What are the consequences of a completed myocardial infarction (heart attack)?

From the Guidelines

Myocardial infarction completed requires a comprehensive management approach to prevent complications and future cardiac events, focusing on dual antiplatelet therapy, high-intensity statins, beta-blockers, ACE inhibitors, lifestyle modifications, and cardiac rehabilitation, as recommended by the most recent guidelines 1. The management of completed myocardial infarction involves several key components, including:

• Dual antiplatelet therapy with aspirin (81mg daily indefinitely) and a P2Y12 inhibitor like clopidogrel (75mg daily) for at least 12 months, as supported by the 2017 AHA/ACC clinical performance and quality measures 1
• A high-intensity statin such as atorvastatin 40-80mg daily to lower cholesterol and stabilize plaques, as recommended by the same guidelines 1
• Beta-blockers (metoprolol 25-100mg twice daily) and ACE inhibitors (lisinopril 5-40mg daily) to reduce cardiac workload and prevent adverse remodeling, as suggested by earlier studies 1
• Lifestyle modifications, including smoking cessation, regular physical activity, weight management, and a heart-healthy diet low in saturated fats and sodium, which are crucial for improving outcomes and preventing future cardiovascular events
• Cardiac rehabilitation programs, which provide supervised exercise and education to improve outcomes, as emphasized by the European Society of Cardiology 1 Regular follow-up with cardiology is essential to monitor recovery, adjust medications, and assess for complications like heart failure, arrhythmias, or recurrent ischemia. The most recent guidelines from the American College of Cardiology/American Heart Association Task Force on Performance Measures 1 provide the foundation for this comprehensive approach, which prioritizes morbidity, mortality, and quality of life as the primary outcomes.

From the FDA Drug Label

The Gruppo Italiano per lo Studio della Sopravvienza nell’Infarto Miocardico (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 Patients receiving lisinopril (n=9,646), alone or with nitrates, had an 11% lower risk of death (p = 0.04) compared to patients who did not receive lisinopril (n=9,672) (6.4% vs. 7. 2%, respectively) at six weeks

The use of lisinopril in patients with myocardial infarction may reduce the risk of death. Key points include:

• Mortality reduction: 11% lower risk of death at six weeks
• Study details: The GISSI-3 study, a multicenter, controlled, randomized trial with 19,394 patients
• Lisinopril treatment: Patients received 5 mg of lisinopril within 24 hours of symptom onset, and 10 mg daily thereafter 2

From the Research

Myocardial Infarction Completed

• Myocardial infarction with non-obstructive coronary arteries (MINOCA) is common and occurs in 6-8% of all patients fulfilling the diagnostic criteria for acute myocardial infarction (AMI) 3
• The use of secondary prevention therapies in MINOCA varies considerably, and there is a limited basis for guideline recommendations in MINOCA 3
• A combination therapy with aspirin, an ACE inhibitor, and a statin reduces 1-year mortality in patients after AMI 4
• The implementation of guideline-recommended therapies has improved over time, with the highest-risk groups demonstrating the greatest benefit in outcomes 5
• End-stage renal disease patients are far less likely than non-ESRD patients to be treated with aspirin, beta-blockers, and ACE inhibitors during an admission for AMI 6
• Over the last 40 years, our understanding of the pathogenesis of myocardial infarction has evolved and allowed new treatment strategies that have greatly improved survival 7

Treatment and Management

• Oral beta blockade and ACEI/ARB treatment may reduce the composite endpoint of death of any cause, readmission because of AMI, ischemic stroke or heart failure in patients discharged after MINOCA 3
• A polypill approach with aspirin, an ACE inhibitor, and a statin should be considered to increase drug compliance and reduce mortality after acute myocardial infarction 4
• Drug-eluting stents and potent antiplatelets were more commonly used over time in all risk-strata, leading to improved outcomes 5
• The early administration of aspirin and beta-blockers was less likely to be administered to ESRD patients than to non-ESRD patients, despite similar benefits on 30-day mortality 6

Outcome and Prognosis

• Patients with MINOCA have an increased risk of serious cardiovascular events and death 3
• The rates of 1-year mortality remained unchanged in high-risk, very high-risk, and extremely high-risk groups, despite improved outcomes in terms of MACE 5
• Patients who develop cardiogenic shock still face a high 30-day mortality of at least 40% 7