What is the optimal management plan for a patient following a ST-Elevation Myocardial Infarction (STEMI)?

Post-STEMI Care Management

All patients surviving STEMI must receive comprehensive secondary prevention therapy including indefinite dual antiplatelet therapy, high-intensity statin therapy, beta-blockers, ACE inhibitors (especially in high-risk patients), and aggressive risk factor modification to reduce mortality and recurrent cardiovascular events. 1, 2

Antiplatelet Therapy

Dual antiplatelet therapy (DAPT) is mandatory and must be continued indefinitely in all post-STEMI patients. 1, 2

• Aspirin 75-162 mg daily indefinitely - this is non-negotiable unless absolute contraindication exists 1, 2
• P2Y12 inhibitor added to aspirin immediately: 1, 2, 3
  • Prasugrel 10 mg daily (preferred if underwent PCI, avoid if age >75 or weight <60 kg) 2
  • Ticagrelor 90 mg twice daily (alternative to prasugrel) 2
  • Clopidogrel 75 mg daily (acceptable but less effective alternative; note that 2-4% of patients are CYP2C19 poor metabolizers with reduced efficacy) 2, 3
• If aspirin is contraindicated, use clopidogrel 75 mg daily OR warfarin (INR 2.5-3.5) 1

Lipid Management

Start high-intensity statin therapy immediately at discharge regardless of baseline LDL-C level. 1, 2

• Target LDL-C substantially <100 mg/dL, ideally <70 mg/dL 1, 2
• All patients with LDL-C ≥100 mg/dL must receive statin therapy at discharge 1
• Even patients with LDL-C <100 mg/dL should receive statin therapy 1
• Obtain fasting lipid profile within 24 hours of admission 1

For elevated triglycerides (≥200 mg/dL): 1

• Primary goal becomes non-HDL-C substantially <130 mg/dL 1
• If TG 200-499 mg/dL: after LDL-lowering therapy, consider adding fibrate or niacin 1
• If TG ≥500 mg/dL: consider fibrate or niacin before LDL-lowering therapy; add omega-3 fatty acids 1

For low HDL-C (<40 mg/dL) with controlled LDL-C: 1

• Emphasize nonpharmacological therapy (exercise, weight loss, smoking cessation) 1
• Consider niacin or fibrate therapy if HDL-C remains <40 mg/dL despite lifestyle modifications 1

Beta-Blocker Therapy

Oral beta-blockers must be started within 24 hours and continued indefinitely in all patients without contraindications. 1, 2, 4

• Beta-blockers reduce mortality by 35% in post-MI patients with LV dysfunction 4
• This is a Class I, Level A recommendation - never discontinue beta-blockers to accommodate other medication needs 4
• Observe usual contraindications: cardiogenic shock, decompensated heart failure, heart block, severe bradycardia 1
• Do NOT use intravenous beta-blockers acutely - associated with increased mortality in certain subsets 2

ACE Inhibitor Therapy

ACE inhibitors should be initiated in all post-STEMI patients indefinitely, with early initiation (within 24 hours) in high-risk patients. 1, 2, 5

High-risk criteria requiring early ACE inhibitor initiation: 1, 2, 5

• Anterior MI (LAD territory infarction) 1, 2, 5
• Previous MI 1, 2
• Killip class ≥II 1, 2
• S3 gallop, rales, or radiographic heart failure 1, 2
• LVEF <40% 1, 2

Practical implementation algorithm for lisinopril: 5

1. Confirm systolic BP ≥100 mmHg 5
2. Check creatinine ≤2.5 mg/dL (men) or ≤2.0 mg/dL (women) 5
3. Verify potassium ≤5.0 mEq/L 5
4. Start lisinopril 5 mg orally within 24 hours 5
5. Target dose: 10 mg daily (this is the evidence-based dose from GISSI-3 trial) 5
6. Uptitrate as tolerated based on BP and renal function 5
7. Continue indefinitely 5

