For an elderly female patient who recently had a STEMI with multivessel PCI, transient atrial fibrillation now in sinus rhythm, heart‑failure with reduced ejection fraction (LVEF 35‑40 %), chronic kidney disease, and is currently on metoprolol succinate, sacubitril/valsartan (Entresto), spironolactone, dapagliflozin (Farxiga), apixaban (Eliquis) 2.5 mg twice daily, high‑intensity atorvastatin, and ticagrelor (Brilinta) after aspirin discontinuation, and who has discontinued the LifeVest because of fatigue, is this medication and device management plan appropriate?

Medication and Device Management Plan Assessment

The overall plan is reasonable with several important modifications needed: the reduced-dose Eliquis 2.5 mg twice daily is inappropriate for this patient, atorvastatin 80 mg must be restarted immediately, and the aggressive GDMT uptitration with Entresto and high-dose metoprolol is appropriate, though the patient's declining LifeVest is acceptable given her age and preferences.

Critical Medication Issues Requiring Immediate Correction

Anticoagulation Dosing Error

• The reduction of Eliquis to 2.5 mg twice daily is inappropriate and potentially dangerous. 1
• Apixaban 2.5 mg twice daily is only indicated when patients meet at least 2 of 3 criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1
• While the patient has elevated creatinine and reduced GFR, age alone (described as "elderly" but not specified as ≥80) and weight concerns do not automatically justify dose reduction without meeting the specific FDA criteria.
• The standard dose of 5 mg twice daily should be maintained unless she clearly meets 2 of the 3 dose-reduction criteria. 1
• The switch from Xarelto to Eliquis is reasonable, as NOACs have rapidly replaced warfarin in elderly patients with AF post-PCI. 1

Statin Therapy - Critical Gap

• Restarting atorvastatin 80 mg daily is absolutely essential and should not have been discontinued. 2
• High-intensity statin therapy must be started as early as possible and maintained long-term in all post-MI patients. 2
• The LDL-C goal is <1.8 mmol/L (70 mg/dL) or at least 50% reduction from baseline. 2
• With current LDL of 66 mg/dL, the patient is close to but not at the target of <55 mg/dL, making high-intensity statin continuation mandatory. 2
• CoQ10 supplementation for myalgia prevention is a reasonable adjunct but should not delay statin initiation. 3

Guideline-Directed Medical Therapy for HFrEF - Appropriate Escalation

Beta-Blocker Uptitration

• Increasing metoprolol succinate to 200 mg daily is appropriate and guideline-concordant. 2
• Beta-blocker therapy is recommended in patients with LVEF <40% and/or heart failure after stabilization to reduce risk of death, recurrent MI, and hospitalization. 2
• Oral treatment with beta-blockers is indicated in patients with heart failure and/or LVEF <40% unless contraindicated. 2
• Metoprolol succinate is one of the three beta-blockers with proven mortality benefit (along with carvedilol and bisoprolol). 3, 4

ARNI Therapy (Entresto)

• Discontinuing losartan and starting Entresto 24/26 mg twice daily represents optimal contemporary HFrEF management. 5
• Sacubitril/valsartan is indicated for adults with chronic heart failure to reduce risk of death and hospitalization, particularly when the heart cannot pump a normal amount of blood. 5
• The starting dose of 24/26 mg twice daily is appropriate, with planned uptitration. 5
• ACE inhibitors or ARBs are recommended as soon as hemodynamically stable for all patients with LVEF <40% and/or heart failure. 2

Mineralocorticoid Receptor Antagonist

• Continuing spironolactone 12.5 mg daily is appropriate and guideline-recommended. 2
• MRAs are recommended in patients with ejection fraction <40% and heart failure or diabetes who are already receiving an ACE inhibitor/ARB and beta-blocker, provided there is no severe renal failure or hyperkalemia. 2
• Close monitoring of renal function and potassium is essential, particularly with the patient's elevated creatinine and reduced GFR. 4

SGLT2 Inhibitor Management

• Restarting dapagliflozin 10 mg daily is appropriate despite the patient's fatigue concerns. 3, 4
• The temporary discontinuation to assess fatigue was reasonable, but SGLT2 inhibitors are a cornerstone of modern HFrEF therapy. 3, 4
• However, given the patient's worsening renal function (elevated creatinine, reduced GFR), careful monitoring is required as SGLT2 inhibitors can affect renal function. 3
• If fatigue persists after restarting, consider whether it is truly medication-related versus disease-related chronic heart failure symptoms.

