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    Which comes first: ACE inhibitors or Beta Blockers?

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    We all know ACE inhibitors and beta blockers are the corner stone of CHF (systolic dysfunction) management. Why? Because they lower morbidity and mortality. 

    But, practically speaking, does the order in which we prescribe these medications matter?

    Perhaps…

    Some suggest ACE inhibitors be started before beta blockers.

    The rationale is that ACE inhibitors provide rapid hemodynamic and renal improvement, without exacerbating heart failure symptoms. 

    Beta blockers, on the other hand, may cause worsening of heart failure symptoms – initially. This includes fluid retention, hypotension, bradycardia, heart block, and fatigue. 

    Patients should have minimal edema before starting beta blocker therapy and a 3 pound increase should prompt possible diuretic therapy. 

    This is also the reason we want to start with low doses, followed by a gradual increase, based on the patients symptoms. 

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