Prevention
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