Beta blockers or angiotensin-converting-enzyme inhibitor/angiotensin receptor blocker: What should be first?

The historical choice of angiotensin-converting enzyme (ACE) inhibition as first-line therapy in heart failure is challenged by early activation of the sympathetic system and multiple ways beta blockade (in particular, unselective agents such as carvedilol) may affect cardiac remodeling, its underlying mechanisms, and, hence, progression of heart. failure, compared with ACE inhibition. Existing comparisons indicate similar or possible greater efficacy of beta blockade than ACE inhibition. As beta blockade is well tolerated, it could be considered in individual stable patients. However, early combined treatment with both neurohormonal antagonists remains preferable to either neurohormonal antagonist alone and should not be delayed.