Post-MI Care

Abbreviations

  • OAC – Oral Anticoagulant (includes warfarin, NOACs etc..)
  • DAPT – Dual AntiPlatelet Therapy
  • PPI – Proton Pump Inhibitor
  • CCS – Canadian Cardiovascular Society
  • AHA – American Heart Associatinon
  • CCS – Canadian Cardiovascular Society
  • ARB – Angiotensin Receptor Blocker
  • ACEi – ACE Inhibitor
  • BB – Beta Blocker
  • FFR – Fractional Flow Reserve

Pillars of post-MI care

  1. Determine a need for further revascularization
  2. Optimize medical therapy
  3. Risk factor modification
  4. Cardiac Rrehab
  5. Arrange appropriate follow-up

Determine a need for further revascuarlization

  • If there is are ongoing signs/symptoms of ischemia, further revascularization of potential flow-limiting non-culprit lesions can be considered.
  • Controversy has existed about “bystander” lesions found during a STEMI that are significant (either visually > 70% stenosis or by FFR).  Latest trials recommend complete revascularization either during index PCI procedure or as a staged procedure. Decision is made with the interventional cardiologist.
  • Post-STEMI – Culpritonly PCI, consider complete revascularization in 2-30 days based on visual assessment of stenosis and FFR

    COMPLETE Trial

    In patients with STEMI + multivessel coronary artery disease –>  complete revascularization superior to culprit-lesion-only PCI in reducing the risk of CV death or MI, as well as the risk of CV Death, MI, or ischemia-driven revascularization

    (COMPLETE, PRAMI, CULPRIT favour complete revasc) 
  • Patients in shock – Culprit-only PCI

    CULPRIT-SHOCK Trial

    In patients with acute MI with multi-vessel CAD and cardiogenic shock culprit-only PCI is associated with 9.5% absolute reduction in the rate of death or renal replacement therapy at 30 days. This was driven primarily by a 7.3% absolute reduction in all-cause mortality with culprit-lesion only PCI.

    (CULPRIT-SHOCK Trial)

Anti-Thrombotic Therapy

  • Patients should remain on dual antiplatelet therapy post-MI
  • ASA, Tticagrelor, Cclopidogrel, and Pprasugrel all have mortality benefit post-MI
  •  Optimal duration:
    • STEMI or NSTEMI: –>At least 1 year
      CCS 2018 – Recommendations for duration of DAPT in patients who undergo elective PCI
      (CCS)
    • Elective PCI (Outpatient): –>  At least 6mo
      CCS 2018 – Recommendations for duration of DAPT in patients with ACS (STEMI or NSTEACS) who undergo PCI
      (CCS)
    • There is evidence to continue >1 year
    • At 1 year, weigh risks of bleeding vs. risk of ischemic events (See Table to the left right)
    • Generally, if tolerating DAPT at 1 year post-MI, continue for up to 3 years with one of the following proven regimens:
      • ASA 81mg daily + Tticagrelor 60mg BID (REDUCED DOSE) (PEGASUS-TIMI-54 Trial)
      • ASA 81mg daily + Cclopidogrel 75mg daily (DAPT Trial)
      • ASA 81mg daily + Pprasugrel 10mg daily (DAPT Trial) – not available in Canada

Interruption of antiplatelet therapy

  • Reasons to consider early interruption (<1 yr) of therapy in patients with a stent:
    • High-risk of bleeding
    • Elective non-cardiac surgery
    • Semi-urgent non-cardiac surgery
    • CABG (urgent or elective)
  • Continue ASA monotherapy through surgery if possible
  • Early interruption increases risk of stent thrombosis
  • Resume DAPT post-op once “deemed safe by the surgeon” (CCS 2018)
CCS 2018 Antiplatelet Guidelines
Interruption of antiplatelet therapy
  • Minimum treatment duration: (i.e. delay elective surgery if possible)
    • Drug-eluting stents: 3 mo
      • Semi-urgent non-cardiac surgery: 1 mo (i.e. cancer surgery)
    • Bare-metal stents: 1 mo
  • CABG (special case):
    • Continue ASA peri-operatively (operate on ASA)
    • Ticagrelor & Cclopidogrel: interrupt at least 48-72hrs pre-CABG (ideally 5 days)
    • Prasugrel: interrupt at least 5 days pre-CABG (ideally 7 days)
    • Urgent cases: try to wait at least 24hrs (sometimes wait not possible)
  • Overall, weigh risks of bleeding, and thrombosis.  Include others in the decision (surgeon, cardiologist, attending physician)

