What to consider when choosing between ACE inhibitors and ARBs in a patient with HF?

• A. ACE inhibitors are never first-line
• B. ARBs are first-line and ACE inhibitors are avoided
• C. ACE inhibitors are typically first-line; ARBs used if ACE inhibitors are not tolerated due to cough or angioedema
• D. ARBs should always be used with beta-blockers and diuretics

Answer: (C)

In heart failure with reduced ejection fraction, blocking the renin–angiotensin system improves survival and symptoms, so an ACE inhibitor is typically started first. An ACE inhibitor is preferred because it has strong evidence of mortality benefit and well-tolerated profile for most patients. If a patient cannot tolerate an ACE inhibitor—most commonly due to a persistent cough from bradykinin buildup or a risk of angioedema—an ARB is used as an effective alternative. ARBs provide comparable benefits without the cough, and with a lower risk of angioedema, making them the go-to option when intolerance to ACE inhibitors occurs. Both classes are part of standard therapy alongside beta-blockers and diuretics, and some patients may later switch to or incorporate newer agents as appropriate, but the guiding choice is to start with an ACE inhibitor and move to an ARB if intolerance develops.