ACE inhibitors are reasonable for all patients with STEMI and no contraindications to their use.427 429 (Level of Evidence: A) Oral ACE inhibitors reduce fatal and nonfatal major cardiovascular events in patients with STEMI.360,361,420,422,428 Their protective effects have been demonstrated indepen- dent of the use of other pharmacotherapies (ie, fibrinolytics, aspirin, and beta blockers). The magnitude of clinical benefit is greatest in high-risk patient subgroups (ie, anterior MI, EF 0.40, HF, prior MI, and tachycardia).431 Demonstra- tion of an early benefit (within the first 24 hours) supports the prompt use of these agents in patients without existing contraindications (hypotension, shock, bilateral renal artery stenosis or history of worsening of renal function with ACE inhibitor/ARB exposure, renal failure, or drug allergy). The role of routine long-term ACE inhibitor therapy in low- risk patients after STEMI who have been revascularized and treated with aggressive lipid-lowering therapies is less ARBs are indicated for ACE inhibitor intolerant patients. Specifically, valsartan was found to be noninferior to captopril in the VALIANT (Valsartan in Acute Myocardial The EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival) study estab- lished the benefit of an aldosterone antagonist, eplerenone, added to optimal medical therapy in eligible patients (creati- nine 2.5 mg/dL in men and 2.0 mg/dL in women, potas- sium 5.0 mEq/L) 3 to 14 days after STEMI with EF 0.40 and either symptomatic HF or diabetes mellitus.426 A post hoc analysis of the EPHESUS trial suggested a time-dependent treatment effect of eplerenone. Earlier initiation of the drug (<7 days) significantly reduced the rates of all-cause mortal- ity, sudden cardiac death (SCD), and cardiovascular mortality/ hospitalization, whereas initiation 7 days had no significant effect on outcomes.433 8.3. Lipid Management: Recommendations Class I 1. 