These agents effectively lower BP and may relieve ischemic symptoms. All CCBs have the potential to cause hypotension, and the nondihydropyridine CCBs may precipi- tate conduction disturbances, particularly when used in con- junction with -blockers. 5.3.4. ACE Inhibitors ACE inhibitors are indicated for most patients with ACS and are a preferred option for BP management in both STEMI and non-ST elevation ACS. The data are most robust for ACE inhibitors in the STEMI population, in whom most of the tri- als have been performed, with results extrapolated to UA/ NSTEMI. Rosendorff et al Treatment of Hypertension in Patients With CAD 1391 In STEMI, ACE inhibitors reduce infarct expansion, pre- venting LV remodeling and chamber dilatation,202 which help to prevent downstream sequelae such as ventricular arrhyth- mia, HF, or even myocardial rupture. The GISSI-3, ISIS-4, and CCS-1 trials demonstrated a benefit from early adminis- tration of ACE inhibitors, with absolute reductions in mortal- ity of 0.8%, 0.5%, and 0.5% seen as early as 4 weeks after A meta-analysis from the ACE Inhibitor Myocardial Infarction Collaborative Group, which included 100 000 patients treated within 36 hours of acute MI, found a 7% lower relative mortality rate at 30 days in patients treated with ACE inhibitors.204 The benefit was largest in high-risk groups such as those with HF at presentation (23 lives saved per 1000 patients) and those with an anterior MI (11 lives saved per 1000 patients). Rates of nonfatal HF were also reduced, but hypotension and renal dysfunction were more common. When ACE inhibitors are started later after MI among individuals with LV dysfunction and continued long term, their benefits are even more robust; mortality rates have been reduced by 20% to 25% in long-term trials evaluating ACE inhibitors in these high-risk subgroups.205,206 5.3.5. 