Correspondence

Age and the Cardiovascular System

N Engl J Med 1993; 328:1279-1280April 29, 1993

Article

To the Editor:

Wei is to be commended for her scholarly review of the effect of age on the cardiovascular system (Dec. 10 issue)1. However, her recommendations for treating systolic dysfunction do not reflect the results of several studies documenting the beneficial effects of angiotensin-converting-enzyme inhibitors in patients with reduced systolic function.

The Cooperative North Scandinavian Enalapril Survival Study,2 conducted among patients with a mean age of 71 years and severe congestive heart failure (New York Heart Association functional class IV), demonstrated decreased mortality among those given enalapril as compared with those given placebo. The Studies of Left Ventricular Dysfunction trial,3 also a comparison of enalapril and placebo, was conducted in patients with a mean age of 61 years, chronic congestive heart failure, and an ejection fraction of ≤ 0.35. Both mortality and the rate of hospitalization were decreased in the enalapril-treated patients. The second Vasodilator-Heart Failure Trial4 compared enalapril treatment with hydralazine-isosorbide dinitrate treatment in men with a mean age of 61 years and chronic congestive heart failure, and demonstrated a reduced rate of sudden death among those treated with enalapril. These studies did not include adequate numbers of patients over the age of 75 to draw firm conclusions about this age group, but the results do apply to patients 65 to 75 years of age and may apply to some over 75 years of age.

A possible caveat is that elderly patients may be more susceptible to adverse effects of sudden and prolonged reductions in blood pressure; in that case, the use of small doses of a short-acting angiotensin-converting-enzyme inhibitor during dose titration should minimize the potential risks of the therapy.

Margaret A. Winker, M.D.
Journal of the American Medical Association, Chicago, IL 60610

4 References

1. 1

   Wei JY. Age and the cardiovascular system. N Engl J Med 1992;327:1735-1739
   Full Text | Web of Science | Medline

2. 2

   The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med 1987;316:1429-1435
   Full Text | Web of Science | Medline

3. 3

   The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991;325:293-302
   Full Text | Web of Science | Medline

4. 4

   Cohn JN, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991;325:303-310
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Wei replies:

To the Editor: I fully agree with Dr. Winker that angiotensin-converting-enzyme inhibitors are beneficial to older patients (at least those 65 to 75 years old) who have reduced systolic function. In the text of my review, I stated that therapy for systolic dysfunction in elderly patients, as in younger patients, includes vasodilators, but did not specifically mention angiotensin-converting-enzyme inhibitors. I thank Dr. Winker for elaborating on this point.

Jeanne Wei, M.D., Ph.D.
Beth Israel Hospital, Boston, MA 02215