozik • Tatiana Leitmann • Magdalena Kuzelova • Rashmi Shah
•
Received: 6 March 2013 / Accepted: 29 October 2013 / Published online: 30 April 2014 Ó Springer International Publishing Switzerland 2014
Abstract Background and aims The underutilization of beneficial cardiovascular medications such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) in the elderly patients continues to be a matter of concern. The aim of the presented study was to compare the prescription of ACEI and ARB in elderly hypertensive patients at the time of hospital admission and discharge and to identify patient-related factors which determine the prescription of ACEI/ARB. M. Wawruch (&) V. Slezakova Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University, Sasinkova, 4, 811 08 Bratislava, Slovakia e-mail: [email protected]; [email protected] J. Murin 1st Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia J. Luha Department of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University, Bratislava, Slovakia M. Bozik Department of Trauma Surgery, University Hospital Bratislava, Bratislava, Slovakia T. Leitmann Department of Geriatrics, Faculty of Medicine, Slovak Medical University, Bratislava, Slovakia M. Kuzelova Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University, Bratislava, Slovakia R. Shah Gerrards Cross, Bucks, UK
Methods The study sample (n = 1111) was selected from 2,157 patients hospitalised at long-term care departments of three municipal hospitals during the period between January 1, 2008 and December 31, 2009 and included hypertensive patients aged C65 years suffering from myocardial infarction, heart failure, atrial fibrillation, diabetes mellitus or nephropathy. Results In hypertensive patients with myocardial infarction, diabetes mellitus and nephropathy, a significant increase was found in the use of ACEI/ARB during hospitalisation. However, there was no similar change in the use of such medications during hospitalisation in patients with heart failure and atrial fibrillation. Age C85 years (OR = 0.59 and OR = 0.50 at hospital admission and discharge, respectively), depression (OR = 0.63 at hospital discharge) and the systolic blood pressure B115 mmHg (OR = 0.45 at hospital discharge) decreased the probability of ACEI/ARB prescription. On the other hand, increasing the number of evaluated co-morbid conditions increased the patient’s likelihood of being an ‘‘ACEI/ARB user’’ (OR = 1.20 at hospital discharge). Conclusions Our study has identified a subset of elderly hypertensive patients (with heart failure, atrial fibrillation) in whom the use of ACEI/ARB could be improved. Keywords Elderly Hypertension Co-morbidity Atrial fibrillation Diabetes mellitus Heart failure
Introduction The prevalence of arterial hypertension increases with advancing age. Wolf-Maier et al. [1] reported a 27 % prevalence of hypertension in six European countries in the age group of 35–44 years and 78 % prevalence among
123
308
persons aged 65–74 years. The treatment of arterial hypertension in elderly patients represents special challenge and guidelines for treatment of arterial hypertension in this group pay special attention [2–4]. In the past, high blood pressure was often believed to be a compensatory mechanism in response to narrowing of the coronary and cerebral vasculature that accompanies the ageing process [5]. Arterial hypertension represents an important risk factor for coronary events, stroke, heart failure and peripheral arterial disease. The favourable effect of antihypertensive treatment in reducing cardiovascular events in patients aged C65 years proved to be a landmark finding from a number of trials reported during 1980s and 1990s [6]. The benefit of antihypertensive therapy in elderly persons aged C80 years was also confirmed in 2008 by the Hypertension in the Very Elderly Trial (HYVET) [7]. Despite the importance of hypertension as a risk factor for adverse outcomes, elderly patients have the lowest rate of adequate blood pressure control. Frequent co-morbidities, polypharmacy, high cost of medication as well as the failure of many physicians to appreciate that most elderly patients should be treated according to guidelines contribute to inadequate blood pressure control in this patient population [8]. According to the Recommendation of the European Society of Hypertension and its Reappraisal, all major antihypertensive drug classes—diuretics, angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), calcium channel blockers and betablockers—have shown benefits in terms of reduction of cardiovascular events in randomised trials among elderly patients. The choice of antihypertensive medication is largely determined by co-morbidities present in these patients [2–4]. The activation of renin–angiotensin–aldosterone system plays an important