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Original Research: Diffuse Lung Disease |

Ordering of the Serum Angiotensin-Converting Enzyme Test in Patients Receiving Angiotensin-Converting Enzyme Inhibitor TherapyAngiotensin-Converting Enzyme Test Ordering: An Avoidable but Common Error

Matthew D Krasowski, MD, PhD; Johanna Savage, MD; Alexandra Ehlers, BS; Jon Maakestad, BS; Gregory A. Schmidt, MD, FCCP; Sonia L. La’ulu, BS; Natalie N. Rasmussen, BS; Frederick G. Strathmann, PhD; Jonathan R. Genzen, MD, PhD
Author and Funding Information

From the Department of Pathology (Drs Krasowski and Savage, Ms Ehlers, and Mr Maakestad) and the Department of Internal Medicine (Dr Schmidt), University of Iowa, Iowa City, IA; the ARUP Institute for Clinical and Experimental Pathology (Mss La’ulu and Rasmussen and Drs Strathmann and Genzen), Salt Lake City, UT; and the Department of Pathology (Drs Strathmann and Genzen), University of Utah, Salt Lake City, UT.

CORRESPONDENCE TO: Matthew D. Krasowski, MD, PhD, Department of Pathology, University of Iowa Hospitals and Clinics, C-671 GH, 200 Hawkins Dr, Iowa City, IA 52242; e-mail: mkrasows@healthcare.uiowa.edu


FUNDING/SUPPORT: This work was supported by internal funding from the University of Iowa Hospitals and Clinics Department of Pathology (Department Executive Office, Nitin Karandikar, MD, PhD) and the ARUP Institute for Clinical and Experimental Pathology.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(6):1447-1453. doi:10.1378/chest.15-1061
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BACKGROUND:  Serum angiotensin-converting enzyme (ACE) levels may be decreased by use of ACE inhibitor (ACEI) medication. In this study, we determined how often 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. These data were compared with a large, deidentified dataset of ACE levels measured at a national reference laboratory; in vitro studies of ACEI inhibition; and liquid chromatography time-of-flight 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 effect 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. The deidentified 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-flight mass spectrometry, the presence of lisinopril was confirmed in a subset of specimens with low ACE activity. In vitro studies of two different ACE assays showed significant inhibition of activity at clinically relevant concentrations.

CONCLUSIONS:  Assessment of ACE activity is often measured for patients receiving ACEIs, potentially leading to low ACE concentrations and inaccurate interpretations.

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