Drug therapy
Offer all people who have had an acute MI treatment with the following drugs:

ACE (angiotensin-converting enzyme) inhibitor
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
beta-blocker
statin.
Ensure that a clear management plan is available to the person who has had an MI and is also sent to the GP, including:

details and timing of any further drug titration
monitoring of blood pressure
monitoring of renal function.
Offer all people who have had an MI an assessment of bleeding risk at their follow-up appointment.

Offer an assessment of left ventricular function to all people who have had an MI.

ACE inhibitors
Offer people who present acutely with an MI an ACE inhibitor as soon as they are haemodynamically stable. Continue the ACE inhibitor indefinitely.

Titrate the ACE inhibitor dose upwards at short intervals (for example, every 12–24 hours) before the person leaves hospital until the maximum tolerated or target dose is reached. If it is not possible to complete the titration during this time, it should be completed within 4–6 weeks of hospital discharge.

Do not offer combined treatment with an ACE inhibitor and an angiotensin II receptor blocker (ARB) to people after an MI, unless there are other reasons to use this combination.

Offer people after an MI who are intolerant to ACE inhibitors an ARB instead of an ACE inhibitor.

Renal function, serum electrolytes and blood pressure should be measured before starting an ACE inhibitor or ARB and again within 1 or 2 weeks of starting treatment. Patients should be monitored as appropriate as the dose is titrated upwards, until the maximum tolerated or target dose is reached, and then at least annually.
More frequent monitoring may be needed in patients who are at increased risk of deterioration in renal function. Patients with chronic heart failure should be monitored in line with Chronic heart failure (NICE clinical guideline 108).

Offer an ACE inhibitor to people who have had an MI more than 12 months ago. Titrate to the maximum tolerated or target dose (over a 4–6-week period) and continue indefinitely.

Offer people who have had an MI more than 12 months ago and who are intolerant to ACE inhibitors an ARB instead of an ACE inhibitor. [new 2013]

Antiplatelet therapy

Offer aspirin to all people after an MI and continue it indefinitely, unless they are aspirin intolerant or have an indication for anticoagulation.

Offer aspirin to people who have had an MI more than 12 months ago and continue it indefinitely.

For patients with aspirin hypersensitivity, clopidogrel monotherapy should be considered as an alternative treatment.

People with a history of dyspepsia should be considered for treatment in line with Dyspepsia (NICE clinical guideline 17).

After appropriate treatment, people with a history of aspirin-induced ulcer bleeding whose ulcers have healed and who are negative for Helicobacter pylori should be considered for treatment in line with Dyspepsia (NICE clinical guideline 17).

This guidance incorporates NICE technology appraisal guidance 236 on ticagrelor for the treatment of acute coronary syndromes. Guidance on prasugrel for the treatment of acute coronary syndromes has not been incorporated in this guidance because this technology appraisal is currently scheduled for update.

Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months as a treatment option in adults with acute coronary syndromes (ACS) that is, people:

with ST-segment-elevation myocardial infarction (STEMI) – defined as ST elevation or new left bundle branch block on electrocardiogram – that cardiologists intend to treat with primary percutaneous coronary intervention (PCI) or
with non-ST-segment-elevation myocardial infarction (NSTEMI)

Offer clopidogrel as a treatment option for up to 12 months to:

people who have had an NSTEMI, regardless of treatment[1]
people who have had a STEMI and received a bare-metal or drug-eluting stent.

Offer clopidogrel as a treatment option for at least 1 month and consider continuing for up to 12 months to:

people who have had a STEMI and medical management with or without reperfusion treatment with a fibrinolytic agent.
Continue the second antiplatelet agent for up to 12 months in people who have had a STEMI and who received coronary artery bypass graft (CABG) surgery. [new 2013]

Offer clopidogrel instead of aspirin to people who also have other clinical vascular disease, in line with Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (NICE technology appraisal guidance 210), and who have:

had an MI and stopped dual antiplatelet therapy or
had an MI more than 12 months ago.
Antiplatelet therapy in people with an indication for anticoagulation

Take into account all of the following when thinking about treatment for people who have had an MI and who have an indication for anticoagulation:

bleeding risk
thromboembolic risk
cardiovascular risk.
Unless there is a high risk of bleeding, continue anticoagulation and add aspirin to treatment in people who have had an MI who otherwise need anticoagulation and who:

have had their condition managed medically or
have undergone balloon angioplasty or
have undergone CABG surgery.
Continue anticoagulation and add clopidogrel to treatment in people who have had an MI, who have undergone percutaneous coronary intervention (PCI) with bare-metal or drug-eluting stents and who otherwise need anticoagulation.

