What is the recommended medication regimen for a middle‑aged to older adult with grade 2 diastolic dysfunction (heart failure with preserved ejection fraction) and a prior inferior myocardial infarction, including disease‑modifying, symptom‑relieving, and secondary‑prevention drugs while monitoring for bradyarrhythmia?

Medication Regimen for HFpEF with Prior Inferior MI

For a patient with grade 2 diastolic dysfunction (HFpEF) and prior inferior myocardial infarction, initiate SGLT2 inhibitor (empagliflozin or dapagliflozin), beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), high-intensity statin (atorvastatin 80 mg), aspirin, and ACE inhibitor or ARB, with loop diuretics as needed for congestion, while monitoring heart rate and blood pressure for bradyarrhythmia risk. 1

Disease-Modifying Therapy for HFpEF

SGLT2 Inhibitors (First-Line)

• Empagliflozin is the strongest evidence-based therapy for HFpEF, reducing HF hospitalization by 29% and the composite endpoint of HF hospitalization or cardiovascular death by 21% in patients with LVEF >40%. 1
• Start empagliflozin 10 mg daily regardless of diabetes status, as benefit was similar with or without diabetes. 1
• The benefit was consistent across LVEF ranges, though slightly attenuated at LVEF >62.5%. 1
• Dapagliflozin and canagliflozin are also Class I recommendations for reducing HF hospitalization risk. 1

Mineralocorticoid Receptor Antagonists (Second-Line)

• Spironolactone reduces HF hospitalization (HR 0.83) in appropriately selected HFpEF patients, particularly those with LVEF at the lower end of the preserved spectrum (45-50%). 1
• Initiate only if: LVEF ≥45%, elevated BNP or HF admission within 1 year, eGFR >30 mL/min/1.73 m², creatinine <2.5 mg/dL, and potassium <5.0 mEq/L. 1
• Start spironolactone 12.5-25 mg daily with careful monitoring of potassium and renal function at 1 week, 1 month, then every 3 months. 1
• Hyperkalemia risk is substantial in older adults—check potassium within 3-7 days of initiation. 1, 2

ACE Inhibitors or ARBs (For Post-MI and Blood Pressure Control)

• ACE inhibitors are Class I for all post-MI patients, especially with anterior infarction, HF, or EF ≤0.40, and should be started within 24 hours. 1
• For inferior MI with preserved EF, ACE inhibitors still provide secondary prevention benefit and blood pressure control. 1
• Start lisinopril 2.5-5 mg daily, titrate to 10 mg or higher as tolerated, OR ramipril 2.5 mg twice daily, titrate to 5 mg twice daily. 1
• If ACE inhibitor intolerant (cough), substitute ARB: valsartan 20 mg twice daily, titrate to 160 mg twice daily. 1
• Monitor for hypotension, renal dysfunction, and hyperkalemia, particularly when combined with MRA. 1
• Candesartan specifically has Class IIb recommendation for improving NYHA functional class in HFpEF. 1

Beta-Blockers (Essential for Post-MI)

• Beta-blockers are mandatory for secondary prevention after MI, reducing death by 23% in long-term trials and preventing sudden cardiac death. 1
• Use one of three proven agents: carvedilol, metoprolol succinate (sustained-release), or bisoprolol—these lack intrinsic sympathomimetic activity. 1
• Start metoprolol succinate 12.5-25 mg daily or carvedilol 3.125 mg twice daily, titrate slowly to target doses (metoprolol succinate 200 mg daily, carvedilol 25 mg twice daily). 1
• Continue for minimum 3 years post-MI in uncomplicated cases; indefinitely if hypertension or LV dysfunction present. 1
• Critical monitoring for bradyarrhythmia: Check heart rate and rhythm at each titration, hold if HR <50 bpm or symptomatic bradycardia develops. 1
• Contraindications include heart failure decompensation, bradycardia, hypotension, high-grade AV block, or active bronchospasm. 1

Symptom-Relieving Therapy

Loop Diuretics (For Congestion)

• Diuretics are Class I for any signs or symptoms of fluid congestion in HFpEF, improving symptoms but not mortality. 1
• Start furosemide 20-40 mg daily or bumetanide 0.5-1 mg daily, titrate to lowest effective dose for euvolemia. 1
• Use cautiously in HFpEF—excessive diuresis causes hypotension and low cardiac output due to dependence on adequate preload. 3
• Monitor daily weights, orthostatic blood pressure, and electrolytes (potassium, magnesium) weekly during titration. 1

Blood Pressure Control

• Target systolic BP <130 mm Hg using GDMT medications (ACE inhibitor/ARB, beta-blocker, diuretic). 1
• Avoid nifedipine and other dihydropyridine calcium channel blockers in HFpEF—only amlodipine or felodipine have safety data if absolutely required. 4
• Nondihydropyridine calcium channel blockers (diltiazem, verapamil) may be used for rate control in atrial fibrillation but avoid combining with beta-blockers. 1