role in the pathogenesis of several cardiovascular and renal diseases (myocardial infarction, heart failure, atrial fibrillation, diabetic and non-diabetic nephropathy). In addition to the blood pressure lowering effects of ACEI and ARB, their specific ancillary desirable effects (such as antimitotic or anti-atherosclerotic properties) have made these groups of drugs a preferred option in the treatment of hypertensive patients with such co-morbid conditions [8–10]. In the HOPE (Heart Outcomes Prevention Evaluation) study, ramipril significantly reduced cardiovascular death, all-cause mortality, stroke and myocardial infarction in high-risk patients (mean age 66 years) with pre-existing vascular disease or diabetes mellitus [11]. The LIFE (Losartan Intervention For Endpoint reduction in hypertension) study evaluated the effects of losartan versus atenolol in diabetic patients (mean age 67 years) with hypertension and left ventricular hypertrophy. Cardiovascular morbidity and mortality as well as
123
Aging Clin Exp Res (2014) 26:307–314
mortality from all causes were reduced in favour of losartan [12]. ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) showed similar efficacy between telmisartan and ramipril in a large population of patients (mean age 66 years) with vascular disease or diabetes mellitus [13]. ACEI/ARB exert favourable effects on the quality of life. These drugs do not interfere with, and may in fact even improve, cognitive functions [14]. The aim of our study was to compare the utilisation of ACEI/ARB in elderly hypertensive patients at the time of their hospital admission and at discharge and to identify patient-related factors which influence the choice of ACEI/ ARB as the preferred antihypertensive therapy. The underutilisation of beneficial cardiovascular medications such as ACEI/ARB in the elderly patients has been documented in several studies and has been a matter of concern [15– 18]. The effects of ACEIs were extensively studied in elderly heart failure patients by GIFA (Gruppo Italiano di Farmacoepidemiologia nell’Anziano) investigators [19– 21]. However, to our knowledge, there is no large study which has evaluated the influence of hospitalisation on the prescription of ACEI/ARB in hypertensive patients with certain co-morbid conditions in which such medications are known to be beneficial.
Methods Study population The sample of our retrospective study (n = 1111) was drawn from 2,157 patients hospitalised at long-term care departments of three municipal hospitals (Malacky, Nitra and Ilava) in the Slovak Republic during the period between January 1, 2008 and December 31, 2009. The same source was also used in a previous evaluation [22]. Criteria for inclusion in the study were (a) age C65 years, (b) arterial hypertension recorded in patient’s medical records at hospital admission, (c) treatment with at least one antihypertensive medication at hospital admission and (d) the presence of at least one of the following co-morbidities of interest, namely heart failure, myocardial infarction, atrial fibrillation, diabetes mellitus or nephropathy. According to guidelines of the European Society of Hypertension, use of ACEI/ARB is beneficial and fully justified in hypertensive patients with these co-morbidities [3]. Patients with contraindications for the use of ACEI/ ARB such as hyperkalaemia and bilateral renal artery stenosis were excluded. Patients with arterial hypertension newly diagnosed at hospital admission and those suffering from secondary hypertension and emergency hypertensive situations were also excluded. Patients who died during
Aging Clin Exp Res (2014) 26:307–314
hospitalisation and those with incomplete documentation for our evaluation (e.g. patients transferred to other hospital departments) were not included in the study. Of 2,157 patients hospitalised during the study period, 1,111 patients fulfilled the criteria mentioned above and formed the study sample for analysis. We considered this sample size to be sufficiently large, adequate and representative for our evaluation. The basic demographic characteristics of the patients (age, gender), data on their social status (living alone or with somebody else), duration of hospitalisation, the value of systolic and diastolic blood pressure at the time of hospital admission as well as the presence of immobilisation were recorded for each patient. Co-morbid conditions were evaluated in line with the 10th Edition of the International Classification of Diseases [23]. Antihypertensive medications were recorded separately at the time of hospital admission and discharge, respectively. Data for our study were extracted from patient’s medical records. Patient confidentiality and data protection were fully respected in compliance of all ethical principles and legislation.
