From the Guidelines
Patients at risk of myocardial infarction (MI) should be managed with a comprehensive approach that includes lifestyle modifications and medication regimens, prioritizing smoking cessation, blood pressure control to below 140/90 mmHg, lipid management with a goal LDL of 100 mg/dL, regular physical activity, weight management, and diabetes control with a target HbA1c of 7%. The management of patients at risk of MI involves several key strategies, including:
- Smoking cessation: assess tobacco use and encourage complete cessation through counseling, pharmacological therapy, and formal smoking cessation programs 1.
- Blood pressure control: initiate lifestyle modification and add blood pressure medication if necessary, with a goal of 140/90 mmHg or 130/80 mmHg for patients with diabetes or chronic kidney disease 1.
- Lipid management: start dietary therapy and consider adding drug therapy, with a primary goal of LDL 100 mg/dL 1.
- Physical activity: encourage at least 30 minutes of moderate-intensity exercise 3 to 4 days per week 1.
- Weight management: calculate BMI and measure waist circumference, with a goal of BMI 18.5-24.9 kg/m2 1.
- Diabetes management: aim for HbA1c 7% through appropriate hypoglycemic therapy and management of other risks 1. Additionally, antiplatelet agents such as aspirin 75-325 mg/d should be started and continued indefinitely if not contraindicated, and ACE inhibitors should be used indefinitely after MI, with consideration for chronic therapy in all other patients with coronary or other vascular disease 1. These interventions are crucial for reducing the risk of MI and improving overall cardiovascular health.
From the FDA Drug Label
Lowering blood pressure lowers the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal
The recommended management strategies for patients at risk of myocardial infarction (MI) include:
- Control of high blood pressure as part of comprehensive cardiovascular risk management
- Lipid control
- Diabetes management
- Antithrombotic therapy
- Smoking cessation
- Exercise
- Limited sodium intake
- Aggressive treatment to a lower blood pressure goal in patients with higher absolute risk, such as those with diabetes or hyperlipidemia 2
From the Research
Risk Factors for Myocardial Infarction (MI)
The risk factors for myocardial infarction (MI) include older age, significant comorbidities such as chronic kidney disease, prior coronary artery bypass grafting (CABG), heart failure, and peripheral artery disease 3.
Management Strategies for Patients at Risk of MI
The management strategies for patients at risk of MI include the use of drug-eluting stents and potent antiplatelets, which have been shown to improve outcomes over time, particularly in very high-risk and extremely high-risk groups 3.
Medication Therapies for Secondary Prevention
Medication therapies such as aspirin, angiotensin-converting enzyme (ACE) inhibitors, and statins have been shown to be effective in reducing 1-year mortality after acute myocardial infarction (AMI) 4.
- Aspirin has been shown to reduce the risk of major adverse cardiac events (MACE) and mortality in patients with AMI.
- ACE inhibitors have been shown to reduce the risk of MACE, mortality, and myocardial infarction in patients with AMI.
- Statins have been shown to reduce the risk of MACE, mortality, and myocardial infarction in patients with AMI.
Comparison of Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs)
ACEIs have been shown to be more effective than ARBs in reducing the risk of major adverse cardiac events, cardiac death, all-cause death, and myocardial infarction in hypertensive patients with AMI 5.
- ACEIs have been associated with lower incidence of 2-year major adverse cardiac events, cardiac death, all-cause death, and myocardial infarction compared to ARBs.
- ARBs have been associated with higher incidence of 2-year cardiac death, all-cause death, and myocardial infarction compared to ACEIs.
Calcium Channel Blockers (CCBs) for Hypertensive Patients
CCBs have been shown to be effective in reducing blood pressure and major cardiovascular events in hypertensive patients with previous stroke and/or coronary artery disease 6.
- CCBs have been associated with reduced risk of stroke and major cardiovascular events in patients with coronary artery disease.
- CCBs have been shown to be at least as efficacious as other classes of antihypertensive medications in reducing blood pressure.