Switching antiplatelet therapy (CCS 2018)

    • Do not switch unless compelling reason to do so (stent thrombosis, bleeding, side effects, etc..)
    • Clopidogrel → –> Ticagrelor (load 180mg + 90mg BID regardless of last dose)
    • Ticagrelor → –> Clopidogrel (load 600mg at time of next ticag dose) (OPTI-CROSS Trial)
    • Do not load when switching from prasugrel (see CCS 2018 guideline)
      • Clopidogrel → –> Pprasugrel (load 60mg + 10mg daily regardless of last dose)
      • Prasugrel → –> Tticagrelor (do not load, give 90mg BID at time of next dose)
      • Ticagrelor → –> prasugrel (load 60mg + 10mg daily at time of next dose)
      • Prasugrel → –> Cclopidogrel (do not load, give 75mg at time of next dose)

ACS in patient with atrial fibrillation

Atrial Fibrillation ACS or high-risk PCI:

  • ASA + Clopidogrel + Reduced Dose OAC [(aka “triple therapy”)]
    • ASA can be discontinued from 1 day after PCI to 6mo (Trials enrolled in 1-3 weeks, interventionalist will generally dictate duration)
    • Once ASA discontinued, patient continues on clopidogrel + OAC (aka “dDual Ttherapy)
  • NOTE: The dose of OAC depends on whether it is used for triple or dual therapy (see below).
  • OACs regimens tested in triple therapy:
    • Rivaroxaban 2.5mg BID + ASA + clopidogrel
    • Warfarin (Ttarget INR 2.0-2.5) + ASA + Cclopidogrel
    • Apixaban 5mg BID + ASA + clopidogrel
  • OACs tested in dual therapy:
    • Rivaroxaban 15mg daily + clopidogrel (PIONEER)
      (Rivaroxaban 10mg in renal dysfunction)
    • Dabigatran 150mg BID + clopidogrel (RE-DUAL trial)
      (Dabigatran 110mg BID = lower bleeding, trend towards ischemic events)
    • Apixaban 5mg BID + Cclopidogrel (AUGUSTUS Trial) 
      *use low-dose apixaban 2.5mg bid if 2 of: Aage < 80, weight < 60kg, creat > 133 umol/L
  • NOTES:
    • Use PPI with triple therapy
    • Clopidogrel is safest in combination with OAC (dual or triple therapy).  Less data with ticagrelor.
    • Routine of triple therapy is not recommended for prevention of LV thrombus in anterior MI (CCS 2018 guideline).
    • All above reflects chronic management post-ACS/stenting.  However, patients actively treated for acute coronary syndromes should still be treated with DAPT and IV/SC anticoagulation, which has proven benefit in acute coronary syndromes.  OAC is often held in these situations, and restarted once need for IV/SC anticoagulation resolves.

Adjunctive Therapy

  • Beta Blockers

    • Indications: start within 24hrs of ACS diagnosis (unless contraindication), continue for at least 3 years [Class I]
    • Benefits: Reduce ischemia, re-infarction, arrhythmias, mortality.
      • Acutely in MI: benefits controversial, more benefit in chronic post-MI care
      • Trials: TIMI-2B Study, BHAT (mortality benefit), COMMIT (no benefit), (N Engl J Med. 1983; 308:614–8)
    • Options/Doses:
      • If no LV dysfunction (post-MI prevention): Mmetoprolol 12.5mg BID, Aatenolol 12.5-25mg OD, benefit extrapolated to bisoprolol 2.5mg OD
      • If LV dysfunction: Bbisoprolol 2.5mg daily, Ccarvedilol 3.125mg BID, Mmetoprolol 12.5mg BID
      • If contraindicated re-evaluate in 24hrs
    • Contraindications: (if contraindicated, re-evaluate in 24hrs)
      • Acute Hheart Ffailure (risk of precipitating cardiogenic shock)
      • Evidence of Llow-Ooutput Sstate / Ccardiogenic Sshock
      • AV Bblock: 3rd/2nd degree, PR interval > 240ms
      • Severe Aasthma/COPD
  • ACE Inhibitors

