What medications are typically prescribed after a myocardial infarction (heart attack)?

Medications Typically Prescribed After a Heart Attack

After a myocardial infarction (heart attack), patients should receive a combination of antiplatelet therapy, beta-blockers, ACE inhibitors/ARBs, statins, and in some cases aldosterone antagonists to reduce mortality and prevent recurrent cardiovascular events. 1

Core Medication Regimen

Antiplatelet Therapy

• Aspirin: 75-100 mg daily indefinitely 2, 1
• P2Y12 inhibitor: In addition to aspirin for 12 months 2, 1
  • Preferred options: Ticagrelor or prasugrel
  • Alternative: Clopidogrel (if ticagrelor/prasugrel unavailable or contraindicated)
• Proton pump inhibitor: Recommended with dual antiplatelet therapy (DAPT) for patients at high risk of gastrointestinal bleeding 2

Beta-Blockers

• Should be prescribed to all post-MI patients without contraindications 2
• Reduce mortality and reinfarction by 20-25% 2, 1
• Proven benefit with: propranolol, metoprolol, timolol, acebutolol, and carvedilol 2
• Contraindications: Hypotension, acute heart failure, AV block, severe bradycardia 1

ACE Inhibitors/ARBs

• ACE inhibitors: Should be prescribed at discharge for all patients without contraindications 2, 3
  • Particularly important for patients with:
    • Left ventricular systolic dysfunction (LVEF <40%)
    • Heart failure
    • Diabetes
    • Anterior infarction
• ARBs (valsartan or candesartan): Alternative for patients intolerant to ACE inhibitors 2, 1

Statins

• High-intensity statin therapy should be started as early as possible 1
• Target LDL-C: <70 mg/dL or ≥50% reduction from baseline 1

Aldosterone Antagonists (MRAs)

• Recommended for patients with:
  • LVEF ≤40% and heart failure or diabetes
  • Already receiving ACE inhibitor and beta-blocker
  • No significant renal dysfunction or hyperkalemia 2, 1

Special Considerations

High Bleeding Risk Patients

• Consider discontinuing P2Y12 inhibitor after 6 months 2
• Use lower doses of aspirin (75-100 mg) 2
• Add proton pump inhibitor when using DAPT 2

Patients Requiring Anticoagulation

• For patients with LV thrombus, anticoagulation should be administered for up to 6 months 2
• For patients with other indications for anticoagulation (e.g., atrial fibrillation):
  • Triple therapy (DAPT + anticoagulant) should be considered for 1-6 months 2
  • Carefully balance ischemic and bleeding risks

Medication Selection Nuances

Beta-Blocker Selection

• Evidence supports propranolol, metoprolol, timolol, acebutolol, and carvedilol 2
• Carvedilol has shown benefit in patients with reduced LVEF (<25%) 2

ACE Inhibitor Evidence

• Lisinopril has demonstrated an 11% lower risk of death when given within 24 hours of MI onset 3
• Captopril, enalapril, ramipril, and trandolapril have also shown benefits in post-MI patients 2

Calcium Channel Blockers

• Evidence for benefit is much weaker than for beta-blockers 2
• Verapamil or diltiazem may be appropriate when beta-blockers are contraindicated, especially in obstructive airways disease 2
• Caution with impaired ventricular function 2

Nitrates

• No evidence that oral or transdermal nitrates improve long-term prognosis after MI 2

Common Pitfalls and Caveats

1. Undertreatment: Studies show that only 69% of patients receive complete guideline-adherent therapy at discharge, with ACE inhibitors most commonly omitted (21.2%) 4

2. Medication Interactions:

   • Avoid ibuprofen as it blocks the antiplatelet effects of aspirin 2
   • Avoid using ticagrelor or prasugrel as part of triple antithrombotic therapy 2

3. Patient-Specific Considerations:

   • Elderly patients (>75 years) and those weighing <60 kg should avoid prasugrel 5
   • Patients with history of stroke/TIA should not receive prasugrel 5

4. Duration of Therapy:

   • Beta-blockers and ACE inhibitors should be continued indefinitely in most patients 2
   • DAPT typically for 12 months, but may be shortened to 6 months in high bleeding risk patients 2

5. Medication Adherence:

   • Poor adherence is common and significantly impacts outcomes
   • Cardiac rehabilitation programs improve medication adherence 1

By implementing this comprehensive medication regimen after MI, mortality and recurrent cardiovascular events can be significantly reduced, with the greatest benefit seen when all recommended medications are prescribed according to guidelines.