This finding is surprising, as ACE inhibitors/ARBs are indicated as first-line HF treatment and have been shown conclusively to reduce mortality and hospitalizations for HF in major clinical trials.25 This finding may be explained by the fact that overall scores on the HF3 indicator were generally high throughout the study period, and this ‘ceiling effect’ of QOF achievement may have limited its effectiveness as a discriminator between practices. This evidence concerns the gene ACE and hydrops fetalis.