ST elevation myocardial infarction secondary prevention

Acute Coronary Syndrome Main Page
ST Elevation Myocardial Infarction Microchapters
Home
Patient Information
Overview
Pathophysiology
Pathophysiology of Vessel Occlusion
Pathophysiology of Reperfusion
Gross Pathology
Histopathology
Causes
Differentiating ST elevation myocardial infarction from other Diseases
Epidemiology and Demographics
Risk Factors
Triggers
Natural History and Complications
Risk Stratification and Prognosis
Pregnancy
Diagnosis
Diagnostic Criteria
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
EKG Examples
Chest X Ray
Cardiac MRI
Echocardiography
Coronary Angiography
Treatment
Pre-Hospital Care
Initial Care Oxygen Nitrates Analgesics Aspirin Beta Blockers Antithrombins The coronary care unit The step down unit STEMI and Out-of-Hospital Cardiac Arrest Pharmacologic Reperfusion Reperfusion Therapy (Overview of Fibrinolysis and Primary PCI) Fibrinolysis Reperfusion at a Non–PCI-Capable Hospital:Recommendations Mechanical Reperfusion The importance of reducing Door-to-Balloon times Primary PCI Adjunctive and Rescue PCI Rescue PCI Facilitated PCI Adjunctive PCI CABG Management of Patients Who Were Not Reperfused Assessing Success of Reperfusion Antithrombin Therapy Antithrombin therapy Unfractionated heparin Low Molecular Weight Heparinoid Therapy Direct Thrombin Inhibitor Therapy Factor Xa Inhibition DVT prophylaxis Long term anticoagulation Antiplatelet Agents Aspirin Thienopyridine Therapy Glycoprotein IIbIIIa Inhibition Other Initial Therapy Inhibition of the Renin-Angiotensin-Aldosterone System Magnesium Therapy Glucose Control Calcium Channel Blocker Therapy Lipid Management
Pre-Discharge Care
Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT
Post Hospitalization Plan of Care
Long-Term Medical Therapy and Secondary Prevention Overview Inhibition of the Renin-Angiotensin-Aldosterone System Cardiac Rehabilitation Pacemaker Implantation Long Term Anticoagulation Implantable Cardioverter Defibrillator ICD implantation within 40 days of myocardial infarction ICD within 90 days of revascularization
Case Studies
Case #1
Case #2
Case #3
Case #4
Case #5
ST elevation myocardial infarction secondary prevention On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on ST elevation myocardial infarction secondary prevention
CDC on ST elevation myocardial infarction secondary prevention
ST elevation myocardial infarction secondary prevention in the news
Blogs on ST elevation myocardial infarction secondary prevention
Directions to Hospitals Treating ST elevation myocardial infarction
Risk calculators and risk factors for ST elevation myocardial infarction secondary prevention

For the chapter on Secondary Prevention of Coronary Artery Disease in general, click here.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Identifying and, when present, treating category I risk factors can be an optimal secondary prevention strategy in patients with STEMI. You can read more about general coronary heart disease secondary prevention HERE

Long-term Medical Therapy and Secondary Prevention

Patients are usually treated with several long-term medications following a ST elevation myocardial infarction with the goal of preventing secondary cardiovascular events such as further myocardial infarctions, congestive heart failure or cerebrovascular accident (CVA). Unless contraindicated, such medications may include:

• Antiplatelet drug therapy such as aspirin and/or clopidogrel should be continued to reduce the risk of plaque rupture and recurrent myocardial infarction. Aspirin is first-line, owing to its low cost and comparable efficacy, with clopidogrel reserved for patients intolerant of aspirin. The combination of clopidogrel and aspirin may further reduce risk of cardiovascular events, however the risk of hemorrhage is increased.

• Beta blocker therapy such as metoprolol or carvedilol should be commenced. These have been particularly beneficial in high-risk patients such as those with left ventricular dysfunction and/or continuing cardiac ischaemia. β-Blockers decrease mortality and morbidity. They also improve symptoms of cardiac ischemia in NSTEMI.

• ACE inhibitor therapy should be commenced 24-48 hours post-MI in hemodynamically-stable patients, particularly in patients with a history of MI, diabetes mellitus, hypertension, anterior location of infarct (as assessed by EKG), and/or evidence of left ventricular dysfunction. ACE inhibitors reduce mortality, the development of heart failure, and decrease ventricular remodelling post-MI.

• Statin therapy has been shown to reduce mortality and morbidity post-MI. The effects of statins may be more than their LDL lowering effects. The general consensus is that statins have plaque stabilization and multiple other ("pleiotropic") effects that may prevent myocardial infarction in addition to their effects on blood lipids. A study by AJC by Herbert D. Aranow, et al. indicates that, for patients who underwent lipid-lowering therapy prior to having an acute myocardial infarction (AMI), infarct size was significantly less than for patients who had not received this earlier treatment. Data from 10,548 patients were collected from both the Global Use of Streptokinase or t-PA for Occluded Coronary Arteries (GUSTO) IIb (n=6,414) and the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Supression Using Integrilin Therapy (PURSUIT) (n=4,134) studies, with infarct size measured by patients' peak creatine kinase (CK) -MB levels. Patients who had lipid-lowering therapy had a median peak CK-MB of 4.2 times the upper limit of normal (ULN) compared to 5.2 times the ULN for those who were not pre-treated (p<0.0001). These results suggest a potential benefit of lipid-lowering therapy for patients at risk for an AMI. Noted limitations of the study include: the observational study design (both the potential effects of confounding variables and the "healthy-user bias" ); the lack of documented information differentiating between statin and nonstatin therapies; and the exclusion from analysis of patients who died during the index hospitalization.

