Table 1 Perceived internal and external barriers for prescribing ACE-I for CHF, divided in literature-based and self-reported barriers (N = number of GPs reporting barrier)

Literature-based barriers

N

Self-reported barriers

N

Internal

Do not agree with: I believe that the standard therapy for new CHF patients should be an ACE-I, irrespective of the severity of the disease

1

I believe that the standard therapy for known CHF patients should be an ACE-I, irrespective of the severity of the disease

2

I believe that ACE-I should be prescribed in as high a dose as possible for CHF patients

2

Agree with: I believe one should be reserved in prescribing ACE-I to CHF patients, because of the risk of renal insufficiency

11

Starting, checking, and titrating ACE-I dose is difficult

3

I believe one should be reserved in prescribing ACE-I to CHF patients, because of the risk of hypotension

12

Fears about adverse effects of ACE-I

8

I find initiating ACE-I difficult in CHF patients already using a diuretic

18

I find it difficult to frequently titrate the ACE-I dose in CHF patients

25

I believe that CHF patients who are stable on their current medication, should not be put on an ACE-I

18

Not wanting to change treatment when patients are stable

4

I believe it is not useful to prescribe ACE-I to very old CHF patients

10

Doubts about usefulness of ACE-I, especially in elderly patients

3

Difficulties with treating complex cases (comorbidity/polyfarmacy)

3

External

Problems with patient compliance or motivation

5

I believe that a cardiologist should initiate ACE-I therapy in CHF patients

3

Problems in interacting with specialist care

9

I find it hard to change treatment initiated by a cardiologist

33

Time constraints

1

Difficulties with screening for undertreated heart failure patients

4