In an adult who recently had anginal chest pain and was treated for a ST‑segment‑elevation myocardial infarction (STEMI), which long‑term medication regimen is recommended for secondary prevention?

Long-Term Medication Regimen After STEMI

C) Aspirin with High statin is the correct answer for long-term secondary prevention after STEMI.

Core Long-Term Medication Regimen

Every patient discharged after STEMI must receive low-dose aspirin (75–100 mg daily) indefinitely combined with high-intensity statin therapy targeting LDL-C < 70 mg/dL. 1 This combination forms the foundation of secondary prevention and should be initiated as early as possible during the index hospitalization and maintained long-term. 1

Why This Combination Is Essential

• Low-dose aspirin (75–100 mg daily after an initial loading dose of 162–325 mg) provides equivalent cardiovascular protection with fewer bleeding events compared to higher doses and must be continued indefinitely in all post-MI patients. 1

• High-intensity statin therapy (atorvastatin 40–80 mg or rosuvastatin 20–40 mg daily) should be started immediately and maintained indefinitely, targeting LDL-C < 70 mg/dL or achieving ≥ 50% reduction if baseline LDL-C is 70–135 mg/dL. 1

Additional Mandatory Long-Term Medications

While the question asks specifically about the regimen, it is critical to understand that beta-blockers and ACE inhibitors are also mandatory components of post-STEMI care:

Beta-Blocker Therapy

• Oral beta-blockers should be started within the first 24 hours in hemodynamically stable patients and continued indefinitely (minimum 3 years). 1
• Patients with heart failure or LVEF < 40% derive particular benefit, with a 20–25% reduction in mortality and recurrent infarction. 1

ACE-Inhibitor/ARB Therapy

• ACE-inhibitor therapy should be initiated within 24 hours for patients with anterior MI, heart failure, LVEF ≤ 40%, diabetes, or hypertension, and continued indefinitely. 1
• Even in the absence of these high-risk features, ACE-inhibitors are recommended for all post-MI patients. 1

Dual Antiplatelet Therapy Duration

• Dual antiplatelet therapy (aspirin + P2Y12 inhibitor such as ticagrelor or prasugrel) must be continued for exactly 12 months after MI, irrespective of whether the patient was managed medically, with fibrinolysis, or with PCI. 1
• After 12 months of DAPT, patients should transition to aspirin monotherapy indefinitely. 1

Why Other Options Are Incorrect

Option A (Low aspirin with statin)

While this includes the correct medications, the term "low statin" is problematic—high-intensity statin therapy is mandatory, not low-dose. 1

Option B (Beta blocker and aspirin)

This omits the critical high-intensity statin component, which is a Class I recommendation for all post-STEMI patients. 1

Option D (CCBs - Calcium Channel Blockers)

Calcium-channel blockers have no mortality benefit for long-term secondary prevention after STEMI and should not be routinely prescribed. 1 They are specifically contraindicated as a primary long-term therapy. 1

The ABCDE Mnemonic for Comprehensive Care

The ACC/AHA recommends the "ABCDE" approach for structuring long-term secondary prevention: 1

• Aspirin, anti-anginals, and ACE inhibitors
• Beta-blockers and Blood pressure control
• Cholesterol (statins) and Cigarettes (cessation)
• Diet and Diabetes management
• Education and Exercise (cardiac rehabilitation)

Critical Implementation Points

• Start high-intensity statin therapy as early as possible during the index hospitalization—do not wait for discharge. 1
• Aspirin should be given as a loading dose (162–325 mg) on day 1, then continued at low dose (75–100 mg) indefinitely. 1
• All post-STEMI patients should be enrolled in a structured cardiac rehabilitation program. 1
• Target blood pressure < 140/90 mmHg (or < 130/80 mmHg with diabetes or chronic kidney disease). 1