Post Myocardial Infarction Medications

Aka: Post Myocardial Infarction Medications

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II. Medications: Beta Blocker

  1. Contraindications: Following ST Elevation MI
    1. Includes general contraindications (see below)
    2. Delayed management of STEMI
    3. Signs of Heart Failure, low output state or risk of Cardiogenic Shock
      1. Age over 70 years
      2. Heart Rate <60 or over 110
      3. Systolic Blood Pressure <120 mmHg
  2. Contraindications: General
    1. Overt Congestive Heart Failure
    2. Bradycardia (Heart Rate under 60)
    3. Acute Exacerbation of Asthma
    4. Second degree Heart Block or PR Interval > 0.24 seconds (relative contraindication)
  3. Preferred Beta Blockers after Myocardial Infarction
    1. Metoprolol
      1. Titrate over weeks to months to a maximum of 200 mg daily
    2. Carvedilol (if decreased ejection fraction)
      1. Titrate over weeks to months to a maximum of 50 mg daily
  4. Protocol (AHA)
    1. Start within 24 hours of Myocardial Infarction
      1. Aim for resting Heart Rate of 55-60
      2. If systolic Blood Pressure is low, decrease non-Beta Blockers first (e.g. Diuretics, nitrates, Calcium Channel Blockers)
    2. Preserved systolic function (ejection fraction)
      1. Continue Beta Blocker for at least 1 year (previously 3 years) following Myocardial Infarction
    3. Reduced systolic function LVEF <40 to 50%
      1. Titrate gradually (typically Carvedilol) and continue indefinately
  5. Efficacy
    1. May not improve short-term or longterm mortality in Myocardial Infarction with preserved systolic function
      1. Perez (2009) Cochrane Database Syst Rev (4): CD006743 [PubMed]
      2. Bangalore (2012) JAMA 308(13): 1340-9 [PubMed]
    2. Beta Blockers do not reduce overall mortality beyond first 30 days after Myocardial Infarction
      1. Bangalore (2014) Am J Med 127(10): 939-53 [PubMed]
    3. Primary benefit in Post-MI is for those with reduced ejection fraction (<50%)
      1. Continue for at least 1 year after Myocardial Infarction (previously recommended for 3 years)
      2. Post-MI with revascularization and preserved ejection fraction appears to benefit little from Beta Blockers
      3. Yndigegn (2024) N Engl J Med 390(15):1372-81 +PMID: 38587241 [PubMed]

III. Medications: ACE Inhibitor (or Angiotensin Receptor Blocker if unable to take ACE Inhibitor)

  1. Indications (Consider in all patients following Myocardial Infarction)
    1. Left Ventricular Ejection Fraction <40%
    2. Hypertension
    3. Diabetes Mellitus
    4. Chronic Kidney Disease
  2. Efficacy: Very significant benefit
    1. Lower overall mortality
    2. Lower Cardiovascular death
    3. Lower sudden death
    4. Lower sudden Congestive Heart Failure
  3. ACE Inhibitors (Preferred)
    1. Lisinopril (titrate to 20 mg daily)
    2. Ramipril (titrate to 10 mg daily)
    3. Trandolapril (titrate to 4 mg daily)
  4. Angiotensin Receptor Blockers (ARBs) if ACE Inhibitors are contraindicated (i.e. cough)
    1. Candesartan (titrate to 32 mg daily)
    2. Telmisartan (titrate to 80 mg daily)
    3. Valsartan (titrate to 320 mg daily)
  5. Protocol
    1. Started within first 48 hours following Myocardial Infarction
    2. Avoid using Angiotensin Receptor Blocker together in combination with ACE Inhibitor
      1. No added benefit and increased adverse effects
    3. Variable data on efficacy in first 24 hours
      1. Some early studies suggested may be detrimental if given in first 24 hours
      2. Recent studies suggest mortality benefit in first 24 hours
      3. Perez (2009) Cochrane Database Syst Rev (4): CD006743 [PubMed]
  6. References
    1. Kober (1995) N Engl J Med 333:1670-6 [PubMed]

IV. Medications: Statins (HMG-CoA Reductase Inhibitors)

  1. Efficacy
    1. Prescribe a Statin drug in patients discharged post-Myocardial Infarction
    2. Lowers risk of recurrent symptomatic ischemic event
    3. MIRACL study started Lipitor within 96 hours of ACS
    4. Schwartz (2001) JAMA 285:1711-8 [PubMed]
  2. Protocol
    1. Aim for 50-60% LDL Cholesterol reduction (and LDL <70 mg/dl)
    2. Consider high dose Statin (e.g. Atorvastatin 80 mg) in those with Myocardial Infarction while on lower dose Statin
      1. Higher dose Statins (e.g. Atorvastatin) reduce cardiovascular events over the subsequent 2 years after ACS/MI

