My Synopsis of "Myocardial Infarction: Management of the Subacute Period"

Myocardial Infarction: Management of the Subacute Period
MICHAEL G. MERCADO, MD, Naval Hospital Camp Pendleton Family Medicine Residency Program, Camp Pendleton, California DUSTIN K. SMITH, DO, U.S, Naval Hospital Guam, Agana Heights, Guam MICHAEL L. MCCONNON, MD, Naval Hospital Pensacola Family Medicine Residency Program, Pensacola, Florida
Am Fam Physician. 2013 Nov 1;88(9):581-588.

     Acute management of an MI usually starts with aspirin/clopidogrel, anticoagulation, fibrinolysis, echo and angiography. Depending on the LVEF and the results of the angiogram, a bypass, PCI stenting, or medical management will be recommended. Discharge medication will be prescribed depending on the situation. 
     All patients will be given aspirin indefinitely. The dose should be lowered at discharge. Patients who have an allergy to aspirin can take clopidogrel. Dual antiplatelet therapy (aspirin and clopidogrel or other P2Y12 inhibitor) is recommended for up to a year in patients with bear metal stents and at least a year in patients with drug-eluting stents. Post MI patients can be given dual therapy of 2 different P2Y12 inhibitors (clopidogrel and ticagrelor) for up to a year. A PPI can be added in patients with GI bleeding. 
     Beta blockers may be started gradually and indefinitely on patients with a LVEF less than 40%. Mortality benefit had not been documented for the first month post MI. It can be started within 24 hours after an event. It may not benefit patients who had a remote history of MI. Patients with preserved systolic function can take it for at least three years. 
     All post MI patients with a history of hypertension, diabetes, heart failure, chronic kidney injury or LVEF less than 40% should be on an ACEI. It should be continued indefinitely. ARBs can be used on those patients who cannot tolerate ACEIs. The two medications should not be used together. Aldosterone blockers (eplerenone) can reduce mortality in post MI patients with a low LVEF, diabetes or signs of heart failure. The creatinine clearance should be above 30 and the potassium should be less than 5. 
     Statins should be started and continued indefinitely on these patients before they are discharged. Patients already on a statin may benefit from a higher dose (up to 80 mg/day). The dose can be titrated to get an LDL less than 70-100. 
    Discharge planning is an important tool which is not always done properly. It includes medication review, patient education, referral to cardiac rehab, activity and lifestyle recommendations, and a follow up plan. Sexual activity can resume in a week. Driving can start in three weeks. Air travel should be halted for two weeks. Physical activity can be resumes as tolerated