What are the recommended medications for a patient with left ventricular ejection fraction (LVEF) of 38% post percutaneous coronary intervention (PCI) for non-ST-elevation myocardial infarction (NSTEMI)?

From the Guidelines

For a patient with a left ventricular ejection fraction (LVEF) of 38% following a non-ST elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention (PCI), I recommend a comprehensive medication regimen to improve cardiac function and prevent further events. The core medications should include:

• an ACE inhibitor (such as ramipril 2.5-10mg daily or lisinopril 5-40mg daily) or an ARB if ACE inhibitors are not tolerated;
• a beta-blocker (such as metoprolol succinate 25-200mg daily or carvedilol 3.125-25mg twice daily);
• a statin (such as atorvastatin 40-80mg daily);
• dual antiplatelet therapy with aspirin 81mg daily indefinitely plus a P2Y12 inhibitor (typically clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily) for at least 12 months post-PCI, as supported by the guidelines from 1;
• and a mineralocorticoid receptor antagonist (spironolactone 25-50mg daily or eplerenone 25-50mg daily) given the reduced LVEF below 40%. Consider adding an SGLT2 inhibitor (such as dapagliflozin 10mg daily or empagliflozin 10mg daily) which has shown benefit in heart failure with reduced ejection fraction. These medications work synergistically to reduce cardiac workload, prevent adverse remodeling, reduce inflammation and thrombosis risk, and improve overall cardiac function. Regular monitoring of renal function, electrolytes, and blood pressure is essential, with medication doses titrated to the maximum tolerated levels for optimal benefit, as recommended by 1.

Key considerations for the P2Y12 inhibitor include:

• Clopidogrel 75 mg daily,
• Prasugrel 10 mg daily, or
• Ticagrelor 90 mg twice daily, each with its own set of considerations regarding bleeding risk, patient weight, and history of stroke or TIA, as outlined in the guidelines from 1. The choice of P2Y12 inhibitor should be individualized based on patient-specific factors, including the risk of bleeding and the potential for drug interactions, as discussed in 1.

In patients with a history of stroke or TIA, the use of prasugrel is generally not recommended due to the increased risk of fatal and intracranial bleeding, unless in high-risk situations, as noted in 1. Similarly, in patients aged 75 years or older, prasugrel is generally not recommended due to the increased risk of bleeding, except in high-risk situations, as stated in 1.

Overall, the management of patients with NSTEMI and reduced LVEF requires a comprehensive and individualized approach, taking into account the patient's specific clinical characteristics, medical history, and potential risks and benefits of each medication, as emphasized in the guidelines from 1.

From the FDA Drug Label

Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.

The recommended medication for a patient with left ventricular ejection fraction (LVEF) of 38% post percutaneous coronary intervention (PCI) for non-ST-elevation myocardial infarction (NSTEMI) is prasugrel.

• The dosage is a single 60 mg oral loading dose and then continue at 10 mg orally once daily.
• Patients taking prasugrel tablets should also take aspirin (75 mg to 325 mg) daily 2.
• Left ventricular ejection fraction (LVEF) is not a factor in the dosage of prasugrel.
• Consider lowering the maintenance dose to 5 mg in patients <60 kg 2.

From the Research

Medications for Left Ventricular Ejection Fraction (LVEF) of 38% Post Percutaneous Coronary Intervention (PCI) for Non-ST-Elevation Myocardial Infarction (NSTEMI)

• The patient's condition with an LVEF of 38% post PCI for NSTEMI indicates a reduced left ventricular ejection fraction, which is associated with higher mortality 3.
• Guideline-recommended medications such as beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins are associated with lower mortality in patients with reduced LVEF 3.
• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (e.g., ticlopidine, clopidogrel, prasugrel, ticagrelor) is recommended to reduce the risk of stent thrombosis and subsequent cardiovascular events post-PCI 4.
• Prasugrel and ticagrelor are more efficient than clopidogrel in reducing cardiovascular ischemic events in patients with acute coronary syndromes, but are associated with a higher bleeding risk 5.
• Anticoagulation therapy, including unfractionated heparin, low molecular weight heparin, and direct factor IIa inhibitors, may be used in patients with ACS, but the choice of anticoagulant depends on the individual patient's risk factors and treatment plan 6.
• For patients with LVEF ≤35% at least 40 days after acute myocardial infarction, implantable cardioverter-defibrillator (ICD) placement is recommended to reduce the risk of sudden cardiac death, and factors such as age, comorbidities, and use of guideline-directed medical therapy (GDMT) can influence ICD placement 7.

Key Medications

• Beta-blockers
• Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers
• Statins
• Aspirin
• P2Y12 inhibitors (e.g., prasugrel, ticagrelor, clopidogrel)

Considerations for ICD Placement

• LVEF ≤35% at least 40 days after acute myocardial infarction
• Age and comorbidities
• Use of GDMT (e.g., beta-blockers, ACE inhibitors, mineralocorticoid receptor antagonists)