Evaluation of the use of ACEI/ARB In the study presented here, the analyses of the use of ACEI/ARB were carried out at the time of hospital admission and separately at discharge. The study group (n = 1111) was divided into two subgroups. Patients who were taking ACEI or ARB constituted the group of ‘‘ACEI/ARB users’’, and those without the prescription of such medications formed the group of ‘‘ACEI/ARB non-users’’. We evaluated the effect of hospitalisation on the utilization of ACEI/ARB by comparing the number of ‘‘ACEI/ARB users’’ and ‘‘ACEI/ARB non-users’’ at the time of hospital admission and at the time of discharge, respectively. Such comparison was also made separately with patients stratified by the presence of co-morbidities of interest which had formed the criteria for inclusion in this study (myocardial infarction, heart failure, atrial fibrillation, diabetes mellitus and nephropathy). Factors which characterised patients who were prescribed ACEI/ARB were identified by comparing the presence of demographic signs (age C80 and C85 years, female sex), living alone, immobilisation as well as the levels of systolic and diastolic blood pressure recorded at the time of hospital admission (systolic blood pressure: C140, C150 and B115 mmHg; diastolic blood pressure: C90, C95 and B75 mmHg) between the group of ‘‘ACEI/ARB users’’ and ‘‘ACEI/ARB nonusers’’.
309
Statistical analysis Continuous variables were characterised as means ± standard deviations. Categorical variables were expressed as frequencies and percentages. The distribution of categorical variables between two evaluated groups was analysed using the v2 test. The presence of dichotomous variables (‘‘ACEI/ARB users’’ and ‘‘ACEI/ARB non-users’’) at the time of hospital admission and discharge was evaluated using the McNemar test. Continuous variables were compared between the two groups using the Mann–Whitney U test. The comparison of continuous variables at the time of hospital admission and discharge was carried out using the Wilcoxon matched-pair test. The use of non-parametric tests mentioned above was based on the non-Gaussian distribution of evaluated continuous variables. The normality of the distribution of continuous variables was tested using the Kolmogorov– Smirnov test. Factors characterising patients with the prescription of ACEI/ARB were identified in the multivariate analysis using the binary logistic regression model. The odds ratios and the 95 % confidence intervals of the odds ratios were determined for the characteristics of ‘‘ACEI/ARB users’’ [24]. All statistical tests were realised at a significance level of a = 0.05. The statistical software used was SPSS for Windows, version 20 (IBM SPSS Inc., Chicago, IL, USA).
Results The mean age of patients in the entire cohort (n = 1111) was 78.7 ± 6.7 years. Women (n = 730; 65.7 %) prevailed over men (n = 381; 34.3 %). Women were significantly older than men (79.0 ± 6.4 vs 77.9 ± 7.1; p = 0.013 according to the Mann–Whitney U test). Hospitalisation led to a significant increase in the number of prescribed antihypertensive medications (2.4 ± 1.1 vs 2.6 ± 1.1 at hospital admission and discharge, respectively; p \ 0.001 according to the Wilcoxon matched-pair test). The mean number of co-morbid conditions, which represented the criteria for inclusion in our study, was 2.0 ± 0.9 per patient. No significant difference was found between ‘‘ACEI/ARB users’’ and ‘‘ACEI/ARB non-users’’ in terms of the number of these co-morbid conditions at the time of hospital admission (2.0 ± 0.9 vs 1.9 ± 0.9; p = 0.376 according to the Mann–Whitney U test) and at discharge (2.0 ± 0.9 vs 1.9 ± 0.9; p = 0.058 according to the Mann–Whitney U test). There was no significant difference in the duration of hospitalisation between patients being prescribed ACEI/ARB and those without prescription of such medication at hospital
123
310
Aging Clin Exp Res (2014) 26:307–314
Table 1 Antihypertensive medications used in the evaluated group Antihypertensive medication class
At admission
At discharge
Table 2 Comparison of the distribution of ‘‘ACEI/ARB users’’ and ‘‘ACEI/ARB non-users’’ at hospital admission and discharge stratified by co-morbidity