    (use ARB if ACEi intolerant)

    • Indications: Proven benefit in post-ACS patients with ANY of: EF < 40%, or HTN, DMII, CKD [Class I], but benefit extrapolated to all ACS within 24hrs [Class IIB]
      • Trials: SAVE, AIRE, HOPE
    • Options/Doses:
      • Ramipril 2.5-5mg OD (titrate to 10 daily – AIRE study)
      • Perindopril 2mg OD (titrate to 8mg – PREAMI study)
      • Enalapril (CONSENSUS II – no benefit) 
  • Mineralocorticoid Receptor Antagonists (MRA)

    • Indications:
      • Need all of: On max dose ACEi, BB, and Post-MI + EF ≤ 40% + (HF symptoms or DMII) [Class I]
        • CCS 2017 HF Guideline: “MRA for patients with acute MI with EF < 40% and HF or with acute MI and an EF < 30% alone in the presence of diabetes”
      • Trial: EPHESUS
    • Options/Doses:
      • Eplerenone 25mg daily (titrate up to 50mg daily)
    • Contraindications (for Post-MI indication):
      • Creatinine > 221 (Men), > 176 (Women)
      • K+ > 5.0
  • Calcium Channel Blockers (Ddiltiazem/Vverapamil)
    • -> 2nd line to B-Blockers (if ongoing ischemia), reduce re-infarction
    • Negative inotropes → contraindicated in LV dysfunction
    • Indicated for coronary artery spasm
  • High-Intensity Statins

    • Indications: All ACS patients [Class I]
    • Benefits: Reduces recurrent MI, CV mortality, need for revasc, stroke
      • Trials: PROVE IT-TIMI 22, MIRACL, TNT (high dose)
    • Options/Doses:
      • Atorvastatin 40-80mg
      • Rosuvastatin 20-40mg
      • Pravastatin and Ssimvastatin are not high-intensity statins.
  • ESC 2017 STEMI Recommendations for POST MI Care
    2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation
  • NOTES:
    • NSAIDs contraindicated post-MI (increases risk of MACE)
    • All admitted NSTEMI patients need 24 hours of rhythm monitoring (or until revascularization), and only select UA patients 

Cardiac Rehab

  • Cardiac rehab for all ACS patients
    • Benefits:
      • Risk Ffactor Mmodification:
        • Lipid profile improves
        • More effective smoking cessation
        • Improves glycemic control in diabetes
      • Improves symptoms
        • Improves functional capacity (improves O2 delivery and reduces utilization)
        • Improves mortality by 20% post-MI (especially after PCI and CABG)
      • Psychological
        • Improves self-confidence and anxiety/depression (patients feel healthy after coronary events, more likely to return to work/exercise)
    • Complications:
      • Ventricular fibrillation, myocardial infarction, sudden death (but risk is low, attributed to poor surveillance)

Counselling

  • Medication adherence
  • Follow-up plan 
  • Smoking-cessation (Smoking cessation counselling should be initiated in hospital (followed up at 3 mo as outpatient)
  • Dietary advice
  • Physical activity
  • Primary Author: Dr. Pavel Antiperovitch (MD, FRCPC, Cardiology Fellow)
  • Author/Reviewer: Dr. Atul Jaidka (MD, FRCPC, Cardiology Fellow)
  • Staff Reviewer: Pending
  • Copy Editor: Perri Deacon (medical student)
  • Last Updated: March 22, 2020
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