What is the recommended outpatient follow‑up plan for a patient recently discharged after an acute myocardial infarction complicated by systolic heart failure with a reduced ejection fraction (<40%)?

Outpatient Follow-Up Management After MI with Systolic Heart Failure (EF <40%)

All patients discharged after acute MI complicated by systolic heart failure with reduced ejection fraction require four foundational medication classes (ACE inhibitor or ARB, evidence-based β-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor), structured early follow-up within 7-14 days, enrollment in cardiac rehabilitation, and systematic medication titration over the first 4-6 weeks. 1

Immediate Post-Discharge Medication Regimen

Core Pharmacologic Therapy (All Four Required)

• ACE inhibitor therapy must be continued indefinitely at target doses (enalapril 10 mg BID, ramipril 10 mg daily, or lisinopril 10 mg daily), with titration over 4-6 weeks to trial-based doses 2, 1

• Evidence-based β-blockers only (carvedilol, metoprolol succinate, or bisoprolol—not metoprolol tartrate) should be continued at doses targeting resting heart rate 55-60 bpm, with uptitration every 2 weeks as tolerated 2, 1, 3

• Mineralocorticoid receptor antagonist (spironolactone or eplerenone) is mandatory for all patients with EF <40% who have diabetes or heart failure symptoms and are already receiving ACE inhibitor and β-blocker 2, 1

• SGLT2 inhibitor (dapagliflozin or empagliflozin) should be initiated regardless of diabetes status, as this is now foundational therapy that reduces mortality and hospitalization 1

Additional Essential Medications

• High-intensity statin therapy must be continued indefinitely with target LDL-C <70 mg/dL (1.8 mmol/L) 2

• Dual antiplatelet therapy (aspirin 75-100 mg plus P2Y12 inhibitor) should continue for 12 months post-PCI, then transition to aspirin alone 1

• Sublingual or spray nitroglycerin should be prescribed with specific instructions: if chest pain persists >5 minutes after one dose, call 9-1-1 immediately 2

Structured Follow-Up Schedule

First Outpatient Visit (7-14 Days Post-Discharge)

• Schedule with cardiologist or heart failure specialist within 7-14 days of discharge, as early follow-up reduces rehospitalization and mortality 2, 4

• Check renal function (creatinine/eGFR) and serum potassium 1-2 weeks after discharge or any medication dose adjustment; therapy is contraindicated if creatinine >2.5 mg/dL (men) or >2.0 mg/dL (women) or potassium >5.0 mEq/L 1

• Assess for medication side effects, particularly hypotension, bradycardia (target HR 55-60 bpm, contraindicated if <50 bpm), cough from ACE inhibitor, or hyperkalemia 1, 3, 5

• Begin β-blocker dose escalation every 2 weeks toward target doses used in mortality trials 1, 3

Weeks 2-6: Medication Titration Phase

• Weekly telephone follow-up for the first 4 weeks can reinforce education, monitor recovery progress, address concerns, and assess medication tolerance 2

• Uptitrate ACE inhibitor to target doses over 4-6 weeks with monitoring of blood pressure, renal function, and potassium at each increase 1

• Continue β-blocker titration every 2 weeks until target heart rate 55-60 bpm or maximum tolerated dose is achieved 1, 3

• Nearly half of patients receive no dose escalation in real-world practice—this represents a critical quality gap that must be actively addressed 4

Ongoing Long-Term Management

• Cardiac rehabilitation enrollment is mandatory and should occur before discharge or at first outpatient visit, as it enhances education, compliance, and outcomes 2, 1

• Continue all four foundational medications indefinitely; discontinuing ACE inhibitor or ARB even after EF recovery significantly increases risk of death, MI, or rehospitalization (HR 2.20) 6

• β-blockers should continue for minimum 3 years and preferably indefinitely in post-MI heart failure with reduced EF 1, 3

Critical Monitoring Parameters

Laboratory Surveillance

• Renal function and potassium must be checked 1-2 weeks after starting or increasing ACE inhibitor or mineralocorticoid receptor antagonist doses 1

• NT-proBNP levels should be monitored; elevation suggests inadequate therapy or worsening heart failure 2

Clinical Assessment at Each Visit

• Blood pressure target <130/80 mmHg while avoiding diastolic BP <60 mmHg in patients >60 years due to myocardial ischemia risk 3

• Resting heart rate should be 55-60 bpm on β-blocker therapy 1, 3

• Weight monitoring and assessment for volume overload (edema, orthopnea, paroxysmal nocturnal dyspnea) 7

Managing ACE Inhibitor Intolerance

• If persistent cough, angioedema, or allergic reaction develops, switch immediately to ARB (valsartan, candesartan, or losartan); ARBs are reserved exclusively for documented ACE inhibitor intolerance 2, 1

• After 36-hour washout from ACE inhibitor, consider switching to sacubitril/valsartan (ARNI) if patient remains symptomatic despite optimal guideline-directed medical therapy 1

• Do not routinely combine ACE inhibitor with ARB, as this increases hyperkalemia and renal insufficiency risk without clear mortality benefit 1

Patient and Family Education

Symptom Recognition and Emergency Response

• Anginal discomfort lasting >2-3 minutes should prompt cessation of activity; if pain persists after immediate rest, take one nitroglycerin dose sublingually 2

• If chest pain is unimproved or worsening 5 minutes after one nitroglycerin dose, call 9-1-1 immediately; additional nitroglycerin may be taken at 5-minute intervals (maximum 2 additional doses) while awaiting emergency services 2

• Contact physician immediately if anginal pattern changes—more frequent, more severe, precipitated by less effort, or occurring at rest 2

Medication Adherence Support

• Provide written instructions documenting medication type, purpose, dose, frequency, and pertinent side effects in culturally sensitive, easily understood language 2

• Face-to-face instruction before discharge should be reinforced with written materials and telephone follow-up 2

• Use the ABCDE mnemonic to guide comprehensive management: Aspirin/antianginals/ACE inhibitors; Beta-blockers/blood pressure; Cholesterol/cigarettes; Diet/diabetes; Education/exercise 2

Common Pitfalls to Avoid

• Using non-evidence-based β-blockers (e.g., metoprolol tartrate, atenolol) instead of carvedilol, metoprolol succinate, or bisoprolol eliminates proven mortality benefit 1, 3, 5

• Delaying mineralocorticoid receptor antagonist initiation beyond the first week reduces opportunity for early mortality benefit 1

• Omitting SGLT2 inhibitors overlooks foundational therapy that improves outcomes regardless of diabetes status 1

• Failing to uptitrate medications to target doses—46% of patients in real-world practice receive no dose escalation, losing therapeutic benefit 4

• Discontinuing ACE inhibitor or ARB after EF recovery significantly increases risk of adverse outcomes (HR 2.20 for death/MI/rehospitalization) 6

• Inadequate follow-up scheduling—only 59% of patients see primary care within 14 days and only 23% see cardiology, contributing to poor outcomes 4