ACEI
717 (64.5)
759 (68.3)
Co-morbidity
ARB
144 (13.0)
158 (14.2)
Thiazide diuretics
226 (20.3)
238 (21.4)
Furosemide
408 (36.7)
481 (43.3)
Beta-blockers
539 (48.5)
653 (58.8)
DHP calcium channel blockers
320 (28.8)
334 (30.1)
Non-DHP calcium channel blockers
77 (6.9)
73 (6.6)
112 (10.1)
117 (10.5)
Alfa1-receptor antagonists
44 (4.0)
51 (4.6)
Urapidil
61 (5.5)
78 (7.0)
I1-receptor agonists
Values represent the frequency, the percentages are provided in brackets (% of n = 1111) ACEI angiotensin-converting enzyme inhibitors, ARB angiotensin receptor blockers, DHP dihydropyridine, Non-DHP nondihydropyridine
At admission
Pa
At discharge
ACEI/ ARB Non-user
ACEI/ ARB User
ACEI/ ARB Non-user
ACEI/ ARB User
Myocardial infarction (n = 194)
33 (17.0)
161 (83.0)
15 (7.7)
179 (92.3)
0.001
Heart failure (n = 396)
88 (22.2)
308 (77.8)
73 (18.4)
323 (81.6)
0.054
Atrial fibrillation (n = 365)
90 (24.7)
275 (75.3)
88 (24.1)
277 (75.9)
0.883
Diabetes mellitus (n = 555)
123 (22.2)
432 (77.8)
83 (15.0)
472 (85.0)
ORIGINAL ARTICLE
Influence of hospitalisation on the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in elderly hypertensive patients Martin Wawruch • Veronika Slezakova • Jan Murin Jan Luha • Michal Bozik • Tatiana Leitmann • Magdalena Kuzelova • Rashmi Shah
•
Received: 6 March 2013 / Accepted: 29 October 2013 / Published online: 30 April 2014 Ó Springer International Publishing Switzerland 2014
Abstract Background and aims The underutilization of beneficial cardiovascular medications such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) in the elderly patients continues to be a matter of concern. The aim of the presented study was to compare the prescription of ACEI and ARB in elderly hypertensive patients at the time of hospital admission and discharge and to identify patient-related factors which determine the prescription of ACEI/ARB. M. Wawruch (&) V. Slezakova Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University, Sasinkova, 4, 811 08 Bratislava, Slovakia e-mail: [email protected]; [email protected] J. Murin 1st Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia J. Luha Department of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University, Bratislava, Slovakia M. Bozik Department of Trauma Surgery, University Hospital Bratislava, Bratislava, Slovakia T. Leitmann Department of Geriatrics, Faculty of Medicine, Slovak Medical University, Bratislava, Slovakia M. Kuzelova Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University, Bratislava, Slovakia R. Shah Gerrards Cross, Bucks, UK
Methods The study sample (n = 1111) was selected from 2,157 patients hospitalised at long-term care departments of three municipal hospitals during the period between January 1, 2008 and December 31, 2009 and included hypertensive patients aged C65 years suffering from myocardial infarction, heart failure, atrial fibrillation, diabetes mellitus or nephropathy. Results In hypertensive patients with myocardial infarction, diabetes mellitus and nephropathy, a significant increase was found in the use of ACEI/ARB during hospitalisation. However, there was no similar change in the use of such medications during hospitalisation in patients with heart failure and atrial fibrillation. Age C85 years (OR = 0.59 and OR = 0.50 at hospital admission and discharge, respectively), depression (OR = 0.63 at hospital discharge) and the systolic blood pressure B115 mmHg (OR = 0.45 at hospital discharge) decreased the probability of ACEI/ARB prescription. On the other hand, increasing the number of evaluated co-morbid conditions increased the patient’s likelihood of being an ‘‘ACEI/ARB user’’ (OR = 1.20 at hospital discharge). Conclusions Our study has identified a subset of elderly hypertensive patients (with heart failure, atrial fibrillation) in whom the use of ACEI/ARB could be improved. Keywords Elderly Hypertension Co-morbidity Atrial fibrillation Diabetes mellitus Heart failure
Introduction The prevalence of arterial hypertension increases with advancing age. Wolf-Maier et al. [1] reported a 27 % prevalence of hypertension in six European countries in the age group of 35–44 years and 78 % prevalence among
123
308
