What are the recommended medications and management strategies for patients post myocardial infarction?

Post-Myocardial Infarction Management

All patients post-MI should be discharged on aspirin 75-162 mg daily indefinitely, dual antiplatelet therapy for 12 months (aspirin plus ticagrelor or prasugrel preferred over clopidogrel), high-intensity statin therapy targeting LDL-C <70 mg/dL, beta-blockers (especially if LVEF <40% or heart failure), ACE inhibitors (particularly if LVEF <40%, heart failure, diabetes, or anterior MI), and enrollment in cardiac rehabilitation. 1, 2

Antiplatelet Therapy

Aspirin forms the foundation of post-MI management:

• Initiate aspirin 75-162 mg daily immediately and continue indefinitely 1, 2
• Low-dose aspirin (75-100 mg) is preferred for long-term use due to similar efficacy with fewer adverse events compared to higher doses 1, 2
• If true aspirin allergy exists, substitute clopidogrel 75 mg daily 1

Dual antiplatelet therapy (DAPT) is mandatory after PCI:

• Continue DAPT (aspirin plus P2Y12 inhibitor) for 12 months post-PCI 1, 2
• Ticagrelor or prasugrel are preferred over clopidogrel due to more potent antiplatelet effects 2
• For patients treated with fibrinolysis without PCI, clopidogrel is recommended for at least 1 month, with consideration for extending to 12 months 1
• After fibrinolysis followed by PCI, continue DAPT for 12 months using clopidogrel as the P2Y12 inhibitor of choice 1

Critical pitfall: Avoid ibuprofen as it blocks aspirin's antiplatelet effects 1

ACE Inhibitors/Angiotensin Receptor Blockers

ACE inhibitors should be started within 24 hours in high-risk patients:

• Initiate in all patients with LVEF ≤40%, heart failure, diabetes, or anterior MI 1, 2, 3
• Start with low doses (e.g., lisinopril 2.5-5 mg) and titrate upward 3
• Consider ACE inhibitors in all other post-MI patients even without these high-risk features 1
• If ACE inhibitor intolerance develops, substitute with angiotensin receptor blocker (ARB) in patients with clinical heart failure or LVEF <40% 1

Aldosterone antagonists provide additional benefit:

• Add aldosterone blockade in patients with LVEF ≤40% who have diabetes or heart failure, provided creatinine ≤2.5 mg/dL (men) or ≤2.0 mg/dL (women) and potassium ≤5.0 mEq/L 1, 2

Beta-Blockers

Beta-blockers reduce mortality and should be started in all patients:

• Initiate beta-blocker therapy and continue indefinitely unless contraindicated 1
• Particularly indicated in patients with heart failure and/or LVEF <40% 2
• Observe usual contraindications (severe bradycardia, heart block, decompensated heart failure, severe reactive airway disease) 1

Lipid Management

High-intensity statin therapy is essential:

• Start high-intensity statin as early as possible and maintain long-term 2
• Target LDL-C <70 mg/dL (<1.8 mmol/L) or achieve ≥50% reduction if baseline LDL-C is 70-135 mg/dL 1, 2
• For triglycerides ≥200 mg/dL, target non-HDL cholesterol substantially <130 mg/dL 1

Anticoagulation

Warfarin is indicated in specific high-risk scenarios:

• Manage warfarin to INR 2.0-3.0 in patients with atrial fibrillation, left ventricular thrombus, or other clinical indications 1
• When combining warfarin with aspirin and clopidogrel (triple therapy), target INR 2.0-2.5 with low-dose aspirin (75-81 mg) to reduce bleeding risk 1
• Monitor closely as combination therapy significantly increases bleeding risk 1

Lifestyle Modifications and Cardiac Rehabilitation

Behavioral interventions are Class I recommendations:

• Enroll all patients in cardiac rehabilitation programs 1
• Identify smokers and provide repeated cessation counseling with pharmacotherapy (nicotine replacement, varenicline, or bupropion) 1
• Implement smoking cessation protocols in all hospitals caring for STEMI patients 1
• Advise weight management targeting BMI reduction and waist circumference <35 inches (women) or <40 inches (men) 1
• Encourage physical activity with medically supervised programs for high-risk patients 1

Blood Pressure Management

Target systolic blood pressure <140 mmHg with lifestyle changes and pharmacotherapy:

• In elderly, frail patients, more lenient targets are acceptable 1
• In very high-risk patients tolerating multiple medications, consider target <120 mmHg 1
• Reduce salt intake, increase physical activity, and achieve weight loss 1

Diabetes Management

Aggressive risk factor modification is required:

• Initiate lifestyle modification and pharmacotherapy to achieve near-normal HbA1c 1
• Vigorously modify other risk factors including physical activity, weight, blood pressure, and lipids 1

Medication Adherence Strategies

Poor adherence undermines outcomes:

• Treatment adherence is approximately 57% after 2 years, which is associated with worse outcomes 1
• Consider polypill therapy (combining aspirin, ACE inhibitor, and statin) to improve adherence, though larger trials are needed to confirm clinical benefit 1
• Simplify treatment regimens, provide clear information, implement shared decision-making, and establish repetitive monitoring 1

Influenza Vaccination

Annual influenza vaccination is recommended for all patients with cardiovascular disease 1