V. Medications: Antiplatelet Therapy

  1. See Antiplatelet Therapy for Vascular Disease
  2. Aspirin
    1. Presentation: Aspirin 325 mg non-enteric coated (chewable)
    2. Acute hospitalization: Aspirin 160-325 mg daily
    3. Discharge: Aspirin 81-160 mg daily
  3. P2Y Inhibitor (e.g Clopidogrel)
    1. Used with Aspirin following ST Elevation MI or PCI
    2. Continue as dual therapy with Aspirin for at least 1 year

VI. Medications: Aldosterone Blocker (e.g. Eplerenone)

  1. Eplerenone indications (as second line adjunct to ACE Inhibitor AND Beta Blocker)
    1. Congestive Heart Failure with ejection fraction <40%
    2. Diabetes Mellitus
  2. Contraindications
    1. Serum Potassium >5.0 mEq/L
    2. Creatinine Clearance >30 ml/min
  3. Efficacy
    1. Decreased cardiovascular and all cause mortality when started early (3 days) following Myocardial Infarction
  4. References
    1. Pitt (2005) JAm Coll Cardiol 46(3): 425-31 [PubMed]

VII. Medications: Antianginals

  1. Nitroglycerin: Short Acting Nitrates (sublingual)
    1. All patients with Coronary Artery Disease should have Nitroglycerin on their person
  2. Nitroglycerin: Long Acting Nitrates
    1. No evidence that prolongs life

VIII. Medications: Specific indications

  1. Warfarin (Coumadin)
    1. Coumadin with Aspirin does not lower mortality rate
      1. Does lower recurrent MI and CVA risk
      2. Rothberg (2005) Ann Intern Med 143:241-50 [PubMed]
    2. Indications
      1. Thrombophlebitis
      2. Large antero-apical Myocardial Infarction
      3. Mural thrombus
      4. Left Ventricular Ejection Fraction under 25%
  2. Implantable Defibrillator Indications
    1. Ejection Fraction <30%

IX. Medications: Miscellaneous

  1. Magnesium oral supplementation
    1. Appears to improve Angina and Exercise tolerance
    2. Shechter (2003) Am J Cardiol 91:517-21 [PubMed]

X. Management: Comorbid Major Depression

  1. Major Depression significantly increases mortality
  2. Treat comorbid Major Depression aggressively
  3. See Myocardial Infarction Stabilization for prognosis
  4. References
    1. Bush (2001) Am J Cardiol 88:337-41 [PubMed]

XI. Precautions: NSAIDS are contraindicated (esp. post-STEMI)

  1. Acute
    1. NSAIDS are absolutely contraindicated in acute post-STEMI period
    2. Increased risk of mortality, reinfarction, Heart Failure and myocardial rupture post-STEMI
  2. Long-term
    1. Consider NSAIDs as a medication allergy in post-STEMI patients
    2. Choose non-NSAID agents first: Acetaminophen, Tramadol
    3. Consider non-acetylated Salicylates (Exercise caution due to Peptic Ulcer risk)
      1. Aspirin
      2. Salsalate
    4. If pain refractory to non-NSAID Analgesics
      1. Use non-cox2 selective agents (e.g. Naprosyn) sparingly

XII. References

  1. (2013) Presc Lett 20(10): 55-6
  2. Anderson (2007) J Am Coll Cardiol 50(7): e1-157 [PubMed]
  3. Antman (2008) Circulation 117(2): 296-329 [PubMed]
  4. Jneid (2012) J Am Coll Cardiol 60(7): 645-81 [PubMed]
  5. Mercado (2013) Am Fam Physician 88(9): 581-8 [PubMed]

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Related Studies

Ontology: Myocardial Infarction (C0027051)

Definition (MEDLINEPLUS)

Each year over a million people in the U.S. have a heart attack. About half of them die. Many people have permanent heart damage or die because they don't get help immediately. It's important to know the symptoms of a heart attack and call 9-1-1 if someone is having them. Those symptoms include

  • Chest discomfort - pressure, squeezing, or pain
  • Shortness of breath
  • Discomfort in the upper body - arms, shoulder, neck, back
  • Nausea, vomiting, dizziness, lightheadedness, sweating

These symptoms can sometimes be different in women.

What exactly is a heart attack? Most heart attacks happen when a clot in the coronary artery blocks the supply of blood and oxygen to the heart. Often this leads to an irregular heartbeat - called an arrhythmia - that causes a severe decrease in the pumping function of the heart. A blockage that is not treated within a few hours causes the affected heart muscle to die.

