Secondary Prevention

Antiplatelet Therapy

• Aspirin
  
  • Standard 1st-line antiplatelet therapy; daily administration should continue indefinitely in all patients unless contraindicated
  • Results in a significant reduction in mortality and nonfatal reinfarction and nonfatal stroke

• Clopidogrel or Prasugrel
  
  • Should be given for at least 12 months in patients receiving a stent (bare-metal stent or drug-eluting stent) during percutaneous coronary intervention (PCI)
  • Duration of therapy may be extended beyond 15 months in patients undergoing drug-eluting stent placement
  • If the risk of bleeding outweighs benefit, earlier discontinuation of either Clopidogrel or Prasugrel should be considered

• Ticagrelor
  
  • May be given for 12 months, in conjunction with Aspirin, to patients who underwent stent implantation to prevent thromboembolic events

• Vorapaxar
  • Newly approved protease activated receptor-1 (PAR-1) antagonist that inhibits platelet activation
  • Studies showed that Vorapaxar, when given with other antiplatelet agents, significantly reduced incidences of MI, stroke, and death caused by cardiovascular disease

Anticoagulation (Oral)

• Warfarin
  
  • Recommended in patients with persistent atrial fibrillation (A-fib)
  • Patients with left ventricular thrombus may be treated for 3-6 months then reassessed
  • Use of Warfarin with antiplatelet agents is associated with increased risk of bleeding and should be closely monitored

Beta-Blocker

• Continue indefinitely in all post-MI patients unless contraindicated
• Has been shown to reduce mortality from a reduction in sudden and non-sudden cardiac death

ACE Inhibitor

• ACE inhibitors should be continued indefinitely in patients with LV dysfunction
• If patient has no evidence of symptomatic or asymptomatic LV dysfunction, ACE inhibitors may be stopped in 4-6 weeks
  
  • There may be a benefit to administering ACE inhibitors at least 4-5 years even if a patient does not suffer from ventricular dysfunction if the drug is tolerated
  • This benefit may be even greater in DM patients after MI
• Decrease in mortality has been shown when ACE inhibitors were started soon after MI
  • Patients with left ventricular dysfunction (LVEF <40%), HF in the acute event, or wall motion index of ≤1.2 have seen the greatest benefit

Angiotensin II Antagonist

• Continue in any patients intolerant of ACE inhibitors and with clinical or radiological signs of heart failure or LVEF <40%

Aldosterone Antagonist (Mineralocorticoid Receptor Antagonist)

• May be considered in post STEMI patients with LVEF <40% and HF or diabetes, provided that creatinine is <2.5 mg/dL (221 mmol/L) in men and <2.0 mg/dL (177 mmol/l) in women and potassium is ≤5.0 mEq/L
• Monitor serum potassium and watch out for hyperkalemia

Calcium Antagonist

• May be considered in patients with contraindications to beta-blockers and do not suffer heart failure or left ventricular dysfunction
• A randomized controlled trial in the chronic phase of STEMI showed reduction in the risk of reinfarction and death with Verapamil in those not on beta-blockers 
• Evidence of benefit is not as strong as for beta-blockers

Treat Hyperlipidemia

• Patients should have their lipid profile checked within 24 hours of MI symptom onset
• On discharge, patients should be counseled about cholesterol-lowering diet recommendations
• All patients should be started with statins, if without contraindications, to achieve LDL cholesterol <100 mg/dL (2.5 mmol/L)
• In high-risk patients, further reduction of LDL cholesterol to achieve <70 mg/dL (1.8 mmol/L) may be advised
• Increased consumption of omega-3 fatty acids found in fish or in commercially available capsule preparation, at 1 g per day, should be encouraged for reduction of risk
• Higher doses of omega-3 fatty acids may be needed for treatment of elevated triglycerides
• See Dyslipidemia Disease Management Chart for details

Glucose Control

• Target fasting blood glucose and glycosylated hemoglobin levels should be individualized

Influenza Vaccination

• Patients with cardiovascular disease should have an annual influenza vaccination