What is the recommended dosing strategy for starting ACE inhibitors in chronic HFrEF?

• A. Start at low doses and uptitrate
• B. Start at high doses immediately
• C. Do not uptitrate
• D. Only fixed doses

Answer: (A)

Starting ACE inhibitors in chronic HFrEF should be done by beginning with a low dose and gradually uptitrating to the target or maximum tolerated dose. This approach balances the proven mortality and morbidity benefits of ACE inhibitors with the risk of adverse effects such as hypotension, renal function decline, and hyperkalemia, especially in the early treatment period. Start with a small dose, then reassess blood pressure, renal function, and potassium within 1–2 weeks and increase incrementally as tolerated until the guideline-recommended target doses are reached or until dose-limiting side effects occur. This reflects the real-world strategy of optimizing therapy to achieve the benefits seen in major trials while ensuring patient safety.