Secondary prevention of myocardial infarction (MI) Drug therapy

1. Secondary prevention of myocardial infarction (MI)Drug therapy

2. Prophylaxis for patients who have experienced an MINICE Clinical Guideline 43. May 2007 • ACE-Is should be offered to all patients early after presentation with acute MI • Titrate at every 1-2 weeks to max tolerated or target dose • Continue indefinitely, whether or not symptomatic • Routine use of ARB alone or ARB + ACE-I not recommended • Similar recommendations for patients with proven MI in the past

3. Prophylaxis for patients who have experienced an MINICE Clinical Guideline 43. May 2007 • Aspirin should be offered to all patients after an MI unless contraindicated • Clopidogrel not recommended as first line monotherapy • Non-STEMI ACS • Consider aspirin + clopidogrel as in NICE TA 80 • STEMI • Don’t use aspirin + clopidogrel routinely, but if started, continue for at least 4 weeks • Aspirin hypersensitivity • Consider clopidogrel monotherapy (see NICE TA 90) • Dyspepsia or aspirin-induced bleeding ulcer • Low dose aspirin + PPI (see NICE CG 17 “Dyspepsia”)

4. Prophylaxis for patients who have experienced an MINICE Clinical Guideline 43. May 2007 • Beta blockers should be offered to all patients early after an acute MI • Irrespective of LV function or whether or not LVSD is symptomatic • If patient has LVSD, “clinicians may prefer” to use a beta blocker licensed for use in heart failure • Initiate as soon as patient is clinically stable and titrate upwards • After a proven MI in the past • Patients with LVSD should be offered a beta-blocker • Patients with heart failure should be treated according to NICE CG 5 “Chronic Heart Failure” • Patients with preserved LV function and asymptomatic – beta-blocker only if increased risk of further CV events or other compelling indications

5. Prophylaxis for patients who have experienced an MINICE Clinical Guideline 43. May 2007 • High intensity warfarin (INR>3) should not be considered as an alternative to aspirin first line • Patients unable to tolerate either aspirin or clopidogrel • Consider moderate intensity warfarin (INR 2-3) for up to 4 years, possibly longer • Patients with acute MI who are intolerant to clopidogrel and have low risk of bleeding • Consider moderate intensity warfarin (INR 2-3) plus aspirin • Patients already treated for another indication • Continue warfarin • Consider adding aspirin to moderate intensity warfarin (INR 2-3) in patients at low risk of bleeding • Warfarin plus clopidogrel not routinely recommended

6. Prophylaxis for patients who have experienced an MINICE Clinical Guideline 43. May 2007 • Calcium channel blockers should not be routinely used to reduce CV risk after an MI • If beta-blockers are contraindicated or need to be discontinued • Consider diltiazem or verapamil in patients without pulmonary congestion or LVSD [unlicensed use] • Calcium channel blockers may be used to treat hypertension or angina in patients who are stable • In patients with heart failure • Amlodipine is preferred • Avoid verapamil, diltiazem and short-acting dihydropyridine agents (NICE CG 5 “Chronic Heart Failure”)

7. Prophylaxis for patients who have experienced an MINICE Clinical Guideline 43. May 2007 • Aldosterone antagonists should be initiated in patients with acute MI and symptoms/signs of heart failure or LVSD • Initiate within 3-14 days of the MI, preferably after ACE-I • Patients already being treated for another indication should continue with it or an alternative licensed for early post-MI treatment • In patients with proven MI in the past and heart failure due to LVSD, treat in line with NICE CG 5 “Chronic Heart Failure”

8. NICE CV risk and lipids and guidanceNICE Clinical Guideline 67. May 2008 • For secondary prevention, lipid modification therapy should be offered and should not be delayed by management of modifiable risk factors • Perform blood tests and clinical assessment and treat comorbidities and secondary causes of dyslipidaemia • Statin therapy is recommended for adults with clinical evidence of CVD • Fibrates, nicotinic acid or ion-exchange resins may be considered in people not able to tolerate statins • The decision whether to initiate statin therapy should be made after an informed discussion about the risks and benefits of statin treatment • Take into account additional factors such as comorbidities and life expectancy

9. NICE CV risk and lipids and guidanceNICE Clinical Guideline 67. May 2008 • Initiate treatment for secondary prevention of CVD with simvastatin 40mg. If there are potential drug interactions, or simvastatin 40mg is contraindicated, choose a lower dose or alternative preparation such as pravastatin • In people taking statins for secondary prevention, consider increasing to simvastatin 80mg or a drug of similar efficacy and acquisition cost if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained • Any decision to offer a higher intensity statin should take into account the patient's informed preference, comorbidities, multiple drug therapy, and the benefits and risks of treatment