What medications are given to patients post Myocardial Infarction (MI)?

From the Guidelines

Post-myocardial infarction (MI) patients should be prescribed a combination of medications, including beta-blockers, ACE inhibitors or ARBs, statins, and antiplatelet agents, to prevent further cardiac events and improve outcomes, as recommended by the most recent guidelines 1. The standard regimen includes beta-blockers like metoprolol (25-200 mg daily) or carvedilol (3.125-25 mg twice daily) to reduce heart rate, blood pressure, and myocardial oxygen demand.

• ACE inhibitors or ARBs, such as lisinopril (5-40 mg daily) or valsartan (40-320 mg daily), are given long-term to prevent cardiac remodeling and reduce mortality, as supported by the 2014 AHA/ACC guideline 1.
• High-intensity statins like atorvastatin (40-80 mg daily) or rosuvastatin (20-40 mg daily) are used indefinitely to lower cholesterol and stabilize plaques. Some patients may also receive aldosterone antagonists like spironolactone (25-50 mg daily) if they have heart failure or reduced ejection fraction, as recommended by the 2014 AHA/ACC guideline 1. Additionally, medications such as nitroglycerin, oxygen, and morphine may be given to patients post-MI to manage symptoms and prevent further cardiac events, as outlined in the 2013 ACCF/AHA guideline 1.
• Nitroglycerin (0.4 mg sublingual every 5 min up to 3 doses as BP allows) may be given to patients with ongoing chest pain or hypertension.
• Oxygen (2 to 4 L/min via nasal cannula) may be given to patients with clinically significant hypoxemia, heart failure, or dyspnea.
• Morphine (4 to 8 mg IV initially, with lower doses in elderly) may be given to patients with pain, anxiety, or pulmonary edema. The choice of medication and dosage should be individualized based on the patient's specific needs and medical history, with consideration of potential contraindications and side effects, as outlined in the guidelines 1.

From the FDA Drug Label

The GISSI-3 study was a multicenter, controlled, randomized, unblinded clinical trial conducted in 19,394 patients with acute myocardial infarction (MI) admitted to a coronary care unit... All patients received routine therapies, including thrombolytics (72%), aspirin (84%), and a beta blocker (31%), as appropriate, normally utilized in acute myocardial infarction (MI) patients Patients randomized to lisinopril received 5 mg within 24 hours of the onset of symptoms, 5 mg after 24 hours, and then 10 mg daily thereafter. CAPRICORN was a double-blind study comparing Carvedilol Tablet and placebo in 1,959 patients with a recent myocardial infarction (within 21 days) and left ventricular ejection fraction of less than or equal to 40%, with (47%) or without symptoms of heart failure. Patients given Carvedilol Tablet received 6.25 mg twice daily, titrated as tolerated to 25 mg twice daily.

The medications given to patients post MI are:

• Lisinopril: 5 mg within 24 hours of the onset of symptoms, 5 mg after 24 hours, and then 10 mg daily thereafter 2
• Aspirin: 84% of patients received aspirin 2
• Beta blockers: 31% of patients received a beta blocker 2
• Thrombolytics: 72% of patients received thrombolytics 2
• Carvedilol: 6.25 mg twice daily, titrated as tolerated to 25 mg twice daily 3

From the Research

Medications Post Myocardial Infarction (MI)

The following medications are commonly given to patients post MI:

• Antiplatelet agents, such as aspirin and clopidogrel 4
• Statins, with atorvastatin having the best evidence 4
• Beta-blockers, which decrease mortality and are especially effective in patients with impaired left ventricular function 4, 5
• Renin-angiotensin-aldosterone system blockers, including angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) 4, 5
• Aldosterone blockers, recommended for patients with left ventricular ejection fraction ≤40% and either symptomatic heart failure or diabetes 5
• Calcium-channel blockers, restricted to patients with conserved left ventricular function and no congestion, and in whom beta-blockers are contraindicated 5
• Lipid therapy with a statin, recommended for patients with elevated cholesterol levels 5
• Newer P2Y12 inhibitors, such as ticagrelor or prasugrel, which may be associated with lower rates of early and 1-year mortality compared to clopidogrel 6
• Triple antithrombotic therapy with aspirin, P2Y12 inhibitor, and warfarin, which may be used in patients who require systemic anticoagulation and undergo percutaneous coronary intervention (PCI) 7

Specific Medication Regimens

The choice of medication regimen may depend on individual patient factors, such as:

• Left ventricular function: patients with impaired left ventricular function may benefit from beta-blockers and ACE inhibitors 5
• Ischemia and arrhythmic risk markers: patients with these risk factors may require more intensive medication regimens 5
• Bleeding risk: patients at high risk of bleeding may require caution with the use of newer P2Y12 inhibitors or triple antithrombotic therapy 6, 7