persons aged 65–74 years. The treatment of arterial hypertension in elderly patients represents special challenge and guidelines for treatment of arterial hypertension in this group pay special attention [2–4]. In the past, high blood pressure was often believed to be a compensatory mechanism in response to narrowing of the coronary and cerebral vasculature that accompanies the ageing process [5]. Arterial hypertension represents an important risk factor for coronary events, stroke, heart failure and peripheral arterial disease. The favourable effect of antihypertensive treatment in reducing cardiovascular events in patients aged C65 years proved to be a landmark finding from a number of trials reported during 1980s and 1990s [6]. The benefit of antihypertensive therapy in elderly persons aged C80 years was also confirmed in 2008 by the Hypertension in the Very Elderly Trial (HYVET) [7]. Despite the importance of hypertension as a risk factor for adverse outcomes, elderly patients have the lowest rate of adequate blood pressure control. Frequent co-morbidities, polypharmacy, high cost of medication as well as the failure of many physicians to appreciate that most elderly patients should be treated according to guidelines contribute to inadequate blood pressure control in this patient population [8]. According to the Recommendation of the European Society of Hypertension and its Reappraisal, all major antihypertensive drug classes—diuretics, angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), calcium channel blockers and betablockers—have shown benefits in terms of reduction of cardiovascular events in randomised trials among elderly patients. The choice of antihypertensive medication is largely determined by co-morbidities present in these patients [2–4]. The activation of renin–angiotensin–aldosterone system plays an important role in the pathogenesis of several cardiovascular and renal diseases (myocardial infarction, heart failure, atrial fibrillation, diabetic and non-diabetic nephropathy). In addition to the blood pressure lowering effects of ACEI and ARB, their specific ancillary desirable effects (such as antimitotic or anti-atherosclerotic properties) have made these groups of drugs a preferred option in the treatment of hypertensive patients with such co-morbid conditions [8–10]. In the HOPE (Heart Outcomes Prevention Evaluation) study, ramipril significantly reduced cardiovascular death, all-cause mortality, stroke and myocardial infarction in high-risk patients (mean age 66 years) with pre-existing vascular disease or diabetes mellitus [11]. The LIFE (Losartan Intervention For Endpoint reduction in hypertension) study evaluated the effects of losartan versus atenolol in diabetic patients (mean age 67 years) with hypertension and left ventricular hypertrophy. Cardiovascular morbidity and mortality as well as
123
Aging Clin Exp Res (2014) 26:307–314
mortality from all causes were reduced in favour of losartan [12]. ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) showed similar efficacy between telmisartan and ramipril in a large population of patients (mean age 66 years) with vascular disease or diabetes mellitus [13]. ACEI/ARB exert favourable effects on the quality of life. These drugs do not interfere with, and may in fact even improve, cognitive functions [14]. The aim of our study was to compare the utilisation of ACEI/ARB in elderly hypertensive patients at the time of their hospital admission and at discharge and to identify patient-related factors which influence the choice of ACEI/ ARB as the preferred antihypertensive therapy. The underutilisation of beneficial cardiovascular medications such as ACEI/ARB in the elderly patients has been documented in several studies and has been a matter of concern [15– 18]. The effects of ACEIs were extensively studied in elderly heart failure patients by GIFA (Gruppo Italiano di Farmacoepidemiologia nell’Anziano) investigators [19– 21]. However, to our knowledge, there is no large study which has evaluated the influence of hospitalisation on the prescription of ACEI/ARB in hypertensive patients with certain co-morbid conditions in which such medications are known to be beneficial.
