2. Aldosterone and Cardiovascular Disease The fundamental role of the RAAS in cardiovascular disease is apparent from the results of many large ACE inhibitor trials showing mortality benefit in patients with chronic heart failure and in those with, or at high risk of, coronary artery disease. These beneficial effects have been attributed to prevention of the multiple adverse effects of angiotensin II. Strong evidence suggests that aldosterone may also be an important mediator of cardiac and vascular damage in many disease states. In trials involving patients with chronic heart failure and heart failure complicating myocardial infarction, the addition of the MRBs - spironolactone (RALES) or eplerenone (EPHESUS and EMPHASIS ) - to standard therapy including ACE inhibition reduced mortality by up to 30%. Primary aldosteronism is associated with a greater LV mass and higher risk of adverse cardiovascular events than control hypertensive populations and in patients after myocardial infarction, plasma aldosterone concentration even within the normal range predicts an adverse prognosis. More recently, a study of subjects undergoing coronary angiography confirmed an independent association of plasma aldosterone levels with total and cardiovascular mortality.