Offer clopidogrel with warfarin to people with a sensitivity to aspirin who otherwise need anticoagulation and aspirin and who have had an MI.

Do not routinely offer warfarin in combination with prasugrel or ticagrelor to people who need anticoagulation who have had an MI.

After 12 months since the MI, continue anticoagulation and take into consideration the need for ongoing antiplatelet therapy, taking into account all of the following:

the indication for anticoagulation
thromboembolic risk
bleeding risk
cardiovascular risk
the person’s wishes.
Do not add a new oral anticoagulant (rivaroxaban, apixaban or dabigatran) in combination with dual antiplatelet therapy in people who otherwise need anticoagulation, who have had an MI.

Consider using warfarin and discontinuing treatment with a new oral anticoagulant (rivaroxaban, apixaban or dabigatran) in people who otherwise need anticoagulation and who have had an MI, unless there is a specific clinical indication to continue it.

Beta-blockers
Offer people a beta-blocker as soon as possible after an MI, when the person is haemodynamically stable.

Communicate plans for titrating beta-blockers up to the maximum tolerated or target dose – for example, in the discharge summary.

Continue a beta-blocker for at least 12 months after an MI in people without left ventricular systolic dysfunction or heart failure.

Continue a beta-blocker indefinitely in people with left ventricular systolic dysfunction.

Offer all people who have had an MI more than 12 months ago, who have left ventricular systolic dysfunction, a beta-blocker whether or not they have symptoms. For people with heart failure plus left ventricular dysfunction, manage the condition in line with Chronic heart failure (NICE clinical guideline 108).

Do not offer people without left ventricular systolic dysfunction or heart failure, who have had an MI more than 12 months ago, treatment with a beta-blocker unless there is an additional clinical indication for a beta-blocker. [new 2013]

Calcium channel blockers
Do not routinely offer calcium channel blockers to reduce cardiovascular risk after an MI.

If beta-blockers are contraindicated or need to be discontinued, diltiazem or verapamil may be considered for secondary prevention in patients without pulmonary congestion or left ventricular systolic dysfunction. [2007]

For patients who are stable after an MI, calcium channel blockers may be used to treat hypertension and/or angina.
For patients with heart failure, use amlodipine, and avoid verapamil, diltiazem and short-acting dihydropyridine agents in line with Chronic heart failure (NICE clinical guideline 108).

Potassium channel activators
Do not offer nicorandil to reduce cardiovascular risk in patients after an MI.

Aldosterone antagonists in patients with heart failure and left ventricular dysfunction

For patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, initiate treatment with an aldosterone antagonist licensed for post-MI treatment within 3–14 days of the MI, preferably after ACE inhibitor therapy.

Patients who have recently had an acute MI and have clinical heart failure and left ventricular systolic dysfunction, but who are already being treated with an aldosterone antagonist for a concomitant condition (for example, chronic heart failure), should continue with the aldosterone antagonist or an alternative, licensed for early post-MI treatment.

For patients who have had a proven MI in the past and heart failure due to left ventricular systolic dysfunction, treatment with an aldosterone antagonist should be in line with Chronic heart failure (NICE clinical guideline 108).

Monitor renal function and serum potassium before and during treatment with an aldosterone antagonist. If hyperkalaemia is a problem, halve the dose of the aldosterone antagonist or stop the drug.

Statins and other lipid lowering agents
Statin therapy is recommended for adults with clinical evidence of cardiovascular disease in line with Statins for the prevention of cardiovascular events (NICE technology appraisal guidance 94) and Lipid modification (NICE clinical guideline 67).

NICE-UK.

G Mohan.