Secondary Prevention After MI

High-Intensity Statin Therapy

• Atorvastatin 80 mg daily is Class I for all post-MI patients ≤75 years, reducing major vascular events by 15% compared to moderate-intensity therapy. 1
• For patients >75 years, moderate-intensity statin (atorvastatin 40 mg or rosuvastatin 20 mg) is reasonable. 1
• Target LDL-C <55 mg/dL (<1.4 mmol/L) or ≥50% reduction from baseline in very high-risk patients with MI. 1
• Monitor for myopathy (muscle pain, CK elevation) and hepatotoxicity (transaminases) at baseline and periodically. 1

Antiplatelet Therapy

• Aspirin 81 mg daily indefinitely for secondary prevention after MI. 1
• Consider dual antiplatelet therapy (aspirin + P2Y12 inhibitor) for 12 months post-MI per standard ACS guidelines, then aspirin monotherapy. 1

Anticoagulation (If Atrial Fibrillation Present)

• If CHA₂DS₂-VASc score ≥2, initiate NOAC (preferred over warfarin) for stroke prevention. 1
• NOACs preferred: apixaban, rivaroxaban, edoxaban, or dabigatran. 1
• Monitor renal function every 6-12 months—dose-adjust or avoid if CrCl <30 mL/min (dabigatran) or <15 mL/min (other NOACs). 1

Monitoring for Bradyarrhythmia

High-Risk Scenario: Inferior MI + Beta-Blocker

• Inferior MI involves the right coronary artery, which supplies the AV node—increased risk of AV block, especially with beta-blockers. 1
• Obtain baseline ECG checking for: PR interval >200 ms, second-degree AV block, or third-degree AV block. 1
• If first-degree AV block (PR >200 ms) or Mobitz I present, start beta-blocker at lowest dose with weekly ECG monitoring during titration. 1
• If Mobitz II or third-degree AV block present, beta-blocker is contraindicated until pacemaker placed. 1

Ongoing Monitoring Protocol

• Check heart rate and rhythm at every visit during beta-blocker titration (every 1-2 weeks). 1
• Obtain ECG if patient reports dizziness, syncope, or presyncope. 1
• Hold beta-blocker if HR <50 bpm, symptomatic bradycardia, or new high-grade AV block develops. 1
• Consider 24-hour Holter monitor if intermittent symptoms suggest paroxysmal bradyarrhythmia. 1

Medications to Avoid

Contraindicated in HFpEF

• Avoid nifedipine and most dihydropyridine calcium channel blockers—negative inotropic effects worsen HF. 4
• Avoid combining nondihydropyridine calcium channel blockers (diltiazem, verapamil) with beta-blockers—excessive bradycardia and AV block risk. 1
• Avoid thiazolidinediones (pioglitazone, rosiglitazone)—increase HF hospitalization risk. 1
• Avoid saxagliptin—associated with increased HF hospitalization. 1
• Avoid aliskiren (direct renin inhibitor)—higher risk of hypotension, renal dysfunction, hyperkalemia, and stroke. 1

Use Amiodarone Only When Absolutely Necessary

• Amiodarone should not be first-line for atrial fibrillation in HFpEF—reserve for refractory cases with structural heart disease when rhythm control preferred. 5
• If amiodarone required, use lowest maintenance dose (200 mg daily) and monitor thyroid function, liver function, and pulmonary function every 6 months. 5
• Amiodarone has exceptionally long half-life (58 days)—toxicity persists months after discontinuation. 5
• In patients ≥75 years, amiodarone is a potentially inappropriate medication due to high toxicity risk. 1, 5

Special Considerations in Older Adults

Polypharmacy and Drug Interactions

• Older adults with HFpEF average 5-10 chronic medications—assess for drug-drug interactions at every visit. 2
• Amiodarone reduces warfarin clearance (reduce warfarin dose by 33-50%) and doubles digoxin levels (reduce digoxin dose by 50%). 5
• Statins: limit simvastatin to 20 mg daily with amiodarone due to myopathy risk. 5

Geriatric Syndromes

• Monitor for falls risk—beta-blockers, ACE inhibitors, and diuretics all increase orthostatic hypotension. 2
• Check standing and supine blood pressure at each visit. 1
• Assess for sarcopenia and malnutrition—SGLT2 inhibitors and GLP-1 RAs may cause weight loss. 2
• Cognitive impairment affects medication adherence—simplify regimen when possible. 2

Renal Function Monitoring

• Check eGFR and electrolytes at baseline, 1 week after starting ACE inhibitor/ARB or MRA, then every 3-6 months. 1
• Adjust doses if eGFR declines: hold MRA if eGFR <30 mL/min, reduce ACE inhibitor/ARB dose if eGFR 30-45 mL/min. 1
• SGLT2 inhibitors slow eGFR decline over time—modest initial eGFR drop (5-10%) is expected and acceptable. 1