Recanalization therapy remains the most effective way for treatment of evolving myocardial infarction and thereby salvaging jeopardized tissue. However, the efficacy of reperfusion in limiting infarction and improving recovery of contractile function depends on the amount of irreversible damage occurring prior to initiating reperfusion and is related to failure of energy production to meet the basal needs of the injured myocardium. In recent years, a variety of metabolic therapies that enhance myocardial metabolism and attenuate changes in sodium and calcium homeostasis during ischemia have been proposed. They focus on (a) increasing myocardial glucose metabolism during ischemia or (b) inhibiting fatty acid metabolism to increase glucose use, and (c) inhibiting sodium and calcium influx pathways that deplete high energy phosphates. Recent studies from our laboratory showed that inhibition of aldose reductase, a key regulatory enzyme in the substrate flux via polyol pathway, reduces ischemic injury and improves functional and metabolic recovery after ischemia-reperfusion in hearts. These and subsequent studies have generated considerable interest in the use of aldose reductase inhibitors as potential therapeutic adjuncts in treating evolving myocardial infarction in patients. This review will discuss the mechanisms by which aldose reductase inhibitors protect ischemic myocardium and provide rationale for their use as cardioprotective drugs.