Post-MI Patient
Adult after STEMI or NSTEMI due to plaque rupture (type 1 MI). Start before discharge.
All Pathways
CardiologyManagement
Post-MI Secondary Prevention (ESC 2023, Australia 2025)
Post-MI Secondary Prevention (ESC 2023, Australia 2025): Post-MI Patient → Check First: Pregnancy, SCAD, MINOCA or Type 2 MI → Also Needs Oral Anticoagu...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Warning Check First: Pregnancy, SCAD, MINOCA or Type 2 MI
This pathway is for adults after type 1 MI. In these groups, get cardiology advice first.
- Pregnancy: avoid ACEi, ARB, ARNI, MRA, statin and SGLT2i
- SCAD, MINOCA or type 2 MI: treat the cause; do not use this pathway by default
- Age under 18 years: not covered
03Decision Also Needs Oral Anticoagulation?
For example AF, mechanical valve, LV thrombus or VTE
- If Yes
04Action Needs OAC: Anticoagulant + Clopidogrel, No Ticagrelor or Prasugrel
Aspirin + clopidogrel + OAC for up to 1 week, then OAC + clopidogrel to 12 months, then OAC alone. Mechanical valve: warfarin, not a DOAC.
- Up to 1 month of aspirin if high stent-thrombosis risk and bleeding risk acceptable
- Prefer a DOAC at the stroke-prevention dose. High bleeding risk: rivaroxaban 15 mg daily or dabigatran 110 mg twice daily
- High bleeding risk: stop clopidogrel at 6 months, continue OAC alone
- No PCI (medical therapy): OAC + clopidogrel only, no aspirin
- Give a PPI while on combined antithrombotic therapy
- Mechanical valve or moderate-severe mitral stenosis: warfarin (VKA)
- Warfarin with antiplatelet: INR 2.0-2.5 (mechanical valve: use the valve INR target)
If No05Warning No OAC: Check Before Choosing the P2Y12 Inhibitor
Prior stroke or TIA: no prasugrel. Prior intracranial bleed: no ticagrelor or prasugrel. Strong CYP3A4 inhibitor or moderate-severe liver disease: no ticagrelor.
- Prasugrel only after PCI. Age 75 years or more: generally not advised; if used, 5 mg daily
- Weight under 60 kg: prasugrel 5 mg daily
- Age 70 years or more, or high bleeding risk: consider clopidogrel
06Action No OAC: Dual Antiplatelet Therapy (DAPT)
Aspirin + P2Y12 inhibitor for 12 months. High bleeding risk: stop DAPT at 1-3 months, then single antiplatelet.
- Aspirin 75-100 mg daily
- Plus ticagrelor 90 mg twice daily, or prasugrel 10 mg daily (after PCI only)
- Clopidogrel 75 mg daily if ticagrelor and prasugrel are unsuitable
- After DAPT: lifelong single antiplatelet, clopidogrel 75 mg daily (Australian 2025 preference) or aspirin 75-100 mg daily
- Low ischaemic risk and event-free: single antiplatelet after 3-6 months is an option
- High ischaemic and low bleeding risk: consider DAPT beyond 12 months
- PPI if high risk of gastrointestinal bleeding
- After CABG: restart DAPT and continue for at least 12 months
- Then all patients
07Action All Patients: High-Intensity Statin Now; LDL-C Target <1.4 mmol/L
Also reduce LDL-C by at least 50% from baseline. Recheck lipids 4-6 weeks after each change.
- Atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily, start in hospital
- Rosuvastatin 40 mg: not if Asian ancestry, CrCl <30 mL/min, hypothyroidism or on a fibrate. CrCl <30 mL/min: rosuvastatin max 10 mg
- Already on a statin, or target unlikely with statin alone: add ezetimibe 10 mg daily now
- Not at target on maximum tolerated statin: add ezetimibe, then a PCSK9 inhibitor
- Australia (PBS): PCSK9 inhibitor if LDL-C >1.8 mmol/L after 12 weeks of maximum statin + ezetimibe, plus PBS risk criteria
- New event within 2 years on maximum therapy: LDL-C <1.0 mmol/L may be considered
- Statin intolerance: try another statin or dose; add ezetimibe
08Action ACE Inhibitor (ARB if ACEi Not Tolerated)
Give if HF, LVEF 40% or less, diabetes, hypertension or CKD. Consider for all other patients.
- Check potassium and creatinine 1-2 weeks after start and after each dose increase
- Stop if angioedema. Not in pregnancy
- ARNI is not routine after MI; symptomatic HFrEF: follow the HF guideline
- Never give an ACEi with an ARNI; stop the ACEi 36 hours before starting an ARNI
09Decision LVEF 40% or Less?
Measure LVEF by echo before discharge
- If Yes
10Action LVEF 40% or Less: Beta-Blocker, Long Term
Bisoprolol, carvedilol, metoprolol succinate (CR/XL) or nebivolol. Start only when stable, then titrate to the target dose.
- Do not start in cardiogenic shock, hypotension or decompensated HF; start once stable
- Risk factors for cardiogenic shock: start at a low dose and titrate slowly
- Avoid if second- or third-degree AV block without a pacemaker
11Action LVEF 40% or Less With HF or Diabetes: Add MRA
Eplerenone or spironolactone. Do not start if K+ >5.0 mmol/L or eGFR <30 mL/min/1.73 m2.
