The use of ARBs in combination with an ACE inhibitor is not well established in those with systolic heart failure.132,134 (Level of Evidence: A) Aldosterone blockade Class I 1. Use of aldosterone blockade in post myocardial infarction patients without significant renal dysfunction# or hyperkalemia** is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and -blocker, who have a left ventricular ejection fraction 40%, and who have either diabetes or heart failure.136,137 (Level of Evidence: A) (Continued) Smith et al AHA/ACCF Secondary Prevention: 2011 Update 2461 A) warfarin should be administered.95,99 102 (Level of Evidence: A) (NOTE: Patients receiving low dose aspirin for atherosclerosis should continue to receive it.) ture searches. The recommendations listed in this document are, whenever possible, evidence based. Writing group members performed these relevant supplemental literature searches with key search phrases including but not limited to tobacco/smoking/ smoking cessation; blood pressure control/hypertension; choles- terol/hypercholesterolemia/lipids/lipoproteins/dyslipidemia; physical activity/exercise/exercise training; weight manage- ment/overweight/obesity; type 2 diabetes mellitus manage- ment; antiplatelet agents/anticoagulants; renin/angiotensin/ aldosterone system blockers; b-blockers; influenza vaccination; Table 1. Continued Area for Intervention Recommendations b-Blockers Class I 1. b-Blocker therapy should be used in all patients with left ventricular systolic dysfunction (ejection fraction #40%) with heart failure or prior myocardial infarction, unless contraindicated. (Use should be limited to carvedilol, metoprolol succinate, or bisoprolol, which have been shown to reduce mortality.)138,140,141 (Level of Evidence: A) 2. b-Blocker therapy should be started and continued for 3 years in all patients with normal left ventricular function who have had myocardial infarction or ACS.139,142,143 (Level of Evidence: B) Class IIa 1. It is reasonable to continue b-blockers beyond 3 years as chronic therapy in all patients with normal left ventricular function who have had myocardial infarction or ACS.139,142,143 (Level of Evidence: B) 2. 