In the EPHESUS trial, adding eplerenone to standard therapy in patients with acute myocardial infarction complicated by left ventricular dysfunction and either heart failure or diabetes reduced cardiovascular mortality. Which patient below meets the classic criterion for starting an aldosterone antagonist after MI?

• A EF 45%, hypertension controlled on two drugs, no diabetes
• B EF 32%, diabetic, creatinine 1.4 mg/dL, potassium 4.2 mEq/L ✓
• C EF 38%, creatinine 2.8 mg/dL, potassium 5.4 mEq/L
• D EF 50%, prior stroke, on aspirin and statin only

Explanation

An aldosterone antagonist is indicated after MI in patients with EF of 40% or less who have symptomatic heart failure or diabetes, provided renal function allows it: creatinine below about 2.5 mg/dL in men and potassium below 5.0 mEq/L. Option B fits all criteria. Option C is excluded by renal impairment and hyperkalemia, both major risks of spironolactone and eplerenone, while options A and D fail the ejection fraction threshold that defines the treated population.

Reference: Katzung's Basic and Clinical Pharmacology, 16th ed.

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