In patients with significant renal dysfunction, it is sensible to stabilize renal function before initiating an ACE inhibitor or an ARB, with re-evaluation of creatinine levels after drug initiation. An ARB may be substituted for an ACE inhibitor with similar benefits on survival.277,278 Combining an ACE inhibitor and an ARB may result in an increase in adverse events.277,278 In a study in which patients with AMI with LV dysfunction (LVEF <0.40) with or without HF were randomized 3 to 14 days after AMI to receive eplerenone (a selective aldosterone blocker), eplerenone was efficacious as an adjunct to ACE inhibitors and beta blockers in decreasing long-term mortality.279,287 In a study of patients with HF, >50% of whom had an ischemic etiology, spironolactone (a nonselective aldosterone inhibitor) ; however, RCT data on MI are not available. See Online Data Supplement 14 for additional information on inhibitors of the renin-angiotensin-aldosterone system. 4.3. Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS 4.3.1. Initial Oral and Intravenous Antiplatelet Therapy in Patients With Definite or Likely NSTE-ACS Treated With an Initial Invasive or Ischemia-Guided Strategy: Recommendations See Table 7 for a summary of recommendations from this section and Online Data Supplement 15 for additional infor- mation on initial oral and intravenous antiplatelet therapy in patients with definite or likely NSTE-ACS treated with an early invasive or an ischemia-guided strategy. Class I 1. Non enteric-coated, chewable aspirin (162 mg to 325 mg) I should be given to all patients with NSTE- ACS without contraindications as soon as possible after presentation, and a maintenance dose of aspirin (81 mg/d to 325 mg/d) should be continued indefinite- (Level of Evidence: A) 2. 