Hold ACE inhibitor if: 5

• Systolic BP drops below 100 mmHg or >30 mmHg below baseline 5
• Cardiogenic shock or frank cardiac failure with pulmonary congestion until hemodynamically stable 5

If ACE inhibitor intolerance develops: 1, 5

• Switch to ARB (valsartan 20 mg initially, target 160 mg twice daily, or candesartan) if patient has clinical/radiological heart failure or LVEF <40% 1, 5

Aldosterone Blockade

Add aldosterone antagonist in patients meeting ALL of the following criteria: 1

• Already receiving therapeutic doses of ACE inhibitor 1
• LVEF ≤40% 1
• Either diabetes OR heart failure 1
• WITHOUT significant renal dysfunction or hyperkalemia 1

Blood Pressure Management

Target BP <140/90 mmHg (or <130/80 mmHg if chronic kidney disease or diabetes). 1

If BP ≥120/80 mmHg: 1

• Initiate lifestyle modifications: weight control, physical activity, alcohol moderation, moderate sodium restriction, emphasis on fruits/vegetables/low-fat dairy 1

If BP ≥140/90 mmHg (or ≥130/80 mmHg with CKD/diabetes): 1

• Add blood pressure medications, emphasizing beta-blockers and RAAS inhibition 1

Dietary and Lifestyle Modifications

Dietary therapy must be started at discharge: 1

• <7% of total calories as saturated fat 1
• <200 mg/day cholesterol 1
• Increase omega-3 fatty acids, fruits, vegetables, soluble fiber, whole grains 1
• Balance calorie intake with energy output to achieve healthy weight 1

Weight management goals: 1

• Target BMI 18.5-24.9 kg/m² 1
• Waist circumference <40 inches (men) or <35 inches (women) 1
• If waist circumference exceeds these thresholds, initiate lifestyle changes and treatment strategies for metabolic syndrome 1

Physical activity prescription: 1

• Minimum goal: 30-60 minutes of activity 3-4 days per week 1
• Optimal: daily activity 1
• Assess risk with exercise test to guide prescription 1
• Cardiac rehabilitation programs are strongly recommended, particularly for patients with multiple modifiable risk factors or moderate-to-high-risk patients requiring supervised exercise 1, 2

Smoking cessation is mandatory: 1

• Assess tobacco use at every visit 1
• Provide counseling, pharmacological therapy (nicotine replacement, bupropion), and formal cessation programs 1
• Advise avoidance of secondhand smoke 1

Diabetes Management

Target HbA1c <7% in all diabetic patients. 1, 2

• Appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose 1
• Aggressive treatment of other cardiovascular risks (physical activity, weight management, BP, cholesterol) 1, 2

Patient and Family Education

Before discharge, all patients and families must receive comprehensive education: 1

• Recognition of acute cardiac symptoms and appropriate response: 1

  • Call 9-1-1 if symptoms are unimproved or worsening 5 minutes after onset 1
  • OR if symptoms are unimproved or worsening 5 minutes after 1 sublingual nitroglycerin dose 1

• Family members should be referred to CPR training programs and learn about AEDs, ideally with social support component targeting high-risk patient families 1

• Active involvement in planning for adherence to lifestyle changes and drug therapies 1

Critical Pitfalls to Avoid

• Never delay or discontinue beta-blockers - they provide Class I, Level A mortality benefit that outweighs other considerations 4
• Never give IV beta-blockers acutely - associated with increased mortality 2
• Never continue NSAIDs (except aspirin) - increases cardiovascular risk 2
• Never use streptokinase if given within previous 6 months 2
• Never start lisinopril at 2.5 mg - this is below the evidence-based dose that demonstrated mortality benefit 5
• Never use dietary-supplement niacin as substitute for prescription niacin 1

Post-Discharge Monitoring

Continuous cardiac monitoring for minimum 24 hours post-reperfusion. 2

Assess for complications: 2

• Arrhythmias 2
• Heart failure 2
• Mechanical complications 2

Follow-up visits every 3-6 months to assess: 4

• Medication adherence 4
• Symptom status 4
• Risk factor control 4
• Functional status 4