Improving ACE inhibitor use in patients hospitalized with systolic heart failure: a cluster randomized controlled trial of clinical practice guideline development and use

J Eval Clin Pract. 2003 Aug;9(3):373-82. doi: 10.1046/j.1365-2753.2003.00441.x.


Rationale, aims and objectives: The efficacy of angiotensin-converting enzyme (ACE) inhibitors in treating heart failure is well established, but there is concern that these agents are underutilized. This study aimed to evaluate the effect of developing and implementing Clinical Practice Guidelines (CPGs) on the quality of care given to patients receiving ACE inhibitors for systolic heart failure.

Methods: Twenty cardiology units in Lorraine (France) were randomized to an experimental (n = 10) or a control group (n = 10). In each experimental unit, doctors were involved in drafting and implementing CPGs; those at control units were not. Practice surveys were conducted in all units before and after the intervention; 723 patients with heart failure and less than 75 years old were included. The main outcome was compliance with the CPGs.

Results: Before intervention, clinicians in both groups were already compliant with CPGs relating to indications and contra-indications, adverse effects management, concomitant therapy and monitoring of biologic factors. After intervention, adherence to others CPGs was generally better in the experimental group. Compliance with the CPG relating to ACE inhibitor dose on discharge was higher in the experimental group (P = 0.003). Compliance with CPGs relating to increasing ACE inhibitors doses (P < 0.0001) and the contents of the discharge letter (P = 0.02) improved in all units between the two periods.

Conclusions: These results suggest that doctors involved in drafting and implementing CPGs are more likely to comply with them.

Publication types

  • Clinical Trial
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Angiotensin-Converting Enzyme Inhibitors / administration & dosage
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Cardiology Service, Hospital / standards
  • Female
  • Heart Failure / drug therapy*
  • Humans
  • Male
  • Middle Aged
  • Physician's Role
  • Practice Guidelines as Topic*
  • Practice Patterns, Physicians' / standards
  • Quality of Health Care / standards
  • Randomized Controlled Trials as Topic


  • Angiotensin-Converting Enzyme Inhibitors