Doctors have an exaggerated perception of the risk of using angiotensin converting enzyme (ACE) inhibitors in patients with heart failure, according to a new study. It found that less than 2 per cent of patients on ACE inhibitors had to discontinue treatment because of side effects. Dr James Mason (senior research fellow, centre for health economics, University of York) and colleagues used data from past trials to examine risks and economic costs associated with ACE inhibitor therapy. Of 7,487 patients who took a test dose of enalapril, 1.8 per cent reported side effects severe enough to warrant stopping the drug. A total of 7.8 per cent reported side effects including hypotension, altered taste and rash. None of the patients had a lasting or life-threatening adverse event. A total of 2,569 patients were randomised to receive treatment with enalapril or placebo. Hypotension was most likely to lead to dose reduction of enalapril (odds ratio 2.09). Rates of withdrawal and dose reduction were similar in both groups during the first year of treatment. The study showed that older patients and those with more severe heart failure were at increased risk of side effects. The researchers comment that patients should be started on a small dose of ACE inhibitor that is then increased, (eg, enalapril 2.5mg twice a day increasing to 10mg twice a day, or lisinopril 2.5mg once a day increasing to 20mg once a day). Blood pressure, renal function and serum potassium should be measured before and one week after treatment initiation and dose adjustments. Patients at high risk of hypotension should have a short-acting drug first, they say. The cost per patient of starting enalapril was calculated to be £320. Use of lisinopril increased this to £360 because an additional titration step was required (British Medical Journal 2000;321:1113). In an accompanying leading article, Professor John Cleveland (professor of cardiology, Castle Hill hospital, Kingston upon Hull) and colleagues comment that other factors such as a lack of resources and expertise are barriers to efficient treatment of heart failure. “Proper diagnosis and treatment for Britain’s most common malignant disease should not be beyond the resources of our National Health Service,” they insist (ibid, p1095).