Methods Study population The sample of our retrospective study (n = 1111) was drawn from 2,157 patients hospitalised at long-term care departments of three municipal hospitals (Malacky, Nitra and Ilava) in the Slovak Republic during the period between January 1, 2008 and December 31, 2009. The same source was also used in a previous evaluation [22]. Criteria for inclusion in the study were (a) age C65 years, (b) arterial hypertension recorded in patient’s medical records at hospital admission, (c) treatment with at least one antihypertensive medication at hospital admission and (d) the presence of at least one of the following co-morbidities of interest, namely heart failure, myocardial infarction, atrial fibrillation, diabetes mellitus or nephropathy. According to guidelines of the European Society of Hypertension, use of ACEI/ARB is beneficial and fully justified in hypertensive patients with these co-morbidities [3]. Patients with contraindications for the use of ACEI/ ARB such as hyperkalaemia and bilateral renal artery stenosis were excluded. Patients with arterial hypertension newly diagnosed at hospital admission and those suffering from secondary hypertension and emergency hypertensive situations were also excluded. Patients who died during
Aging Clin Exp Res (2014) 26:307–314
hospitalisation and those with incomplete documentation for our evaluation (e.g. patients transferred to other hospital departments) were not included in the study. Of 2,157 patients hospitalised during the study period, 1,111 patients fulfilled the criteria mentioned above and formed the study sample for analysis. We considered this sample size to be sufficiently large, adequate and representative for our evaluation. The basic demographic characteristics of the patients (age, gender), data on their social status (living alone or with somebody else), duration of hospitalisation, the value of systolic and diastolic blood pressure at the time of hospital admission as well as the presence of immobilisation were recorded for each patient. Co-morbid conditions were evaluated in line with the 10th Edition of the International Classification of Diseases [23]. Antihypertensive medications were recorded separately at the time of hospital admission and discharge, respectively. Data for our study were extracted from patient’s medical records. Patient confidentiality and data protection were fully respected in compliance of all ethical principles and legislation.
Evaluation of the use of ACEI/ARB In the study presented here, the analyses of the use of ACEI/ARB were carried out at the time of hospital admission and separately at discharge. The study group (n = 1111) was divided into two subgroups. Patients who were taking ACEI or ARB constituted the group of ‘‘ACEI/ARB users’’, and those without the prescription of such medications formed the group of ‘‘ACEI/ARB non-users’’. We evaluated the effect of hospitalisation on the utilization of ACEI/ARB by comparing the number of ‘‘ACEI/ARB users’’ and ‘‘ACEI/ARB non-users’’ at the time of hospital admission and at the time of discharge, respectively. Such comparison was also made separately with patients stratified by the presence of co-morbidities of interest which had formed the criteria for inclusion in this study (myocardial infarction, heart failure, atrial fibrillation, diabetes mellitus and nephropathy). Factors which characterised patients who were prescribed ACEI/ARB were identified by comparing the presence of demographic signs (age C80 and C85 years, female sex), living alone, immobilisation as well as the levels of systolic and diastolic blood pressure recorded at the time of hospital admission (systolic blood pressure: C140, C150 and B115 mmHg; diastolic blood pressure: C90, C95 and B75 mmHg) between the group of ‘‘ACEI/ARB users’’ and ‘‘ACEI/ARB nonusers’’.
