Post-MI Secondary Prevention (ESC 2023)

Algorithm Steps

1. ▶

   Start

   Post-MI Patient

   After STEMI or NSTEMI

   1. ●

      Action

      Antithrombotic Therapy

      DAPT then maintenance

      • DAPT x 12 months
      • Aspirin + Ticagrelor/Prasugrel
      • Then aspirin indefinitely
      1. ●

         Action

         Beta-Blocker

         ≥1 year, indefinite if HF

         • Carvedilol, bisoprolol, metoprolol
         • Indefinite if LVEF ≤40%
         • Indefinite if arrhythmia/HF
         1. ●

            Action

            SGLT2 Inhibitor

            If HFrEF/HFmrEF/DM/CKD

            • Dapagliflozin or empagliflozin
            • Growing evidence post-MI
            1. ⚠

               Warning

               ICD Evaluation

               At ≥40 days post-MI

               • If LVEF ≤35% despite OMT x 3mo
               • Primary prevention SCD
               1. ✓

                  Outcome

                  Lifelong Secondary Prevention

                  Regular follow-up, optimize GDMT

            2. ●

               Action

               Cardiac Rehabilitation

               Class I recommendation

               • Exercise training
               • Risk factor education
               • Psychosocial support
   2. ●

      Action

      Lipid Therapy

      Aggressive LDL lowering

      • Target: LDL <55 mg/dL + ≥50% reduction
      • Recurrent event: <40 mg/dL
      • Step 1: High-intensity statin
      • Step 2: + Ezetimibe
      • Step 3: + PCSK9i
      1. ●

         Action

         ACEi/ARB/ARNI

         All post-STEMI patients

         • Especially if LVEF ≤40%
         • Anterior MI, HTN, DM
         • ARNI if HF develops
      2. ●

         Action

         MRA

         If LVEF ≤40% + symptoms/DM

         • Spironolactone or eplerenone
         • Monitor K+ and renal function