Which statement correctly describes ACE inhibitors in heart failure with reduced EF?

• A. They are first-line for mortality reduction in all patients unless intolerance
• B. They should never be used
• C. They have no effect on mortality
• D. They are replaced by diuretics

Answer: (A)

ACE inhibitors reduce mortality in heart failure with reduced ejection fraction by blocking the maladaptive neurohormonal activation that drives progression. By inhibiting angiotensin II formation, they cause vasodilation, decrease preload and afterload, reduce aldosterone-mediated volume retention, and limit adverse remodeling of the ventricle. This survival benefit has been demonstrated in major trials, making ACE inhibitors the first-line therapy for most patients with LV systolic dysfunction who can tolerate them. Intolerance—such as cough, hyperkalemia, hypotension, or worsened renal function—limits their use and may require adjustment or cessation. Diuretics help with symptoms but do not improve mortality, so they do not replace ACE inhibitors as a mortality-reducing therapy.