What is the standard of care for a patient with a cardiovascular disease (CVD) infarct, including any relevant past medical history or comorbid conditions such as diabetes, hypertension, or chronic kidney disease?

Standard of Care for Cardiovascular Disease Infarction

For patients presenting with cardiovascular infarction (NSTE-ACS or STEMI), immediate admission for continuous cardiac monitoring, dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor), anticoagulation, statin therapy, ACE inhibitor/ARB, and beta-blocker (if prior MI) constitute the standard of care, with early invasive strategy for high-risk patients. 1

Immediate Hospital Management

Admission and Monitoring

• Admit all patients with NSTE-ACS (including those with recurrent symptoms, ischemic ECG changes, or positive troponins) for inpatient management with continuous electrocardiographic rhythm monitoring 1
• Patients with continuing angina, hemodynamic instability, uncontrolled arrhythmias, or large MI require coronary care unit admission with 1:1 nursing ratio capable of rapid cardioversion/defibrillation 1
• Stabilized patients can be managed in intermediate care or telemetry units after 24 hours without recurrent ischemia, significant arrhythmias, pulmonary edema, or hemodynamic instability 1

Antiplatelet Therapy

• Initiate dual antiplatelet therapy immediately: aspirin 75-162 mg/day plus a P2Y12 inhibitor (clopidogrel 75 mg, prasugrel, or ticagrelor) 1
• Continue dual antiplatelet therapy for at least 1 year after acute coronary syndrome, with potential benefits beyond this period 1
• For patients with documented aspirin allergy, substitute clopidogrel 75 mg/day 1
• In patients with stable coronary/peripheral artery disease and low bleeding risk, consider aspirin plus low-dose rivaroxaban 2.5 mg twice daily to prevent major adverse cardiovascular and limb events 1

Anticoagulation and Additional Acute Therapies

• Initiate anticoagulant therapy during acute hospitalization 1
• Provide anti-anginal therapy as needed for symptom relief 1
• Assess left ventricular function early, as depressed LVEF influences pharmacological choices (ACE inhibitors indicated) and revascularization strategy (PCI vs CABG) 1

Long-Term Medical Management

Statin Therapy

• All patients with known CVD require high-intensity statin therapy targeting LDL <70 mg/dL 1, 2
• Statin therapy reduces cardiovascular events and should be continued unless contraindicated 1
• Do not discontinue statins due to concerns about cognitive dysfunction—evidence does not support this association 1

ACE Inhibitor or ARB Therapy

• ACE inhibitor or ARB therapy is mandatory in patients with established atherosclerotic CVD, particularly coronary artery disease 1
• These agents reduce cardiovascular events and are especially beneficial in patients with hypertension, diabetes, or chronic kidney disease 1
• In patients with heart failure and reduced ejection fraction, ACE inhibitors improve symptoms and reduce morbidity/mortality 1
• ARBs serve as alternatives for patients intolerant to ACE inhibitors 1

Beta-Blocker Therapy

• Beta-blockers must be continued for at least 3 years after myocardial infarction to reduce mortality 1
• In patients with heart failure and reduced ejection fraction, use beta-blockers with proven cardiovascular outcomes benefit unless contraindicated 1

Blood Pressure Control

• Target BP <130/80 mm Hg for all patients with CVD, diabetes, or chronic kidney disease 1, 3
• Avoid diastolic BP <70 mm Hg as this increases cardiovascular risk 3
• For stage 2 hypertension (≥160/100 mm Hg), initiate two antihypertensive agents from different classes 1

Special Considerations for Comorbidities

Diabetes Management

• In patients with type 2 diabetes and established ASCVD or kidney disease, add an SGLT2 inhibitor with proven cardiovascular outcomes benefit to reduce major adverse cardiovascular events 1
• In patients with type 2 diabetes and heart failure with reduced ejection fraction, SGLT2 inhibitors reduce worsening heart failure and cardiovascular death 1
• Metformin may be continued in stable heart failure if eGFR >30 mL/min/1.73 m², but avoid in unstable or hospitalized heart failure patients 1
• Consider finerenone for patients with type 2 diabetes and chronic kidney disease to reduce cardiovascular risk 1

Chronic Kidney Disease Management

• Estimate creatinine clearance and adjust doses of renally cleared drugs appropriately 1
• Use isosmolar contrast agents (preferred) during angiography to reduce contrast-induced nephropathy risk 1
• ACE inhibitors or ARBs are particularly beneficial in CKD patients with albuminuria 1
• Accept up to 30% creatinine increase within 4 weeks of ACE inhibitor initiation 3
• Monitor serum creatinine and potassium if on ACE inhibitors/ARBs 3

Heart Failure Management

• For symptomatic heart failure with reduced ejection fraction, combine beta-blocker, ACE inhibitor (or ARB/angiotensin receptor-neprilysin inhibitor), and mineralocorticoid receptor antagonist 1
• Diuretics are recommended for congestion relief 1
• Implantable cardioverter-defibrillator is indicated for LVEF <35% with symptomatic heart failure to reduce sudden death 1
• Cardiac resynchronization therapy is recommended for symptomatic patients with LVEF <35%, sinus rhythm, and QRS ≥150 ms with LBBB morphology 1

Revascularization Strategy

Early Invasive vs Ischemia-Guided Approach

• High-risk patients (recurrent ischemia, hemodynamic instability, high-risk features) should undergo early invasive coronary angiography with FFR when necessary 1
• Myocardial revascularization is indicated when angina persists despite optimal medical therapy 1
• Routine coronary angiography is not recommended solely for risk stratification in asymptomatic patients 1, 2

Critical Pitfalls to Avoid

• Never withhold statins, ACE inhibitors, or beta-blockers based on age alone—elderly patients benefit from guideline-directed medical therapy when appropriately selected 1
• Do not routinely screen asymptomatic patients for coronary artery disease, as intensive medical therapy provides outcomes similar to invasive revascularization 1
• Avoid thiazolidinediones and use metformin cautiously in patients with treated heart failure 1
• Do not use prasugrel in patients ≥75 years except in high-risk situations (diabetes or prior MI) where benefit may outweigh bleeding risk 4
• Recognize that patients with CKD have higher bleeding risk with antiplatelet therapy and require careful dose adjustments 1

Ongoing Risk Factor Management

• Comprehensive cardiovascular risk profiling and multidisciplinary management of hypertension, hyperlipidemia, diabetes, anemia, and obesity are essential 1
• Smoking cessation and lifestyle modifications (exercise, weight management) must be reinforced at every visit 1, 2
• Assess cardiovascular risk factors at least annually 1
• Periodic reassessment by cardiovascular healthcare professionals is necessary to monitor adherence, treatment targets, and development of new comorbidities 1