Despite randomized controlled trials demonstrating mortality reduction, many studies have documented persistent low rates of prescription of angiotensinconverting enzyme inhibitors (ACE-I) in patients with heart failures; the reasons for this pattern remain poorly defined. In addition, some authors have argued that the results of carefully controlled clinical trials do not translate well into the uncontrolled world of clinical practice, and the mortality benefits of ACE-I may not extend into

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... cial populations such as the elderly. Objectives: To understand the reasons for failure to prescribe ACE-I to Medicare patients with heart failure and to assess the impact of this failure on mortality. Methods: We obtained data by reviewing charts of Medicare patients discharged from 7 Colorado hospitals with a diagnosis of heart failure during 1994. Results: We identified a diagnosis of heart failure in 1016 patients without a contraindication to ACE-I. Three hundred seventy-eight of these patients were receiving ACE-I at the time of admission. Of the 638 remaining, 257 had their left ventricular systolic function assessed and 92 had diminished function. Of these 92, 50 (54.3%) were discharged on a regimen of ACE-I. The only significant difference in baseline comorbidity or demographic vari-