Antiplatelet Therapy - Appropriate Management

Dual Antiplatelet Therapy

• Continuing Brilinta (ticagrelor) as monotherapy after discontinuing aspirin at 30 days is guideline-concordant. 2, 3, 4
• DAPT with aspirin plus ticagrelor or prasugrel is recommended for 12 months after PCI unless there are contraindications such as excessive bleeding risk. 2
• Early aspirin discontinuation (at 30 days) with continuation of ticagrelor alone is increasingly supported to reduce bleeding risk while maintaining ischemic protection. 3, 4

Gastroprotection

• A proton pump inhibitor should be added given the combination of antiplatelet and anticoagulant therapy. 2, 3, 4
• PPI in combination with DAPT is recommended in patients at high risk of gastrointestinal bleeding. 2
• This patient is at particularly high risk given the combination of Brilinta and Eliquis. 3, 4

Anticoagulation for Atrial Fibrillation

Indication and Management

• Long-term anticoagulation is appropriate for this patient with documented new-onset AF during STEMI. 2
• In patients with documented de novo AF during the acute phase of STEMI, long-term oral anticoagulation should be considered depending on CHA₂DS₂-VASc score. 2
• This patient has multiple risk factors (heart failure, age, vascular disease) making her CHA₂DS₂-VASc score high. 6, 7, 8
• The combination of anticoagulation with antiplatelet therapy increases bleeding risk and requires close monitoring. 2, 1

Triple vs. Dual Therapy

• The current regimen of Eliquis plus Brilinta (dual antithrombotic therapy) is appropriate at this stage post-PCI. 1
• Triple therapy (OAC + aspirin + P2Y12 inhibitor) has significantly higher bleeding risk compared to dual therapy (OAC + P2Y12 inhibitor). 1
• After the initial 30 days when aspirin was discontinued, the patient is now on dual therapy, which is the preferred approach. 1

Wearable Cardioverter-Defibrillator (LifeVest) Decision

Patient Autonomy and Clinical Appropriateness

• The patient's decision to discontinue the LifeVest is reasonable given her age, comorbidities, and quality of life concerns. 2
• ICD therapy is recommended to reduce sudden cardiac death 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 after MI. 2
• The key phrase is "optimal medical therapy for >3 months" - this patient is still in the process of optimizing GDMT. 2
• Re-evaluation for ICD implantation should occur 6-12 weeks after revascularization once GDMT is optimized. 2
• The LifeVest serves as a bridge during this optimization period, but patient tolerance and quality of life are important considerations in elderly patients. 2

Follow-Up and Monitoring Strategy

Echocardiographic Reassessment

• Repeating echocardiography in 2 months to evaluate LV function is appropriate and guideline-concordant. 3, 4
• Routine echocardiography during hospital stay and follow-up to assess resting LV and RV function is recommended. 2
• The mild improvement from LVEF 30-35% to 35-40% is encouraging and suggests potential for further recovery with optimized GDMT. 3, 4
• If LVEF remains <35% after 3 months of optimal medical therapy, formal ICD evaluation is indicated. 2, 3, 4

Laboratory Monitoring

• Close monitoring of renal function, potassium, and electrolytes is essential given the quadruple neurohormonal blockade (Entresto, metoprolol, spironolactone, dapagliflozin). 4
• Reassess symptoms, blood pressure, heart rate, renal function, and potassium levels 1-2 weeks after initiating or adjusting medications. 4
• The patient's elevated creatinine and reduced GFR require particular attention with this medication regimen. 3

Common Pitfalls to Avoid

• Do not underdose anticoagulation based on age alone - use specific FDA criteria for dose reduction. 1
• Do not discontinue high-intensity statins in post-MI patients - this is a critical error that increases cardiovascular risk. 2
• Do not delay GDMT optimization - each component (beta-blocker, ARNI, MRA, SGLT2i) has independent mortality benefit. 2, 3, 4
• Do not forget gastroprotection - the combination of antiplatelet and anticoagulant therapy significantly increases GI bleeding risk. 2, 3
• Do not rush to ICD implantation - allow adequate time (3-6 months) for LVEF recovery with optimal medical therapy. 2