Which First for Heart Failure: ACE Inhibitor or Beta-Blocker?

For patients with heart failure (HF) and left-ventricular systolic dysfunction (LVSD), guidelines recommend treatment with an ACE inhibitor and a beta-blocker (bisoprolol, carvedilol, or sustained-release metoprolol), unless contraindicated. Traditionally, an ACE inhibitor is started first and a beta-blocker is added. In this randomized, open-label trial, researchers sought to assess the noninferiority of the beta-blocker bisoprolol (target dose, 10 mg daily) relative to the ACE inhibitor enalapril (target dose, 10 mg twice daily) as initial therapy in 1010 NYHA class II–III HF patients (age ≥65; 68% men) with LV ejection fractions ≤35%. Patients randomly assigned to one drug started the other drug after 6 months. Mean follow-up was 1.2 yea…