Ordering of the serum angiotensin-converting enzyme test in patients receiving angiotensin-converting enzyme inhibitor th erapy an avoidable but common error

Matthew D. Krasowski, Johanna Savage, Alexandra Ehlers, Jon Maakestad, Gregory A. Schmidt, Sonia L. La'Ulu, Natalie N. Rasmussen, Frederick G. Strathmann, Jonathan R. Genzen

Research output: Contribution to journalArticle

Abstract

BACKGROUND: Serum angiotensin-converting enzyme (ACE) levels may be decreased by use of ACE inhibitor (ACEI) medication. In this study, we determined how oft en ACE levels were measured in patients receiving ACEI therapy. METHODS: ACE levels analyzed over a 54-month preintervention time period at an academic medical center were reviewed retrospectively for tests performed during ACEI therapy. Th ese data were compared with a large, deidentifi ed dataset of ACE levels measured at a national reference laboratory; in vitro studies of ACEI inhibition; and liquid chromatography time-of-fl ight mass spectrometry detection of lisinopril in a subset of clinical specimens. RESULTS: Over a 54-month period, 1,292 patients had ACE levels measured, with 108 patients (8.4%) receiving ACEI therapy at the time of testing. ACE levels measured for patients receiving ACEI therapy were substantially lower. In general, clinical teams did not recognize a medication eff ect on ACE levels. Introduction of a warning prompt in the electronic health record reduced the ordering of ACE levels in patients receiving ACEIs by. 60% in a 17-month postintervention time period. Th e deidentifi ed dataset of ACE levels at a reference laboratory showed a bimodal distribution, with a peak of very low ACE levels. Using liquid chromatography time-of-fl ight mass spectrometry, the presence of lisinopril was confi rmed in a subset of specimens with low ACE activity. In vitro studies of two diff erent ACE assays showed signifi cant inhibition of activity at clinically relevant concentrations. CONCLUSIONS: Assessment of ACE activity is oft en measured for patients receiving ACEIs, potentially leading to low ACE concentrations and inaccurate interpretations.

Original languageEnglish (US)
Pages (from-to)1447-1453
Number of pages7
JournalChest
Volume148
Issue number6
DOIs
StatePublished - Dec 1 2015
Externally publishedYes

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Peptidyl-Dipeptidase A
Angiotensin-Converting Enzyme Inhibitors
Serum
Lisinopril
Liquid Chromatography
Mass Spectrometry
Electronic Health Records
Enzyme Assays
Therapeutics

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Critical Care and Intensive Care Medicine
  • Cardiology and Cardiovascular Medicine
  • Medicine(all)

Cite this

Krasowski, M. D., Savage, J., Ehlers, A., Maakestad, J., Schmidt, G. A., La'Ulu, S. L., ... Genzen, J. R. (2015). Ordering of the serum angiotensin-converting enzyme test in patients receiving angiotensin-converting enzyme inhibitor th erapy an avoidable but common error. Chest, 148(6), 1447-1453. https://doi.org/10.1378/chest.15-1061

Ordering of the serum angiotensin-converting enzyme test in patients receiving angiotensin-converting enzyme inhibitor th erapy an avoidable but common error. / Krasowski, Matthew D.; Savage, Johanna; Ehlers, Alexandra; Maakestad, Jon; Schmidt, Gregory A.; La'Ulu, Sonia L.; Rasmussen, Natalie N.; Strathmann, Frederick G.; Genzen, Jonathan R.

In: Chest, Vol. 148, No. 6, 01.12.2015, p. 1447-1453.

