The proportion of heart failure patients treated with an angiotensin-converting enzyme (ACE) inhibitor has increased over time, however, these drugs continue to be underutilized in this syndrome. There are a number of possible explanations for the failure of physicians to prescribe these agents optimally: (1) failure to recognize that heart failure is an important public health problem worthy of treatment; (2) failure to appreciate fully the magnitude of the clinical benefit of ACE inhibitors in heart failure; (3) failure to understand that the clinical benefits of ACE inhibitors fully justify the cost of these drugs; (4) concern that the adverse effects of ACE inhibitors outweigh their clinical benefits; (5) belief that the benefits observed in clinical trials do not translate into clinical practice. In reality, heart failure is a very common, extremely disabling, costly and deadly disorder. ACE inhibitors substantially reduce the morbidity and mortality related to heart failure, do this cost effectively and with a favourable risk-benefit ratio. Despite these facts, many patients are still denied ACE inhibitor therapy. An improved educational effort and clear and practical guidelines are essential if the uptake of ACE inhibitors is to increase.