309
Statistical analysis Continuous variables were characterised as means ± standard deviations. Categorical variables were expressed as frequencies and percentages. The distribution of categorical variables between two evaluated groups was analysed using the v2 test. The presence of dichotomous variables (‘‘ACEI/ARB users’’ and ‘‘ACEI/ARB non-users’’) at the time of hospital admission and discharge was evaluated using the McNemar test. Continuous variables were compared between the two groups using the Mann–Whitney U test. The comparison of continuous variables at the time of hospital admission and discharge was carried out using the Wilcoxon matched-pair test. The use of non-parametric tests mentioned above was based on the non-Gaussian distribution of evaluated continuous variables. The normality of the distribution of continuous variables was tested using the Kolmogorov– Smirnov test. Factors characterising patients with the prescription of ACEI/ARB were identified in the multivariate analysis using the binary logistic regression model. The odds ratios and the 95 % confidence intervals of the odds ratios were determined for the characteristics of ‘‘ACEI/ARB users’’ [24]. All statistical tests were realised at a significance level of a = 0.05. The statistical software used was SPSS for Windows, version 20 (IBM SPSS Inc., Chicago, IL, USA).
Results The mean age of patients in the entire cohort (n = 1111) was 78.7 ± 6.7 years. Women (n = 730; 65.7 %) prevailed over men (n = 381; 34.3 %). Women were significantly older than men (79.0 ± 6.4 vs 77.9 ± 7.1; p = 0.013 according to the Mann–Whitney U test). Hospitalisation led to a significant increase in the number of prescribed antihypertensive medications (2.4 ± 1.1 vs 2.6 ± 1.1 at hospital admission and discharge, respectively; p \ 0.001 according to the Wilcoxon matched-pair test). The mean number of co-morbid conditions, which represented the criteria for inclusion in our study, was 2.0 ± 0.9 per patient. No significant difference was found between ‘‘ACEI/ARB users’’ and ‘‘ACEI/ARB non-users’’ in terms of the number of these co-morbid conditions at the time of hospital admission (2.0 ± 0.9 vs 1.9 ± 0.9; p = 0.376 according to the Mann–Whitney U test) and at discharge (2.0 ± 0.9 vs 1.9 ± 0.9; p = 0.058 according to the Mann–Whitney U test). There was no significant difference in the duration of hospitalisation between patients being prescribed ACEI/ARB and those without prescription of such medication at hospital
123
310
Aging Clin Exp Res (2014) 26:307–314
Table 1 Antihypertensive medications used in the evaluated group Antihypertensive medication class
At admission
At discharge
Table 2 Comparison of the distribution of ‘‘ACEI/ARB users’’ and ‘‘ACEI/ARB non-users’’ at hospital admission and discharge stratified by co-morbidity
ACEI
717 (64.5)
759 (68.3)
Co-morbidity
ARB
144 (13.0)
158 (14.2)
Thiazide diuretics
226 (20.3)
238 (21.4)
Furosemide
408 (36.7)
481 (43.3)
Beta-blockers
539 (48.5)
653 (58.8)
DHP calcium channel blockers
320 (28.8)
334 (30.1)
Non-DHP calcium channel blockers
77 (6.9)
73 (6.6)
112 (10.1)
117 (10.5)
Alfa1-receptor antagonists
44 (4.0)
51 (4.6)
Urapidil
61 (5.5)
78 (7.0)
I1-receptor agonists
Values represent the frequency, the percentages are provided in brackets (% of n = 1111) ACEI angiotensin-converting enzyme inhibitors, ARB angiotensin receptor blockers, DHP dihydropyridine, Non-DHP nondihydropyridine
At admission
Pa
At discharge
ACEI/ ARB Non-user
ACEI/ ARB User
ACEI/ ARB Non-user
ACEI/ ARB User
Myocardial infarction (n = 194)
33 (17.0)
161 (83.0)
15 (7.7)
179 (92.3)
0.001
Heart failure (n = 396)
88 (22.2)
308 (77.8)
73 (18.4)
323 (81.6)
0.054
Atrial fibrillation (n = 365)
90 (24.7)
275 (75.3)
88 (24.1)
277 (75.9)
0.883
Diabetes mellitus (n = 555)
123 (22.2)
432 (77.8)
83 (15.0)
472 (85.0)
