What is the management plan for post infarction angina?

Management of Post-Infarction Angina

Post-infarction angina requires immediate risk stratification with LVEF measurement, aggressive dual antiplatelet therapy with aspirin plus clopidogrel, and early coronary angiography for most patients to guide revascularization decisions. 1, 2

Immediate Assessment and Risk Stratification

• Measure left ventricular ejection fraction (LVEF) as the primary determinant of management strategy 1, 2
• If LVEF ≤0.40, proceed directly to diagnostic coronary angiography 1, 2
• If LVEF >0.40, perform stress testing to assess for inducible ischemia 1, 2
• Patients with positive stress tests showing moderate or greater reversible ischemia should undergo coronary angiography regardless of symptom status 3

Antiplatelet Therapy

• Continue aspirin 75-162 mg daily indefinitely 1, 2
• Administer clopidogrel 75 mg daily (with loading dose if not previously given) for documented coronary artery disease 1, 2
• Dual antiplatelet therapy (DAPT) should be maintained for at least 12 months in patients with acute coronary syndrome 4
• For patients at high bleeding risk (age ≥65, low BMI, diabetes, prior bleeding, or on anticoagulants), consider shorter DAPT duration of 3-6 months 4
• Never discontinue antiplatelet therapy abruptly, especially in patients who have undergone PCI, as this increases risk of stent thrombosis and recurrent events 2

Anticoagulation Management

• Continue intravenous unfractionated heparin for at least 48 hours or until discharge if medical management is selected 1
• Continue enoxaparin for duration of hospitalization, up to 8 days, if started before angiography 1
• Continue fondaparinux for duration of hospitalization, up to 8 days, if started before angiography 1
• Discontinue anticoagulant therapy after PCI for uncomplicated cases 1

Additional Medical Therapy

• Initiate high-dose statin therapy (atorvastatin 80 mg daily) for all patients with post-infarction angina 2, 3
• Beta-blockers are mandatory, particularly in patients with prior MI or heart failure 2, 5
• Do not abruptly discontinue beta-blockers in patients with coronary artery disease, as this can precipitate severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 5
• When discontinuing beta-blockers, taper gradually over 1-2 weeks with careful monitoring 5
• ACE inhibitors are indicated for patients with hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes 2
• Calcium channel blockers (such as amlodipine 5-10 mg daily) can be added for additional anti-ischemic effect, particularly in patients with ongoing symptoms despite beta-blocker therapy 6

Invasive Strategy Decision-Making

For patients with recurrent symptoms, hemodynamic instability, or high-risk features:

• Proceed urgently to coronary angiography within 24-48 hours 1
• Consider intra-aortic balloon pump placement for patients unresponsive to medical therapy 7
• Revascularization (PCI or CABG) should be performed based on coronary anatomy and clinical status 7

For patients managed medically after angiography showing obstructive CAD:

• Continue aspirin indefinitely 1
• Load with clopidogrel if not previously given 1
• Discontinue GP IIb/IIIa inhibitors if started previously 1
• Continue anticoagulation as outlined above 1

For patients with non-obstructive CAD on angiography:

• Antiplatelet and anticoagulant therapy should be administered at clinician discretion 1
• If coronary atherosclerosis is present (luminal irregularities), prescribe long-term aspirin and secondary prevention measures 1, 2

Secondary Prevention Measures

• Smoking cessation counseling and support 2
• Blood pressure control with target <130/80 mmHg 2
• Diabetes management with target HbA1c <7% 2
• Regular physical activity (30 minutes most days) 2
• Weight management with target BMI 18.5-24.9 kg/m² 2

Critical Pitfalls to Avoid

• Avoid NSAIDs (except aspirin) as they increase cardiovascular event risk 2
• Never use fibrinolytic therapy in post-infarction angina without ST-segment elevation 1
• If CABG is planned, discontinue clopidogrel 5-7 days before elective surgery to reduce bleeding risk 1, 2
• Do not discontinue GP IIb/IIIa inhibitors (eptifibatide or tirofiban) until 4 hours before CABG 1
• Beta-blockers may mask tachycardia in hypoglycemia and hyperthyroidism; monitor accordingly 5
• In patients with bronchospastic disease, use the lowest possible beta-blocker dose and ensure bronchodilators are readily available 5

Ongoing Monitoring

• Regular assessment of angina symptoms to detect recurrence or progression 2
• Periodic evaluation of risk factors and medication adherence 2
• Consider repeat stress testing at 1-2 year intervals in high-risk patients or with changing symptoms 2
• Promptly reassess management strategy if symptoms worsen or become unstable 2