Research output: Contribution to journalArticle

Krasowski, MD, Savage, J, Ehlers, A, Maakestad, J, Schmidt, GA, La'Ulu, SL, Rasmussen, NN, Strathmann, FG & Genzen, JR 2015, 'Ordering of the serum angiotensin-converting enzyme test in patients receiving angiotensin-converting enzyme inhibitor th erapy an avoidable but common error', Chest, vol. 148, no. 6, pp. 1447-1453. https://doi.org/10.1378/chest.15-1061
Krasowski, Matthew D. ; Savage, Johanna ; Ehlers, Alexandra ; Maakestad, Jon ; Schmidt, Gregory A. ; La'Ulu, Sonia L. ; Rasmussen, Natalie N. ; Strathmann, Frederick G. ; Genzen, Jonathan R. / Ordering of the serum angiotensin-converting enzyme test in patients receiving angiotensin-converting enzyme inhibitor th erapy an avoidable but common error. In: Chest. 2015 ; Vol. 148, No. 6. pp. 1447-1453.
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abstract = "BACKGROUND: Serum angiotensin-converting enzyme (ACE) levels may be decreased by use of ACE inhibitor (ACEI) medication. In this study, we determined how oft en ACE levels were measured in patients receiving ACEI therapy. METHODS: ACE levels analyzed over a 54-month preintervention time period at an academic medical center were reviewed retrospectively for tests performed during ACEI therapy. Th ese data were compared with a large, deidentifi ed dataset of ACE levels measured at a national reference laboratory; in vitro studies of ACEI inhibition; and liquid chromatography time-of-fl ight mass spectrometry detection of lisinopril in a subset of clinical specimens. RESULTS: Over a 54-month period, 1,292 patients had ACE levels measured, with 108 patients (8.4{\%}) receiving ACEI therapy at the time of testing. ACE levels measured for patients receiving ACEI therapy were substantially lower. In general, clinical teams did not recognize a medication eff ect on ACE levels. Introduction of a warning prompt in the electronic health record reduced the ordering of ACE levels in patients receiving ACEIs by. 60{\%} in a 17-month postintervention time period. Th e deidentifi ed dataset of ACE levels at a reference laboratory showed a bimodal distribution, with a peak of very low ACE levels. Using liquid chromatography time-of-fl ight mass spectrometry, the presence of lisinopril was confi rmed in a subset of specimens with low ACE activity. In vitro studies of two diff erent ACE assays showed signifi cant inhibition of activity at clinically relevant concentrations. CONCLUSIONS: Assessment of ACE activity is oft en measured for patients receiving ACEIs, potentially leading to low ACE concentrations and inaccurate interpretations.",
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AU - Maakestad, Jon

AU - Schmidt, Gregory A.

AU - La'Ulu, Sonia L.

AU - Rasmussen, Natalie N.

AU - Strathmann, Frederick G.

AU - Genzen, Jonathan R.

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N2 - BACKGROUND: Serum angiotensin-converting enzyme (ACE) levels may be decreased by use of ACE inhibitor (ACEI) medication. In this study, we determined how oft en ACE levels were measured in patients receiving ACEI therapy. METHODS: ACE levels analyzed over a 54-month preintervention time period at an academic medical center were reviewed retrospectively for tests performed during ACEI therapy. Th ese data were compared with a large, deidentifi ed dataset of ACE levels measured at a national reference laboratory; in vitro studies of ACEI inhibition; and liquid chromatography time-of-fl ight mass spectrometry detection of lisinopril in a subset of clinical specimens. RESULTS: Over a 54-month period, 1,292 patients had ACE levels measured, with 108 patients (8.4%) receiving ACEI therapy at the time of testing. ACE levels measured for patients receiving ACEI therapy were substantially lower. In general, clinical teams did not recognize a medication eff ect on ACE levels. Introduction of a warning prompt in the electronic health record reduced the ordering of ACE levels in patients receiving ACEIs by. 60% in a 17-month postintervention time period. Th e deidentifi ed dataset of ACE levels at a reference laboratory showed a bimodal distribution, with a peak of very low ACE levels. Using liquid chromatography time-of-fl ight mass spectrometry, the presence of lisinopril was confi rmed in a subset of specimens with low ACE activity. In vitro studies of two diff erent ACE assays showed signifi cant inhibition of activity at clinically relevant concentrations. CONCLUSIONS: Assessment of ACE activity is oft en measured for patients receiving ACEIs, potentially leading to low ACE concentrations and inaccurate interpretations.

AB - BACKGROUND: Serum angiotensin-converting enzyme (ACE) levels may be decreased by use of ACE inhibitor (ACEI) medication. In this study, we determined how oft en ACE levels were measured in patients receiving ACEI therapy. METHODS: ACE levels analyzed over a 54-month preintervention time period at an academic medical center were reviewed retrospectively for tests performed during ACEI therapy. Th ese data were compared with a large, deidentifi ed dataset of ACE levels measured at a national reference laboratory; in vitro studies of ACEI inhibition; and liquid chromatography time-of-fl ight mass spectrometry detection of lisinopril in a subset of clinical specimens. RESULTS: Over a 54-month period, 1,292 patients had ACE levels measured, with 108 patients (8.4%) receiving ACEI therapy at the time of testing. ACE levels measured for patients receiving ACEI therapy were substantially lower. In general, clinical teams did not recognize a medication eff ect on ACE levels. Introduction of a warning prompt in the electronic health record reduced the ordering of ACE levels in patients receiving ACEIs by. 60% in a 17-month postintervention time period. Th e deidentifi ed dataset of ACE levels at a reference laboratory showed a bimodal distribution, with a peak of very low ACE levels. Using liquid chromatography time-of-fl ight mass spectrometry, the presence of lisinopril was confi rmed in a subset of specimens with low ACE activity. In vitro studies of two diff erent ACE assays showed signifi cant inhibition of activity at clinically relevant concentrations. CONCLUSIONS: Assessment of ACE activity is oft en measured for patients receiving ACEIs, potentially leading to low ACE concentrations and inaccurate interpretations.

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