CHECKLIST AND LONG TERM POST ACS MANAGEMENT

Risk stratification

• Stress test if anatomy undefined; consider stress if signif residual CAD post-PCI of culprit
• Assess LVEF prior to d/c; EF ↑ ~6% in STEMI over 6 mo (JACC 2007;50:149)

Antiplatelet therapy

• Aspirin: 81 mg daily (no clear benefit to higher doses)
• P2Y12 inhibitor: ticagrelor or prasugrel preferred over clopi. In landmark analyses, benefit over clopidogrel both early & late. De-escalation (ticag → clopi or pras 10 → 5 mg) after 1 mo ↓ bleeding w/o clear ↑ MACE, but wide CIs (Lancet 2020;396:1079 & 2021;398:1305).
• Duration controversial. Traditionally ASA lifelong and P2Y12 inhib for 12 mos. Prolonged P2Y12 inhib >12 mos → ↓ MACE but ↑ bleeding (NEJM 2014;371:2155 & 2015;372:1791). Consider if high ischemic and low bleeding risk. Shorter duration (eg, 3–6 mo) if converse or if require major surgery. D/c ASA after 1–3 mos and continuing P2Y12 inhib monoRx (preferably ticagrelor) ↓ bleeding with no ↑ MACE (Circ 2020;142:538).

Anticoagulation

• If need therapeutic a/c (eg, AF) in addition to anti-plt Rx, consider full-dose apixa + P2Y12 (typically clopi) and d/c ASA at time of hospital d/c (NEJM 2019;380:1509)
• In Pts w/o indic. for anticoag, once DAPT completed, rivaroxaban 2.5 bid + ASA ↓ MACE & CV death and ↑ bleeding vs. ASA monoRx (NEJM 2017;377:1319)

Other CV drugs

• β-blocker: 23% ↓ mortality after MI (benefit beyond 3 yrs less clear)

• ACEI/ARB: lifelong if HF, ↓ EF, HTN, DM; 4–6 wk or at least until hosp. d/c in all STEMI. Trend toward ARNI better than ACEI in post-MI Pts w/ ↓ EF (NEJM 2021;385:1845). ? long-term benefit of ACEI/ARB in CAD w/o HF (NEJM 2000;342:145)

• Aldosterone antag: 15% ↓ mort. if EF <40% & either s/s of HF or DM (NEJM 2003;348:1309)

• Nitrates: standing if symptomatic; SL NTG prn for all

• Ranolazine: ↓ recurrent ischemia, no impact on CVD/MI (JAMA 2007;297:1775)

• Low dose colchicine ↓ CV events post MI but ? ↑ PNA (NEJM 2019; 381:2497)

Risk factors and lifestyle modifications (Circ 2019;139:e1082 & EHJ 2020;41:111)

• LDL-C: goal <70 mg/dL (U.S) or <55 (Europe) or even <40 if recurrent events Statin: high-intensity (eg, atorva 80 mg, PROVE-IT TIMI 22, NEJM 2004;350:1495) Ezetimibe: ↓ CV events when added to statin (IMPROVE-IT, NEJM 2015;372:1500) PCSK9 inhibitor: ↓ CV events when added to statin (NEJM 2017;376:1713; 2018;379:2097)

• BP <140/90 and <130/80; quit smoking

• If diabetic, GLP1-RA ↓ MACE & SGLT2i ↓ hospitalization for HF (Lancet D&E 2019;7:776 & Lancet 2019;393:31); further tailor HbA1c goal based on Pt (avoid TZDs and saxa if HF)

• Exercise (30–60′ 5–7×/wk) 1–2 wk after revasc; cardiac rehab; BMI goal 18.5–24.9 kg/m2

• Influenza & S. pneumo vaccines (Circ 2021;144:14764 NEJM 2018;378:345); ✓ for depression

ICD (Circ 2018;138:e272)

• Sust. VT/VF >2 d post-MI w/o revers. isch; ? ↓ death w/ wearable defib (NEJM 2018;379:1205)
• 1° prevention of SCD if post-MI EF ≤30–40% (NYHA II–III) or ≤30–35% (NYHA I); wait 40 d after MI (NEJM 2004;351:2481 & 2009;361:1427)