- Recheck K+ and creatinine at 1 and 4 weeks, then regularly
- K+ >5.5 mmol/L: halve the dose or hold it, and recheck
- Avoid potassium supplements and NSAIDs
- Eplerenone: not with strong CYP3A4 inhibitors (for example clarithromycin, ketoconazole, ritonavir) or potassium-sparing diuretics
12Warning LVEF 40% or Less: Repeat LVEF at 6-12 Weeks for ICD Decision
ICD if LVEF 35% or less with NYHA II-III after at least 3 months of optimal therapy.
- No primary-prevention ICD within 40 days of MI
- Only if expected survival is more than 1 year with good function
- Refer to cardiology for the ICD decision
If No13Action LVEF Above 40%: Beta-Blocker Depends on LVEF
LVEF 41-49%: give a beta-blocker. LVEF 50% or more after revascularisation: benefit uncertain; Australian 2025 advice is to consider withholding.
- Give a beta-blocker for angina, arrhythmia or hypertension if needed
- LVEF 50% or more: trials conflict (no benefit in REDUCE-AMI and REBOOT; fewer events in BETAMI-DANBLOCK)
- Then all patients
14Action SGLT2 Inhibitor if HF, Type 2 Diabetes or CKD
Dapagliflozin 10 mg or empagliflozin 10 mg daily. Not for type 1 diabetes. No proven benefit for MI alone (EMPACT-MI, DAPA-MI).
- Symptomatic HF at any LVEF: recommended
- Do not start if eGFR <25 (dapagliflozin) or <20 mL/min/1.73 m2 (empagliflozin)
- Hold when acutely unwell, fasting or before surgery (ketoacidosis risk)
- Symptomatic HF: manage with the HF guideline (MRA is recommended at any LVEF)
15Action All Patients: Cardiac Rehabilitation and Risk Factors
Refer every patient before discharge to a structured, exercise-based program.
- Stop smoking; offer nicotine replacement, varenicline or bupropion
- Written chest pain plan: GTN spray or tablet; call 000 if pain does not settle. No GTN after recent sildenafil, vardenafil or tadalafil
- Influenza vaccine every year
- Blood pressure and diabetes to target; healthy diet; regular exercise
- Psychosocial support; screen for depression
- Consider colchicine 0.5 mg daily (weak evidence; off-label). Not with severe renal or liver disease, or strong CYP3A4 or P-gp inhibitors
16Outcome Lifelong Secondary Prevention
Review adherence, LDL-C, blood pressure, LVEF and bleeding risk at each visit.
Guideline Source
2023 ESC Guidelines for the management of acute coronary syndromes (with NHFA/CSANZ Australian ACS guideline 2025)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- For adults after type 1 MI only. Not for SCAD, MINOCA, type 2 MI or pregnancy: get cardiology advice
- Beta-blocker advice for LVEF above 40% is changing; ESC 2023 and Australian 2025 guidance differ
- Doses are usual adult maintenance doses; check renal function, interactions and product information
- HF drug titration and ICD selection are simplified; see the ESC 2026 HF guideline
Contraindicated Populations
pediatricpregnancy
Applicable Regions
EUAUUS
AU: NHFA/CSANZ ACS guideline 2025 applies. Prasugrel is PBS-listed again from 1 May 2025 for ACS with PCI. Ticagrelor is PBS-subsidised only with aspirin. PCSK9 inhibitor on PBS: LDL-C >1.8 mmol/L after 12 weeks of maximum statin + ezetimibe, plus risk criteria.
EU: Based on ESC 2023 ACS guideline and 2025 ESC/EAS dyslipidaemia focused update. LDL-C <1.4 mmol/L (55 mg/dL).
US: Convert units: 1.4 mmol/L = 55 mg/dL; 1.8 mmol/L = 70 mg/dL; 1.0 mmol/L = 40 mg/dL. ACC/AHA 2025 ACS thresholds differ; check the ACC/AHA guideline.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Post-MI Secondary Prevention (ESC 2023, Australia 2025)?
The Post-MI Secondary Prevention (ESC 2023, Australia 2025) is a management clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2023 ESC Guidelines for the management of acute coronary syndromes (with NHFA/CSANZ Australian ACS guideline 2025).
What guideline is the Post-MI Secondary Prevention (ESC 2023, Australia 2025) based on?
This algorithm is based on 2023 ESC Guidelines for the management of acute coronary syndromes (with NHFA/CSANZ Australian ACS guideline 2025) (DOI: 10.1093/eurheartj/ehad191).
What are the limitations of the Post-MI Secondary Prevention (ESC 2023, Australia 2025)?
Known limitations include: For adults after type 1 MI only. Not for SCAD, MINOCA, type 2 MI or pregnancy: get cardiology advice; Beta-blocker advice for LVEF above 40% is changing; ESC 2023 and Australian 2025 guidance differ; Doses are usual adult maintenance doses; check renal function, interactions and product information; HF drug titration and ICD selection are simplified; see the ESC 2026 HF guideline. Individual patient factors may require deviation from these recommendations.
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