Guideline Recommended Practice

Prescribing ACE/ARB Therapy

Angiotensin converting enzyme inhibitors (ACEs) should be prescribed to all patients with current or prior symptoms of HF due to LV systolic dysfunction with reduced LVEF unless contraindicated or have shown intolerance to this drug treatment. Angiotensin Receptor Blockers (ARBs) are now considered a reasonable alternative to ACEs, particularly in patients with intolerance to ACEs.

Key points

  • ACE therapy has a favorable effect on survival. Treatment should not be delayed until patient is found to be resistant to other drug therapy.
  • Data suggests there are no differences among available ACEs in their effects on symptoms or survival. Treatment with an ACE inhibitor should be initiated at low doses, followed by gradual dose increments if lower doses have been well tolerated.
  • ACEs are generally used together with a beta blocker.
  • ACE treatment should not be prescribed without diuretics in patients with current or recent history of fluid retention.
  • ACEs are often preferred over ARBs because of greater evidence in support of their effectiveness.
  • ARBs should be used in patients with HF who are ACE inhibitor intolerant. An ARB may also be used as an alternative to an ACE inhibitor in patients who are already taking an ARB for another reason, such as hypertension, and who subsequently develop HF.

ACE or ARB treatment should not be prescribed to patients who:

  • Have experienced life-threatening adverse reactions (angioedema or anuric renal failure) during previous exposure to the drug.
  • Are pregnant or plan to become pregnant in the near future. ACE-I treatment should be discontinued immediately when pregnancy is known.
  • Are at immediate risk of cardiogenic shock.

Performance Measure Reporting

What's Being Measured

Percentage of patients ≥18 years of age diagnosed with heart failure, with current or prior LVEF <40%, that were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting or from hospital discharge.

How to Satisfy this Measure

Prescribe* and document ACE inhibitor or ARB therapy for patients ≥18 years with HF who have a current or prior LVEF < 40%.


Document contraindication(s) to ACE/ARB. At least one of these exceptions must be documented in the patient record lieu of prescription, if they apply:

  • Medical reason(s) for not prescribing ACE/ARB therapy
    • For example: hypotensive patients at immediate risk of cardiogenic shock; hospitalized patients who have experienced marked azotemia; patients who have demonstrated life-threatening adverse reactions to the drug
  • Patient reason(s) for not prescribing ACE/ARB therapy
  • System reason(s) for not prescribing ACE/ARB therapy
    • For example: not covered by insurance plan

*Prescribed may include prescription given to the patient for ACE inhibitor or ARB therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB therapy as documented in current medication list.

SPECIAL NOTE: This measure is paired with performance measure "Beta- Blocker Therapy for Left Ventricular Systolic Dysfunction". They must be implemented together.