Sir,The fact that cardiologists are better for the treatment of patients with heart failure than general physicians is again well substantiated by Davie and McMurray in their recent article.1 Their audit confirmed once again that patients who are looked after by cardiologists are more likely to receive an angiotensin-converting enzyme (ACE) inhibitor, the benefits of which are indisputable, and are more likely to receive them in effective doses.2-5

Their report further confirmed the link between echocardiography and the likelihood of receiving an ACE inhibitor.5 When echocardiography is not readily available, not only is the uptake of ACE inhibitors low but many patients without systolic dysfunction may be treated inappropriately.6 This has led to the concept of the ‘rules of halves’ for heart failure7: among patients currently receiving treatment for heart failure, up to half may have no evidence of cardiac dysfunction; of those patients who do have cardiac dysfunction, half or less have left ventricular systolic dysfunction; of those with left ventricular systolic dysfunction, less than half are receiving appropriate therapy.6 7