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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