Myocardial Infarction: Secondary Prevention

Key points

• Offer all post-MI patients four core treatments: dual antiplatelet therapy · ACE inhibitor (continued indefinitely) · beta-blocker · statin.
• Dual antiplatelet therapy is now ticagrelor- or prasugrel-based with aspirin, usually for 12 months, rather than clopidogrel by default · use clopidogrel with aspirin if there is a high bleeding risk or a separate indication for oral anticoagulation · aspirin continues indefinitely.
• Aldosterone antagonist (e.g. eplerenone) if there is heart failure with left ventricular systolic dysfunction after MI — start within 3-14 days, preferably after the ACE inhibitor.
• Left ventricular systolic dysfunction after MI is treated as heart failure — see NG106: the four pillars now include an SGLT2 inhibitor.
• Lifestyle: Mediterranean-style diet (swap butter and cheese for plant-oil products; do not recommend omega-3 supplements) · 20-30 minutes of exercise a day until slightly breathless · offer cardiac rehabilitation, with assessment within 10 days.
• Sexual activity may resume 4 weeks after an uncomplicated MI · PDE5 inhibitors may be used from 6 months, but never with nitrates or nicorandil.

Decision points in this pathway

• Heart failure with left ventricular systolic dysfunction after the MI?

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