What medications should be started immediately for a patient with a history of myocardial infarction (heart attack), possibly with comorbidities such as diabetes or hypertension?

Immediate Medications for Post-Myocardial Infarction

All patients with a history of myocardial infarction should immediately be started on four core medication classes: dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor), high-intensity statin therapy, a beta-blocker, and an ACE inhibitor or ARB, with additional agents added based on specific clinical features such as left ventricular dysfunction, diabetes, or heart failure. 1

Core Medication Regimen

Antiplatelet Therapy

• Start aspirin 75-100 mg daily immediately and continue indefinitely 1
• Add clopidogrel 75 mg daily (or ticagrelor 90 mg twice daily for higher-risk patients) for 12 months following acute coronary syndrome or percutaneous coronary intervention 1
• For patients with stent placement, use higher-dose aspirin (325 mg daily) for 1 month with bare metal stent, 3 months with sirolimus-eluting stent, or 6 months with paclitaxel-eluting stent, then reduce to 75-100 mg 1
• Add a proton pump inhibitor when using dual antiplatelet therapy in patients at high risk of gastrointestinal bleeding 1, 2, 3

High-Intensity Statin Therapy

• Start atorvastatin 80 mg daily or rosuvastatin 40 mg daily as early as possible and continue indefinitely 1
• Target LDL-C <55 mg/dL (<1.4 mmol/L) or at least 50% reduction from baseline 1
• If LDL-C remains above target after 4-6 weeks on high-intensity statin, immediately add ezetimibe 10 mg daily 1
• If target still not achieved after another 4-6 weeks, add a PCSK9 inhibitor (alirocumab, evolocumab, or inclisiran) 1
• In patients with diabetes or metabolic syndrome, consider starting with pitavastatin plus ezetimibe or lower-dose high-intensity statin (rosuvastatin 20 mg or atorvastatin 40 mg) plus ezetimibe to reduce new-onset diabetes risk 1

Beta-Blocker Therapy

• Start beta-blocker therapy immediately in all patients with MI, particularly those with left ventricular ejection fraction <40% or heart failure, and continue indefinitely 1, 2, 3
• Use carvedilol, metoprolol succinate, or bisoprolol as these have proven mortality benefit 2, 3
• For early treatment during acute MI, administer metoprolol tartrate 5 mg IV every 2 minutes for three doses (total 15 mg), then start oral metoprolol 50 mg every 6 hours for 48 hours, followed by 100 mg twice daily 4
• Avoid intravenous beta-blockers in patients with hypotension, acute heart failure, AV block, or severe bradycardia 1
• Start at low doses and titrate upward over several weeks, reassessing symptoms, blood pressure, heart rate, renal function, and potassium 1-2 weeks after initiation and after dose adjustments 2, 3

ACE Inhibitor or ARB Therapy

• Start ACE inhibitor within the first 24 hours of MI in all patients, particularly those with heart failure, left ventricular ejection fraction <40%, diabetes, or anterior infarct 1
• For acute MI, start lisinopril 5 mg within 24 hours, then 5 mg after 24 hours, then 10 mg daily (use 2.5 mg if systolic blood pressure <120 mmHg) 5
• Continue ACE inhibitor indefinitely in patients with LVEF ≤40%, hypertension, diabetes, or chronic kidney disease 1
• Use angiotensin receptor blocker (preferably valsartan) in patients intolerant of ACE inhibitors who have heart failure or LVEF ≤40% 1

Additional Medications Based on Specific Features

For Patients with LVEF <40% and Heart Failure or Diabetes

• Add mineralocorticoid receptor antagonist (spironolactone or eplerenone) in patients already receiving ACE inhibitor and beta-blocker, provided there is no significant renal dysfunction (creatinine <2.5 mg/dL in men, <2.0 mg/dL in women) or hyperkalemia 1, 2, 3

For Patients with Atrial Fibrillation

• Manage warfarin to INR 2.0-3.0 for paroxysmal or chronic atrial fibrillation 1
• Use of warfarin with aspirin and/or clopidogrel increases bleeding risk and requires close monitoring 1

Critical Non-Pharmacologic Interventions

Mandatory Lifestyle Modifications

• Enroll patient in cardiac rehabilitation program immediately 1, 2, 3
• Provide repeated smoking cessation counseling with follow-up support and pharmacotherapy (nicotine replacement, varenicline, or bupropion) 1, 2, 3
• Implement dietary modifications (healthy diet) and regular physical activity 1

Vaccination

• Administer annual influenza vaccination 1

Monitoring and Follow-Up Strategy

Short-Term Monitoring

• Reassess LDL-C at 4-6 weeks after starting statin therapy and escalate treatment if target not achieved 1
• Monitor blood pressure, heart rate, renal function, and potassium 1-2 weeks after initiating ACE inhibitor or beta-blocker 2, 3

Long-Term Monitoring

• Perform routine echocardiography during hospital stay to assess LV and RV function, detect mechanical complications, and exclude LV thrombus 1
• Repeat echocardiography in 3-6 months to assess response to optimized medical therapy and ventricular remodeling 2, 3
• If LVEF remains <35% after 3 months of optimal medical therapy, evaluate for implantable cardioverter-defibrillator for primary prevention of sudden cardiac death 2, 3

Common Pitfalls to Avoid

• Do not delay statin intensification—start high-intensity statin immediately rather than gradually titrating upward, as this reduces LDL-C variability which is associated with increased recurrent cardiovascular events 1
• Do not withhold beta-blockers in stable patients—the mortality benefit is well-established, but avoid in acute decompensated heart failure or hemodynamic instability 1
• Do not stop ACE inhibitor due to mild creatinine elevation—increases up to 30% above baseline are acceptable and do not require discontinuation 6
• Do not use lower statin doses in patients with diabetes—the cardiovascular benefit far outweighs any small increase in diabetes risk, and newer approaches with pitavastatin or lower-dose high-intensity statin plus ezetimibe can mitigate this concern 1