post-MI care

The weeks to months after an MI are high-risk for recurrent events, arrhythmia, and ventricular remodelling. Secondary prevention centres on DAPT, neurohormonal blockade, lipid-lowering, cardiac rehab, and lifestyle modification. LVEF reassessment at 6–12 weeks guides device and ongoing therapy decisions.

secondary prevention — medications

DAPT

Scenario	Duration	Regimen
standard post-ACS	12 months	ASA + ticagrelor 90 mg BID (or prasugrel 10 mg OD)
high bleed risk	1–3 months then SAPT	SAPT with P2Y12i preferred (favour ticagrelor)
low bleed risk at 12 months, tolerating DAPT	extend up to 3 years	ASA + ticagrelor 60 mg BID — PEGASUS (2015)
stable CAD >1 year post-MI	consider dual pathway	rivaroxaban 2.5 mg BID + ASA — COMPASS (2017)

See Antiplatelet Agents for drug-specific detail.

neurohormonal blockade

Drug class	Indication	Target
ACEi (or ARB)	all post-MI, especially LVEF <40%, anterior MI, HF, HTN, DM, CKD	titrate to evidence-based dose
beta-blocker	LVEF <40%; symptomatic angina	titrate to resting HR 55–60
MRA (eplerenone)	LVEF ≤40% + HF symptoms or diabetes, post-MI	monitor K⁺ and renal function

beta-blockers post-MI with preserved EF

If no prior MI with LVEF <40% and no HF, beta-blockers do not reduce MACE — their role is antianginal only.

lipid-lowering

high-intensity statin for all (atorvastatin 80 mg or rosuvastatin 40 mg)
target LDL <1.8 mmol/L (or ≥50% reduction)
add ezetimibe if target not met
add PCSK9 inhibitor if still not at target on maximally tolerated statin + ezetimibe

additional therapies

SGLT2 Inhibitors or GLP-1RA if post-MI + diabetes
SGLT2i if post-MI + HFrEF (regardless of diabetes)

cardiac rehabilitation

class I-A recommendation post-MI, PCI, and CABG
exercise-based rehab reduces CV mortality and hospital readmissions
≥150 min/wk moderate aerobic + 2 days/wk resistance training
also addresses psychosocial recovery, medication adherence, risk factor management

LVEF reassessment

repeat echocardiography at 6–12 weeks post-MI (allows time for recovery/remodelling on GDMT)
LVEF remains ≤35% after ≥3 months of optimal therapy → assess for ICD (primary prevention SCD)
LVEF 36–50% → reassess symptoms; consider CRT if LBBB + QRS ≥150 ms
see Cardiac Devices for device indications

perioperative management — stents and DAPT

Stent type	Minimum delay for elective non-cardiac surgery
BMS	≥1 month
DES	≥3 months (1 month for semi-urgent)

hold clopidogrel/ticagrelor 5–7 days pre-op; prasugrel 7–10 days
continue ASA perioperatively whenever possible
restart DAPT post-op as soon as deemed safe

lifestyle

smoking cessation (counselling + pharmacotherapy)
vaccines: annual influenza, COVID, pneumococcal
do NOT recommend: dietary supplements, alcohol for CV protection, chronic NSAIDs

what NOT to do

stop statin because LDL is “normal” — post-ACS patients benefit regardless of baseline
use short-acting nifedipine post-MI (reflex tachycardia, harm)
delay cardiac rehab referral — refer before discharge
forget to reassess LVEF at 6–12 weeks (device eligibility window)
forget driving restrictions — see Cardiac Fitness to Drive