Intended for healthcare professionals

Education And Debate

North of England evidence based development project: guideline for angiotensin converting enzyme inhibitors in primary care management of adults with symptomatic heart failure

BMJ 1998; 316 doi: (Published 02 May 1998) Cite this as: BMJ 1998;316:1369
  1. Martin Eccles, professor (,
  2. Nick Freemantle, senior research fellowb,
  3. James Mason, research fellowb

    for the North of England ACE-inhibitor Guideline Development Group.

  1. a Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4AA
  2. b Centre for Health Economics, University of York, York Y)1 5DD
  3. Other members of the guideline development and project groups are listed in theAppendix
  1. Correspondence to: Professor Eccles
  • Accepted 11 December 1997

This article provides recommendations—evidence based where possible—to guide general practitioners in their use of angiotensin converting enzyme inhibitors in adults with heart failure. The development group assumes that doctors will use their knowledge and judgment in applying the principles and recommendations given below in managing individual patients, since recommendations may not be appropriate for use in all circumstances. Doctors must take the decision to adopt any particular recommendation in the light of available resources and the circumstances of each patient. The statements accompanied by categories of evidence (cited as Ia, Ib, II, III, IV) and recommendations classified according to their strength (A, B, C, or D) are as described in our previous article (and in the box).1 All recommendations are for general practitioners and apply to adult patients with heart failure attending general practice. This is a summary of the full guideline.2

Summary points

Heart failure is a common condition in general practice and has a poor prognosis

Only 20-30% of these patients are currently prescribed an angiotensin converting enzyme inhibitor

All patients with symptomatic heart failure and evidence of impaired left ventricular function should be treated with an angiotensin converting enzyme inhibitor; so should patients with a recent myocardial infarction and evidence of left ventricular function

Left ventricular function should ideally be assessed by echocardiography or radionuclide measurements

Strength of recommendation

A—Directly based on category I evidence

B—Directly based on category II evidence or extrapolated recommendation from category I evidence

C—Directly based on category III evidence or extrapolated recommendation from category I or II evidence

D—Directly based on category IV evidence or extrapolated recommendation from category I, II or III evidence

Categories of evidence

Ia—Evidence from meta-analysis of randomised controlled trials

Ib—Evidence from at least one randomised controlled trial

IIa—Evidence from at least one controlled study …

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