NIH: National Heart, Lung, and Blood Institute
Definition (NCI_FDA) Gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis.
Definition (NCI_CTCAE) A disorder characterized by gross necrosis of the myocardium; this is due to an interruption of blood supply to the area.
Definition (NCI) Gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis.
Definition (CSP) gross necrosis of the myocardium, as a result of interruption of the blood supply to the area.
Definition (MSH) NECROSIS of the MYOCARDIUM caused by an obstruction of the blood supply to the heart (CORONARY CIRCULATION).
Concepts Disease or Syndrome (T047)
MSH D009203
ICD10 I22 , I21
SnomedCT 66514008, 266288001, 155304006, 194796000, 233824008, 22298006
LNC LP98884-7, MTHU035551, LA14274-7, LA10558-7
English Myocardial Infarct, Infarctions, Myocardial, Myocardial Infarction, Myocardial Infarctions, Infarcts, Myocardial, Myocardial Infarcts, HEART ATTACK, Infarct, Myocardial, Infarction, Myocardial, MI, Myocardial infarction (MI), Attack heart (NOS), Infarct myocardial, cardiac infarction, Myocardial Infarction [Disease/Finding], attacking heart, heart attacks, attack hearts, infarctions myocardial, infarcts myocardial, myocardial infarctions, Infarction;heart, myocardial infarcts, Infarction;myocardial, AMI, attacks coronary, attacks hearts, coronary attack, disorder infarction myocardial, myocardial necrosis, syndrome myocardial infarction, heart attack, mies, Heart Attack, Attack - heart, Cardiac infarct, myocardial infarction, myocardial infarction (diagnosis), MI, MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, (MI), INFARCTION (MI), MYOCARDIAL, -- Heart Attack, Cardiovascular Stroke, Cardiovascular Strokes, Stroke, Cardiovascular, Strokes, Cardiovascular, Myocardial infarct, Myocardial infarction, Heart attack, MI - Myocardial infarction, Cardiac infarction, Infarction of heart, Myocardial infarction (disorder), cardiac; infarction, infarction; myocardial, Cardiac infarction, NOS, Heart attack, NOS, Infarction of heart, NOS, Myocardial infarction, NOS, Heart Attacks, Infarctions (Myocardial), Myocardial infarction NOS, Attack coronary, heart infarction
German MYOKARDINFARKT, Koronarattacke, Herzanfall, MI, Herzanfall (NNB), HERZANFALL, Herzinfarkt, Myokardinfarkt
Dutch hartaanval, hartinfarct, hartaanval (NAO), MI, cardiaal; infarct, infarct; myocard, myocardinfarct, Hartinfarct, Infarct, myocard-, Myocardinfarct
French Crise coronaire, IM, Crise cardiaque SAI, Crise cardiaque, CRISE CARDIAQUE, INFARCTUS DU MYOCARDE, IDM (Infarctus Du Myocarde), Infarctus du myocarde, Infarctus myocardique
Italian MI, Attacco cardiaco, Attacco coronarico, Attacco cardiaco (NAS), Infarto del miocardio, Infarto miocardico
Portuguese Ataque coronário, Ataque do coração, Ataque cardíaco NE, EM, ATAQUE CARDIACO, ENFARTO DO MIOCARDIO, Enfarte do miocárdio, Infarto do Miocárdio
Spanish IM, Crisis coronaria, Ataque al corazón, Ataque al corazón (NEOM), Infarto miocárdico, ATAQUE CARDIACO, INFARTO DE MIOCARDIO, Infarto al Miocardio, ataque al corazón, infarto cardíaco, infarto de corazón, infarto de miocardio (trastorno), infarto de miocardio, Infarto de miocardio, Infarto del Miocardio
Japanese 心臓発作（ＮＯＳ）, 冠発作, 心臓発作, ｶﾝﾎｯｻ, ｼﾝｿﾞｳﾎｯｻNOS, ｼﾝｿﾞｳﾎｯｻ, ｼﾝｷﾝｺｳｿｸ, 冠状動脈梗塞, 心筋梗塞, 冠動脈梗塞, 心筋梗塞症
Swedish Hjärtinfarkt
Czech infarkt myokardu, Srdeční záchvat, Srdeční záchvat (NOS), IM, Koronární záchvat, Infarkt myokardu
Finnish Sydäninfarkti
Russian INFARKT MIOKARDA, ИНФАРКТ МИОКАРДА
Croatian SRČANI INFARKT
Polish Świeży zawał serca, Zawał serca świeży, Zawał mięśnia sercowego, Zawał serca
Hungarian Coronaria roham, Szívroham (k.m.n.), Szívroham, Infarctus myocardii, Szívizom infarctus, MI
Norwegian Hjerteinfarkt, Hjerteattakk, Myokardinfarkt
Derived from the NIH UMLS (Unified Medical Language System)

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