22. Angiotensin converting enzyme inhibitors should be given long-term to all of the following patients except:

A. A 68 year old male with diabetes and an inferior myocardial infarction

B. A 55 year old female who suffered an anterior myocardial infarction and has a serum creatinine level of 2.0.

C. A 82 year old male who suffered an posterior myocardial infarction and has a serum
potassium level of 4.9.

D. A 55 year old male who suffered an anterior myocardial infarction and his ejection fraction returned completely to normal after percutaneous coronary intervention.

E. A 72 year old male who suffered an anterior myocardial infarction, has an apical left ventricular aneurysm and has an ejection fraction of 45%.

Either an ACE inhibitor or angiotensin receptor blocker should be given to all STEMI patients upon hospital discharge. Caution must be used in the acute setting in order to avoid hypotension which can worsen myocardial ischemia. Guidelines give the use of these drugs a class I indication when there is LV systolic dysfunction or if the patient is diabetic. When LV function returns to normal and the patient is not diabetic, the benefits are less clear and long-term therapy is not mandatory. Usually ARBs are only given if ACE inhibitors are not tolerate due to cough or other side-effects. When the serum creatinine is > 2.5 or the potassium > 5.5, then ACE inhibitors and angiotensin receptor blockers should not be used.