We agree that the efficacy of ACE inhibitors is not proved in the oldest Medicare patients (age older than 70 years). However, the guidelines of the Agency for Health Care Policy and Research do not specify an upper limit to its recommendations. In fact, the guidelines discuss dosing modifications that can be used to safely titrate the elderly.
We decided not to examine ACE inhibitor dosages prescribed in the hospital. In this era of cost-containment and constrained lengths of hospitalizations, many physicians do not feel they have the time to fully titrate the medication dosing of inpatients for ACE inhibitor therapy. Although physicians may choose to initiate treatment with ACE inhibitors during hospitalization, the dose at discharge may not reflect the final maximum dose subsequently achieved. Subtherapeutic dosing is a fruitful area for additional quality research. Valid research in this area will require access to outpatient data.
Peto RR, for The Large State PRO Consortium. Angiotensin-Converting Enzyme Inhibitors for Elderly Patients With Congestive Heart Failure—Reply. Arch Intern Med. 1998;158(1):97-98. doi: