Initial Antihypertensive Treatment for Post-MI Patient
Start a beta-blocker (preferably carvedilol) combined with an ACE inhibitor immediately for this 58-year-old woman with prior myocardial infarction and stage 2 hypertension (160/100 mmHg).
Primary Recommendation: Beta-Blocker Plus ACE Inhibitor
This patient requires dual therapy from the outset given her blood pressure is ≥160/100 mmHg and she has established coronary artery disease from prior MI 1.
Beta-Blocker Selection and Dosing
Carvedilol is the preferred beta-blocker for this patient over metoprolol, as it provides superior mortality reduction (17% greater than metoprolol) in post-MI patients and offers better blood pressure control through combined alpha-1 and beta-blockade 2.
Start carvedilol at 3.125 mg twice daily, then titrate every 2 weeks to a target dose of 25 mg twice daily as tolerated 1, 2.
Oral beta-blockers should be started promptly in hemodynamically stable post-MI patients, even without prior intravenous administration 1.
Beta-blockers are Class I, Level of Evidence A recommendation for all post-MI patients without contraindications 1.
ACE Inhibitor Selection and Dosing
Lisinopril is an appropriate first-line ACE inhibitor, starting at 5-10 mg once daily and titrating to a target of 20-40 mg daily 3.
ACE inhibitors are Class I, Level of Evidence A recommendation for post-MI patients with hypertension, particularly with anterior MI, LV dysfunction, heart failure, or diabetes 1.
ACE inhibitors should be administered early in post-MI patients with persistent hypertension 1.
Multiple trials (SAVE, AIRE, TRACE, HOPE) demonstrated significant mortality reduction with ACE inhibitors in post-MI patients 1.
Target Blood Pressure
Aim for blood pressure <130/80 mmHg 1.
However, avoid lowering diastolic blood pressure below 60 mmHg, as this may worsen myocardial ischemia, particularly in older patients with wide pulse pressures 1.
Lower blood pressure gradually rather than precipitously in the post-MI setting 1.
Monitoring Protocol
Initial Phase (First 2-4 Weeks)
Check blood pressure, heart rate, and symptoms within 1-2 weeks of starting therapy 2.
Monitor serum potassium and creatinine within 1-2 weeks when combining beta-blocker with ACE inhibitor 2.
Target resting heart rate of 55-60 beats per minute 2.
Ensure systolic blood pressure remains >90 mmHg during titration 2.
Contraindications to Monitor
Do not use beta-blockers if patient has decompensated heart failure, cardiogenic shock, heart block, or severe bradycardia at presentation 1.
Avoid ACE inhibitors if serum creatinine >2.5 mg/dL (men) or >2.0 mg/dL (women), or potassium >5.0 mEq/L 1.
Additional Mandatory Therapies
Beyond blood pressure control, this post-MI patient requires:
Aspirin 75-100 mg daily indefinitely (Class I, Level A) 1.
High-intensity statin regardless of cholesterol level, targeting LDL <100 mg/dL (ideally <80 mg/dL) (Class I, Level A) 1.
Clopidogrel 75 mg daily for 12 months if she had stent placement 1.
When to Add Third Agent
If blood pressure remains ≥130/80 mmHg after 4-6 weeks on maximally tolerated doses of beta-blocker plus ACE inhibitor:
Add a thiazide-type diuretic (chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 25 mg daily) as third-line agent 1.
Alternatively, add a long-acting dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily) if diuretic is contraindicated or not tolerated 1.
Critical Pitfalls to Avoid
Never use short-acting nifedipine in post-MI patients, as it increases mortality 1.
Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) if there is any LV dysfunction or heart failure 1.
Do not combine ACE inhibitor with ARB, as this increases adverse events without improving survival 1.
Do not delay beta-blocker therapy waiting for "optimal" blood pressure control—the mortality benefit of beta-blockers in post-MI patients is independent of blood pressure effects 1, 2.