Secondary prevention

Lifestyle Mods - Habits to Halve Heartbreak

• Diet: Mediterranean-style; ↑ fruits, vegetables, whole grains, fish. ↓ Saturated fats, red meat.
• Exercise: Aerobic activity for 30-60 minutes, 5-7 days/week.
• Weight Management: Maintain BMI < 25 kg/m².
• Smoking Cessation: Critical for risk reduction.
  • 📌 5 A's: Ask, Advise, Assess, Assist, Arrange.
• Alcohol: Limit to ≤2 drinks/day (men), ≤1 drink/day (women).

⭐ Quitting smoking after an MI reduces mortality risk by nearly 50% within a year, the most impactful single lifestyle change.

Antiplatelets & Statins - Plaque & Clot Patrol

• Dual Antiplatelet Therapy (DAPT): Prevents stent thrombosis & recurrent ischemic events.

  • Aspirin: Lifelong low-dose (81 mg).
  • P2Y12 Inhibitor: Minimum 12 months post-ACS.
    • Clopidogrel
    • Ticagrelor
    • Prasugrel

• High-Intensity Statin: For plaque stabilization and lipid management.

  • Goal: Lower LDL-C by >50%.
  • Agents:
    • Atorvastatin 40-80 mg
    • Rosuvastatin 20-40 mg

⭐ Prasugrel is contraindicated in patients with a prior history of stroke or TIA due to an increased risk of intracranial hemorrhage.

Cardiac Protection - Remodel & Relax

• Beta-Blockers (e.g., Metoprolol, Carvedilol)

  • Continue for ≥3 years post-MI in all patients; lifelong if LV dysfunction (LVEF ≤40%) or HF.
  • Reduces mortality, arrhythmias, and recurrent ischemia.

• ACE Inhibitors / ARBs (e.g., Lisinopril / Losartan)

  • Start in all patients, especially with LVEF ≤40%, HTN, DM, or stable CKD.
  • Prevents adverse ventricular remodeling.

• Aldosterone Antagonists (e.g., Spironolactone)

  • Add for patients on ACEi/BB with LVEF ≤40% + symptomatic HF or DM.
  • ⚠️ Monitor for hyperkalemia.

• Nitroglycerin

  • Sublingual (SL) PRN for angina episodes.

⭐ ACE inhibitors are crucial post-MI, especially in patients with reduced LVEF (≤40%), as they significantly decrease mortality by mitigating adverse ventricular remodeling and progression to heart failure.

Rehab & Risk Factors - The Long Game

• Cardiac Rehabilitation: Comprehensive, supervised program of exercise, education, and counseling to improve outcomes and reduce risk of future cardiac events.
• Key Targets:
  • Blood Pressure: Goal <130/80 mmHg
  • Glycemic Control: HbA1c <7%
• Preventative Care:
  • Annual influenza vaccine
  • Depression screening

⭐ Depression following an MI is an independent risk factor for mortality; screening is crucial.

High-Yield Points - ⚡ Biggest Takeaways

• Dual Antiplatelet Therapy (DAPT) with aspirin and a P2Y12 inhibitor is standard for at least 12 months post-ACS.
• All patients require high-intensity statin therapy (e.g., atorvastatin 80 mg) indefinitely.
• Beta-blockers are started within 24 hours to reduce mortality.
• ACE inhibitors/ARBs are vital, especially with LVEF <40%, HTN, or DM.
• Add an aldosterone antagonist if LVEF ≤40% with HF symptoms or diabetes.
• Emphasize comprehensive lifestyle changes, including cardiac rehabilitation.