The SAVE (Survival and Ventricular Enlargement) trial demonstrated the benefits of captopril in reducing mortality, recurrent MI and HF hospitalization in AMI patients with an LVEF <40%, but without overt HF on entry.59 Other studies showed comparable findings.60,61 ARBs are reasonable alternatives to ACEIs in patients with AMI and LVSD and can be used for patients who are intolerant to ACEIs. In the VALIANT (Valsartan in Acute Myocardial Infarction) trial, losartan was noninferior to captopril in patients with MI complicated by LVSD, HF, or both.62 Common contraindications to the use of these agents include hypotension, shock, bilateral renal artery stenosis, worsening of renal function with ACEI/ARB exposure, and drug allergy. The ARNI, valsartan/sacubitril, is the first approved ARNI for the treatment of patients with HF and reduced ejection fraction. Compared with the ACEI, enalapril, it reduced the composite endpoint of cardiovascular death or HF hospitalization in the pivotal PARADIGM-HF (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial.17 The ARNI is even recommended as a replacement therapy for symptomatic HF reduced ejection fraction with New York Heart Association class II or III who tolerate an ACEI or ARB.17 An ACEI should not be added to AMI patients already treated with an ARNI given the increased risk of angioedema and other complications (eg, hypotension, renal insufficiency). Additionally, an ARB is already a component of the ARNI regimen and as such, adding ARB is not clinically advocated. Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. 