Medication Management for STEMI Patients with Normal LVEF (>40%)
For patients with STEMI and preserved left ventricular ejection fraction (LVEF >40%), routine beta-blocker therapy should be considered during hospital stay and continued thereafter, while ACE inhibitors should be considered in all patients in the absence of contraindications. 1
Beta-Blockers in STEMI with Preserved LVEF
Recommendations:
- Oral beta-blockers should be considered during hospital stay and continued thereafter in all STEMI patients without contraindications, regardless of LVEF 1
- Intravenous beta-blockers should be considered at the time of presentation in patients undergoing primary PCI with:
- No contraindications
- No signs of acute heart failure
- Systolic blood pressure >120 mmHg 1
- IV beta-blockers must be avoided in patients with:
Evidence Considerations:
While beta-blockers have shown clear mortality benefit in patients with reduced LVEF (<40%), the evidence for patients with preserved LVEF is less definitive. A study by Ozasa et al. showed that beta-blocker therapy was not associated with better 3-year clinical outcomes in STEMI patients with preserved LVEF who underwent primary PCI 3. However, this same study demonstrated significant benefit in the subgroup with LVEF ≤40%.
ACE Inhibitors/ARBs in STEMI with Preserved LVEF
Recommendations:
- ACE inhibitors are recommended within the first 24 hours of STEMI in patients with:
- ACE inhibitors should be considered in all STEMI patients in the absence of contraindications 1
- ARBs (preferably valsartan) are an alternative to ACE inhibitors, particularly for those intolerant to ACE inhibitors 1
Evidence Considerations:
The GISSI-3 study demonstrated that lisinopril treatment in acute MI patients resulted in an 11% lower risk of death compared to patients who did not receive lisinopril, regardless of LVEF 4. This supports the consideration of ACE inhibitors in all STEMI patients.
Comparative studies suggest that the combination of beta-blockers with ACE inhibitors may be more beneficial than beta-blockers with ARBs in reducing major adverse cardiac events in STEMI patients after successful PCI 5, 6.
Additional Essential Medications for STEMI Patients
Antiplatelet Therapy:
- Low-dose aspirin (75-100 mg) is indicated for all STEMI patients 1, 2
- Dual antiplatelet therapy (DAPT) with aspirin plus ticagrelor or prasugrel (or clopidogrel if these are unavailable) is recommended for 12 months after PCI 1, 2
- Proton pump inhibitors should be added for patients at high risk of gastrointestinal bleeding 1
Lipid-Lowering Therapy:
- High-intensity statin therapy should be started as early as possible and maintained long-term 1, 2
- Target LDL-C goal of <1.8 mmol/L (70 mg/dL) or reduction of at least 50% if baseline is between 1.8-3.5 mmol/L 1
Monitoring and Follow-up
- Routine echocardiography during hospital stay to assess LV function and detect complications 1
- Regular assessment of renal function and electrolytes, especially in patients on ACE inhibitors/ARBs 1
- Participation in a cardiac rehabilitation program is strongly recommended 1
Special Considerations
- For patients developing heart failure during hospitalization, add mineralocorticoid receptor antagonists (MRAs) if LVEF drops below 40% 1
- Avoid calcium channel blockers in the acute phase of STEMI 1
- Monitor for hypotension when initiating ACE inhibitors, particularly in patients with anterior MI 4
Remember that medication choices should be adjusted based on the patient's hemodynamic status, comorbidities, and any contraindications that may develop during the course of treatment.