• The aldosterone antagonist agent eplerenone has been shown to further reduce risk of cardiovascular death post-MI in patients with heart failure and left ventricular dysfunction, when used in conjunction with standard therapies above.
• Omega-3 fatty acids, commonly found in fish, have been shown to reduce mortality post-MI. While the mechanism by which these fatty acids decrease mortality is unknown, it has been postulated that the survival benefit is due to electrical stabilization and the prevention of ventricular fibrillation. However, further studies in a high-risk subset have not shown a clear-cut decrease in potentially fatal arrhythmias due to omega-3 fatty acids.
• Reducing excess weight and exercising regularly.
• Keeping blood pressure and diabetes under check.
• Following a diet low in cholesterol (<200 mg daily) and saturated fat.
• Increasing HDL- Patients with low HDL [A lipoprotein that transports cholesterol in the blood; composed of a high proportion of protein and relatively little cholesterol] (<35 mg/dl) are encouraged to exercise regularly and to take medications to increase HDL levels.
• "Among patients with a recent myocardial infarction, colchicine at a dose of 0.5 mg daily led to a significantly lower risk of ischemic cardiovascular events than placebo". In a randomized controlled trial of patients after myocardial infarction, the relative risk ratio of colchicine 0.5 mg once daily, as compared to placebo, for ischemic cardiovascular events was 0.77 and the relative risk reduction was 22.5%. In populations similar to those in this study which had a rate of risk as measured by the ischemic cardiovascular events of 7.1% without treatment, the number needed to treat is 63.

2007 Update of 2004 ACC / AHA Guidelines for the management of ST Segment Elevation Myocardial Infarction - Recommendations for Secondary Prevention (DO NOT EDIT)

Aspirin (DO NOT EDIT)

Class I

"1. For all post-PCI STEMI stented patients without aspirin resistance, allergy, or increased risk of bleeding, aspirin 162 mg to 325 mg daily should be given for at least 1 month after BMS implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75 mg to 162 mg daily. (Level of Evidence: B)"

Class IIa

"1. In patients for whom the physician is concerned about risk of bleeding lower-dose 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation. (Level of Evidence: C)"

Clopidogrel (DO NOT EDIT)

Class I

"1. For all post-PCI patients who receive a DES, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). (Level of Evidence: B)"

"2. For all STEMI patients not undergoing stenting (medical therapy alone or PTCA without stenting), treatment with clopidogrel should continue for at least 14 days. (Level of Evidence: B)"

Class IIa

"1. Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. (Level of Evidence: C)"

Warfarin (DO NOT EDIT)

Class I

"1. Managing warfarin to an INR equal to 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter is recommended, and in post-MI patients when clinically indicated (e.g., atrial fibrillation, left ventricular thrombus). (Level of Evidence: A)"

"2. Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely. (Level of Evidence: B)"

"3. In patients requiring warfarin, clopidogrel, and aspirin therapy, an INR of 2.0 to 2.5 is recommended with low dose aspirin (75 mg to 81 mg) and a 75 mg dose of clopidogrel. (Level of Evidence: C)"

ACE Inhibitors (DO NOT EDIT)

Class I

"1. ACE inhibitors should be started and continued indefinitely in all patients recovering from STEMI with LVEF less than or equal to 40% and for those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. (Level of Evidence: A)"

"2. ACE inhibitors should be started and continued indefinitely in patients recovering from STEMI who are not lower risk (lower risk defined as those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated. (Level of Evidence: B)"

Class IIa

"1. Among lower risk patients recovering from STEMI (i.e., those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed) use of ACE inhibitors is reasonable. (Level of Evidence: B)"

Angiotensin Receptor Blockers (DO NOT EDIT)

Class I

"1. Use of angiotensin receptor blockers is recommended in patients who are intolerant of ACE inhibitors and have HF or have had an MI with LVEF less than or equal to 40%. (Level of Evidence: A)"

"2. It is beneficial to use angiotensin receptor blocker therapy in other patients who are ACE-inhibitor intolerant and have hypertension. (Level of Evidence: B)"

Class IIb

"1. Considering use in combination with ACE inhibitors in systolic dysfunction HF may be reasonable. (Level of Evidence: B)"

Aldosterone Blockade (DO NOT EDIT)

Class I

"1. Use of aldosterone blockade in post-MI patients without significant renal dysfunction or hyperkalemia is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF of less than or equal to 40%, and have either diabetes or HF. (Level of Evidence: A)"

Beta Blockers (DO NOT EDIT)

Class I

"1. It is beneficial to start and continue beta-blocker therapy indefinitely in all patients who have had MI, acute coronary syndrome, or LV dysfunction with or without HF symptoms, unless contraindicated. (Level of Evidence: A)"

Influenza Vaccination (DO NOT EDIT)

Class I

"1. Patients with cardiovascular disease should have an annual influenza vaccination. (Level of Evidence: A)"

Sources

• The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction

• The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction