ACE inhibitors for the prevention and treatment of heart failure: why are they 'under-used'?

Currently there is concern that ACE inhibitors are not being utilised to their maximum potential for the prevention or treatment of heart failure. Underutilisation of ACE inhibitors has been attributed to a lack of appropriate medical education of physicians. However, an alternative explanation is that the trials have failed to answer important questions about how ACE inhibitors should be used in heart failure and that physician prescribing is appropriate to the current state of knowledge. The lack of evidence of benefit in patients with heart failure over the age of 75 years and of any substantial controlled trial in patients with apparent heart failure and well-preserved left ventricular systolic function, a common finding in elderly patients, may be common reasons why ACE inhibitors appear to be prescribed infrequently for heart failure.