Secondary prevention of ischemic heart disease

Everyone who’ve underwent an acute myocardial infarction will be taking multiple medications as secondary prevention for future AMIs, post-myocardial infarction heart failure, sudden cardiac death due to ventricular arrhythmias, and other cardiovascular disease. Most of them must be taken indefinitely.

• Medications to be taken indefinitely
  • Aspirin (75 mg) – in all cases
  • High intensity statin (40 – 80 mg atorvastatin or 20 – 40 mg rosuvastatin) – in all cases
  • Beta blocker (metoprolol) – in case of EF < 40% or HF
  • ACE inhibitor (ramipril) – in case of EF < 40% or HF
  • MRA (spironolactone) – in case of EF < 40% or HF
• Medications to be taken temporarily
  • P2Y12 inhibitors – for 12 months
• Cardiac rehabilitation
• Other targets
  • LDL < 1,4 (and a reduction of at least 50% from baseline LDL)
  • BP < 135/90
  • Control diabetes (HbA1c < 53 mmol/mol)
  • Smoking cessation
  • Mediterranean diet
  • Normal BMI

Aspirin

Ideally, a loading dose (300 mg) aspirin should be administered during the acute presentation of the ACS. 75 mg daily aspirin will thereafter be continued for an indefinite time (class I recommendation). Aspirin is a low-risk but potent antiplatelet agent which reduces the incidence of thrombosis.

High intensity statin

Ideally, a high intensity statin should be administered during the acute presentation of the ACS. The statin will thereafter be continued for an indefinite time (class I recommendation). The high intensity statins are atorvastatin at a dose of 40 or 80 mg, or rosuvastatin at a dose of 20 or 40 mg. The most frequently used is 80 mg atorvastatin.

High intensity statins stabilise atherosclerotic plaques and may even cause the plaques to regress, in addition to their potent LDL-reducing properties. If high intensity statin is not sufficient to reach the LDL target of < 1,8, ezetimibe should be added. Lifestyle interventions to reduce LDL should always be applied.

P2Y12 inhibitor – dual antiplatelet therapy

Dual antiplatelet therapy (DAPT) refers to giving both aspirin and a P2Y12 inhibitor. DAPT should be given for the first 12 months after the ACS (class I recommendation). For STEMI, the P2Y12 inhibitor preferred is prasugrel or ticagrelor.

At patients at high risk for GI bleeding, administering a PPI for the duration of the DAPT is recommended (class I recommendation). Some recommend administering a PPI in all cases, not just for those at high risk.

Beta blocker, ACE inhibitor, MRA

All patients with ACS should have an echocardiography performed before discharge, because the presence of decreased EF has prognostic value and changes the treatment slightly. Decreased left ventricular systolic function (EF < 40%) or heart failure is a poor prognostic factor and is a class I indication for secondary prevention with ACE inhibitors, beta blockers, and MRAs. Ideally, a beta blocker should be administered during the acute presentation of the ACS. In most cases, metoprolol in a depot formulation is used.

However, even in the absence of decreased EF or heart failure, giving these drugs may be reasonable (class II recommendation). If a patient has other indications for any of these (tachycardia for beta blocker, hypertension for ACE inhibitor), they may be administered even in the absence of heart failure or decreased EF.

Cardiac rehabilitation

Cardiac rehabilitation programmes provide exercise training and counselling on risk factor modification for the secondary prevention of coronary artery disease. These are comprehensive, long-term services involving medical evaluation, supervised exercise, risk factor modification, education, and counselling. Participation in a cardiac rehabilitation programme is highly effective in reducing psychologic effects of heart disease, morbidity and mortality after a myocardial infarction and is therefore recommended in all cases (class I recommendation).