What is the recommended management for outpatient post-myocardial infarction (MI) care?

Outpatient Post-MI Management

All post-MI patients should receive indefinite aspirin (75-100 mg daily), dual antiplatelet therapy for 12 months, high-intensity statin therapy targeting LDL-C <1.8 mmol/L (70 mg/dL), ACE inhibitors (especially if LVEF <40%, heart failure, diabetes, or anterior MI), and beta-blockers (if LVEF <40% or heart failure), along with enrollment in cardiac rehabilitation. 1

Antiplatelet Therapy

Aspirin

• Initiate aspirin 75-100 mg daily and continue indefinitely in all post-MI patients unless contraindicated. 1
• After stent implantation, higher doses (162-325 mg) may be used initially: 1 month for bare metal stents, 3 months for sirolimus-eluting stents, and 6 months for paclitaxel-eluting stents, then reduce to 75-162 mg daily. 1

Dual Antiplatelet Therapy (DAPT)

• Continue DAPT with aspirin plus a P2Y12 inhibitor for 12 months after PCI unless excessive bleeding risk exists. 1
• Ticagrelor or prasugrel are preferred over clopidogrel due to superior efficacy in reducing ischemic events. 1
• For patients not undergoing PCI or receiving only medical therapy, clopidogrel 75 mg daily should continue for at least 14 days, though 12 months is reasonable. 1
• In patients at high bleeding risk, consider shortening DAPT duration to 6 months or using clopidogrel instead of more potent P2Y12 inhibitors. 2

Special Considerations

• If warfarin is required (atrial fibrillation, LV thrombus), target INR 2.0-2.5 with low-dose aspirin (75-81 mg) and clopidogrel 75 mg, recognizing increased bleeding risk. 1
• Add a proton pump inhibitor (PPI) to DAPT in patients at high gastrointestinal bleeding risk (history of GI bleeding, peptic ulcer disease, advanced age, concurrent anticoagulation). 1, 2

Lipid Management

• Start high-intensity statin therapy as early as possible and maintain long-term. 1
• Target LDL-C <1.8 mmol/L (70 mg/dL) or at least 50% reduction if baseline LDL-C is 1.8-3.5 mmol/L (70-135 mg/dL). 1
• If goals not achieved with maximum tolerated statin dose, add ezetimibe. 1
• For very high-risk patients not at goal despite statin plus ezetimibe, add a PCSK9 inhibitor. 1

Renin-Angiotensin-Aldosterone System Blockade

ACE Inhibitors

• Start ACE inhibitors within 24 hours in patients with heart failure, LVEF <40%, diabetes, or anterior MI, and continue indefinitely. 1
• ACE inhibitors should be initiated in all patients with LVEF ≤40% and those with hypertension, diabetes, or chronic kidney disease unless contraindicated. 1
• If ACE inhibitors are not tolerated, substitute an ARB (preferably valsartan). 1

Mineralocorticoid Receptor Antagonists (MRAs)

• Add an MRA in patients with LVEF <40% and heart failure or diabetes who are already on ACE inhibitor and beta-blocker, provided no renal failure or hyperkalemia exists. 1
• This reduces cardiovascular hospitalization and death. 1

Beta-Blockers

• Initiate oral beta-blockers in all patients with heart failure and/or LVEF <40% once hemodynamically stable, unless contraindicated. 1
• Beta-blockers reduce death, recurrent MI, and heart failure hospitalization. 1
• Avoid intravenous beta-blockers in patients with hypotension, acute heart failure, AV block, or severe bradycardia. 1

Antianginal Therapy

• Continue antianginal medications (nitrates, beta-blockers, calcium channel blockers) used during hospitalization if needed for symptom control. 1
• Provide sublingual or spray nitroglycerin and instruct patients on proper use. 1
• If anginal symptoms last >2-3 minutes despite rest, take one nitroglycerin dose; if pain persists or worsens after 5 minutes, call 9-1-1 immediately. 1

Cardiac Rehabilitation and Lifestyle Modification

• Enroll all patients in a cardiac rehabilitation program to improve outcomes, enhance medication adherence, and provide education. 1
• Identify all smokers and provide repeated cessation advice with pharmacotherapy (nicotine replacement, varenicline, or bupropion) and follow-up support. 1
• Encourage light-to-moderate physical activity after discharge; extended sick leave is not beneficial. 1
• Target blood pressure <140 mmHg systolic through lifestyle changes and pharmacotherapy. 1

Blood Pressure Control

• In addition to ACE inhibitors/ARBs and beta-blockers, optimize blood pressure control with lifestyle modifications (reduced salt intake, increased physical activity, weight loss). 1
• Target systolic blood pressure <140 mmHg; in very high-risk patients tolerating multiple agents, consider <120 mmHg. 1

Monitoring and Follow-Up

• Perform routine echocardiography during hospital stay to assess LV and RV function, detect mechanical complications, and exclude LV thrombus. 1
• Schedule early outpatient follow-up to enhance medication adherence, which is critical for outcomes. 1
• Provide clear written and verbal instructions about medications (type, purpose, dose, frequency, side effects) before discharge. 1
• Instruct patients to contact their physician immediately if anginal symptoms change in pattern or severity (more frequent, severe, or occurring at rest). 1

Device Therapy Considerations

• Implantable cardioverter-defibrillator (ICD) is indicated in patients with symptomatic heart failure (NYHA class II-III) and LVEF <35% despite optimal medical therapy for >3 months and at least 6 weeks post-MI. 1
• Cardiac resynchronization therapy (CRT) is recommended for symptomatic heart failure patients in sinus rhythm with QRS ≥150 ms and LBBB morphology with LVEF <35% despite optimal medical therapy. 1

Common Pitfalls to Avoid

• Do not discontinue antiplatelet therapy prematurely, particularly in the first few weeks after ACS, as this increases risk of subsequent cardiovascular events. 1
• Do not use prasugrel in patients ≥75 years (except high-risk situations like diabetes or prior MI), <60 kg body weight (consider 5 mg dose), or with history of stroke/TIA. 3
• Ensure adherence monitoring, as medication adherence averages only 57% at 2 years post-MI. 1
• Consider fixed-dose combination pills (polypill) to improve adherence in appropriate patients. 1