What is the recommended long‑term medication regimen for a patient after an acute ST‑elevation myocardial infarction (STEMI) with recent anginal pain?

Long-Term Medication Regimen After STEMI

Every patient discharged after STEMI should receive aspirin (75–100 mg daily), high-intensity statin therapy, an oral beta-blocker, and an ACE inhibitor (or ARB if intolerant), with dual antiplatelet therapy continued for 12 months. 1

Core Four-Drug Regimen (ABCDE Mnemonic)

The ACC/AHA guidelines emphasize the "ABCDE" approach: Aspirin/antianginals/ACE inhibitors, Beta-blockers/blood pressure, Cholesterol/cigarettes, Diet/diabetes, Education/exercise. 2 This framework structures the essential long-term medication strategy.

1. Antiplatelet Therapy

• Start aspirin 162–325 mg immediately on day 1, then continue 75–100 mg daily indefinitely. 1 Low-dose aspirin (75–100 mg) provides equivalent cardiovascular protection with fewer bleeding events than higher doses. 1

• Add a P2Y12 inhibitor (ticagrelor 90 mg twice daily, prasugrel 10 mg daily, or clopidogrel 75 mg daily) to aspirin for exactly 12 months after STEMI, regardless of whether the patient received medical management, fibrinolysis, or PCI. 2, 1

• After 12 months of dual antiplatelet therapy (DAPT), transition to aspirin monotherapy indefinitely. 1

• If true aspirin allergy exists, substitute clopidogrel 75 mg daily indefinitely. 1

2. Beta-Blocker Therapy

• Initiate oral beta-blocker therapy within the first 24 hours in hemodynamically stable patients and continue indefinitely (minimum 3 years). 2, 1 Patients without signs of heart failure, low output state, increased risk for cardiogenic shock, or contraindications (PR interval >0.24 seconds, second- or third-degree heart block, active asthma) should receive beta-blockers. 2

• Carvedilol dosing for post-MI patients: start 6.25 mg twice daily, increase after 3–10 days to 12.5 mg twice daily, then target 25 mg twice daily based on tolerability. 3 A lower starting dose of 3.125 mg twice daily may be used if clinically indicated due to low blood pressure, heart rate, or fluid retention. 3

• Beta-blockers are particularly beneficial in patients with heart failure or left ventricular ejection fraction (LVEF) <40%, providing a 20–25% reduction in mortality and recurrent infarction. 2, 1

3. ACE Inhibitor or ARB Therapy

• Initiate an ACE inhibitor within 24 hours for all post-STEMI patients, especially those with anterior MI, heart failure, LVEF ≤40%, diabetes, or hypertension, and continue indefinitely. 2, 1, 4

• Lisinopril dosing for post-MI: start 5 mg within 24 hours of symptom onset, give 5 mg after 24 hours, then 10 mg daily thereafter. 5 Patients with systolic blood pressure <120 mmHg at baseline should receive 2.5 mg initially. 5

• If ACE inhibitor intolerance occurs (e.g., cough, angioedema), substitute an ARB such as valsartan or candesartan. 2, 1

• Add an aldosterone antagonist when LVEF ≤40% with symptomatic heart failure or diabetes, provided serum creatinine is ≤2.5 mg/dL (men) or ≤2.0 mg/dL (women) and potassium is ≤5.0 mEq/L. 2, 1

4. High-Intensity Statin Therapy

• Start high-intensity statin therapy (atorvastatin 40–80 mg or rosuvastatin 20–40 mg daily) as early as possible during hospitalization and maintain indefinitely. 1, 4

• Target LDL-C <70 mg/dL (1.8 mmol/L) or achieve ≥50% reduction if baseline LDL-C is 70–135 mg/dL. 1, 4

Additional Considerations

Anticoagulation (When Indicated)

• Add warfarin (target INR 2.0–3.0) only for specific indications: atrial fibrillation, left ventricular thrombus, or extensive wall-motion abnormalities. 2, 1

• When warfarin is combined with DAPT (triple therapy), aim for INR 2.0–2.5 and use low-dose aspirin (75–81 mg) to reduce bleeding risk. 1

Gastrointestinal Protection

• Prescribe a proton-pump inhibitor with DAPT for patients at high risk of gastrointestinal bleeding. 1, 4

Cardiac Rehabilitation

• Enroll every post-STEMI patient in a structured cardiac rehabilitation program. 1, 4 Recommend ≥30 minutes of aerobic activity daily (or 3–4 sessions per week) plus increased overall physical activity. 1

Critical Pitfalls to Avoid

• Do not use high-dose aspirin (325 mg) for maintenance therapy; low-dose aspirin is sufficient and safer. 1

• Avoid NSAIDs (except aspirin) during and after hospitalization due to increased risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture. 2, 4

• Calcium-channel blockers (CCBs) have no mortality benefit for long-term secondary prevention after STEMI and should not be routinely prescribed. 1 They are not part of the core regimen. 2

• Do not administer beta-blockers or calcium-channel blockers acutely to STEMI patients with frank cardiac failure evidenced by pulmonary congestion or signs of low output state. 2

• Prasugrel is contraindicated in patients with prior stroke or transient ischemic attack. 1

Summary: The Correct Answer

The long-term regimen is: low-dose aspirin (75–100 mg daily) + high-intensity statin + beta-blocker + ACE inhibitor (or ARB). 1 Dual antiplatelet therapy (aspirin + P2Y12 inhibitor) continues for 12 months, then aspirin alone indefinitely. 1 Calcium-channel blockers are not part of guideline-directed long-term therapy after STEMI. 2, 1