In a patient who recently experienced an acute STEMI, which long‑term secondary‑prevention regimen is recommended?

Long-Term Secondary Prevention After STEMI

All patients post-STEMI should be discharged on low-dose aspirin (75-100 mg daily), high-intensity statin therapy, beta-blocker, and ACE inhibitor (or ARB if intolerant), with dual antiplatelet therapy continued for 12 months. 1, 2

Core Medication Regimen

Antiplatelet Therapy

• Low-dose aspirin (75-100 mg daily) is the cornerstone and should be continued indefinitely in all patients without contraindications 1, 2
• Dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor such as ticagrelor, prasugrel, or clopidogrel) must be maintained for 12 months post-PCI 1
• After 12 months, aspirin monotherapy continues lifelong 1

High-Intensity Statin Therapy

• High-intensity statin therapy should be initiated as early as possible during hospitalization and maintained long-term 1, 2
• Target LDL-C <70 mg/dL (1.8 mmol/L) or achieve ≥50% reduction if baseline LDL-C is 70-135 mg/dL 1, 2
• The early initiation (during acute phase) provides pleiotropic benefits including endothelial protection, anti-inflammatory, and antithrombotic effects that reduce recurrent ischemic events within 4 months 3

Beta-Blocker Therapy

• Oral beta-blockers are indicated indefinitely in all patients, particularly those with heart failure and/or LVEF <40% 1, 2
• Should be initiated within 24 hours in hemodynamically stable patients 1
• Even low-risk patients without heart failure benefit from beta-blocker therapy, with guidelines recommending at least 3 years of treatment 1

ACE Inhibitor or ARB

• ACE inhibitors should be started within the first 24 hours in all patients with anterior MI, heart failure, LVEF ≤40%, or diabetes 1, 2
• ACE inhibitors are reasonable for all other STEMI patients without contraindications 1
• ARBs (particularly valsartan) are indicated for patients intolerant to ACE inhibitors 1
• An aldosterone antagonist should be added if LVEF ≤40% with symptomatic heart failure or diabetes, provided creatinine and potassium levels are acceptable 1

Why CCBs Are NOT Part of Standard Post-STEMI Therapy

Calcium channel blockers are not recommended as routine long-term therapy after STEMI and do not appear in guideline-directed medical therapy 1, 2. The evidence base strongly supports beta-blockers over CCBs for mortality reduction post-MI. Short-acting dihydropyridine CCBs are specifically contraindicated for hypertension management in this population 1.

Clinical Implementation

The combination of aspirin + high-intensity statin + beta-blocker + ACE inhibitor represents the four-drug foundation, with dual antiplatelet therapy (adding a P2Y12 inhibitor) for the first 12 months making it five medications 2, 4. This regimen has demonstrated significant mortality reduction, with combination therapy showing superior outcomes compared to incomplete regimens 5.

Common Pitfalls

• Failure to prescribe optimal therapy at discharge is rarely corrected during follow-up 6
• Women, elderly patients (>65 years), and those with multivessel disease are at highest risk for incomplete prescription 6
• Proton pump inhibitors should be co-prescribed with dual antiplatelet therapy in patients at high gastrointestinal bleeding risk 1

Additional Considerations

• Cardiac rehabilitation enrollment is recommended for all patients 1, 2
• Blood pressure should be controlled to <140/90 mmHg (or <130/80 mmHg with diabetes/chronic kidney disease) using the above medications 1, 2
• Warfarin (INR 2.0-3.0) is added only for specific indications such as atrial fibrillation or left ventricular thrombus 1, 2