For the chapter on Secondary Prevention of Coronary Artery Disease in general, click here.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. ; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. 
Identifying and, when present, treating category I risk factors can be an optimal secondary prevention strategy in patients with STEMI. You can read more about general coronary heart disease secondary prevention HERE
Long-term Medical Therapy and Secondary Prevention
Patients are usually treated with several long-term medications following a ST elevation myocardial infarction with the goal of preventing secondary cardiovascular events such as further myocardial infarctions, congestive heart failure or cerebrovascular accident (CVA). Unless contraindicated, such medications may include:
- ACE inhibitor therapy should be commenced 24-48 hours post-MI in hemodynamically-stable patients, particularly in patients with a history of MI, diabetes mellitus, hypertension, anterior location of infarct (as assessed by EKG), and/or evidence of left ventricular dysfunction. ACE inhibitors reduce mortality, the development of heart failure, and decrease ventricular remodelling post-MI.
- Statin therapy has been shown to reduce mortality and morbidity post-MI. The effects of statins may be more than their LDL lowering effects. The general consensus is that statins have plaque stabilization and multiple other ("pleiotropic") effects that may prevent myocardial infarction in addition to their effects on blood lipids. A study by AJC by Herbert D. Aranow, et al. indicates that, for patients who underwent lipid-lowering therapy prior to having an acute myocardial infarction (AMI), infarct size was significantly less than for patients who had not received this earlier treatment. Data from 10,548 patients were collected from both the Global Use of Streptokinase or t-PA for Occluded Coronary Arteries (GUSTO) IIb (n=6,414) and the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Supression Using Integrilin Therapy (PURSUIT) (n=4,134) studies, with infarct size measured by patients' peak creatine kinase (CK) -MB levels. Patients who had lipid-lowering therapy had a median peak CK-MB of 4.2 times the upper limit of normal (ULN) compared to 5.2 times the ULN for those who were not pre-treated (p<0.0001). These results suggest a potential benefit of lipid-lowering therapy for patients at risk for an AMI. Noted limitations of the study include: the observational study design (both the potential effects of confounding variables and the "healthy-user bias" ); the lack of documented information differentiating between statin and nonstatin therapies; and the exclusion from analysis of patients who died during the index hospitalization.
- The aldosterone antagonist agent eplerenone has been shown to further reduce risk of cardiovascular death post-MI in patients with heart failure and left ventricular dysfunction, when used in conjunction with standard therapies above.
- Omega-3 fatty acids, commonly found in fish, have been shown to reduce mortality post-MI. While the mechanism by which these fatty acids decrease mortality is unknown, it has been postulated that the survival benefit is due to electrical stabilization and the prevention of ventricular fibrillation. However, further studies in a high-risk subset have not shown a clear-cut decrease in potentially fatal arrhythmias due to omega-3 fatty acids.
- Reducing excess weight and exercising regularly.
- Keeping blood pressure and diabetes under check.
- Following a diet low in cholesterol (<200 mg daily) and saturated fat.
- Increasing HDL- Patients with low HDL [A lipoprotein that transports cholesterol in the blood; composed of a high proportion of protein and relatively little cholesterol] (<35 mg/dl) are encouraged to exercise regularly and to take medications to increase HDL levels.
2007 Update of 2004 ACC / AHA Guidelines for the management of ST Segment Elevation Myocardial Infarction - Recommendations for Secondary Prevention (DO NOT EDIT)
Aspirin (DO NOT EDIT)
Clopidogrel (DO NOT EDIT)
|"1. For all post-PCI patients who receive a DES, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). (Level of Evidence: B)"
|"2. For all STEMI patients not undergoing stenting (medical therapy alone or PTCA without stenting), treatment with clopidogrel should continue for at least 14 days. (Level of Evidence: B)"
Warfarin (DO NOT EDIT)
ACE Inhibitors (DO NOT EDIT)
Angiotensin Receptor Blockers (DO NOT EDIT)
Aldosterone Blockade (DO NOT EDIT)
Beta Blockers (DO NOT EDIT)
Influenza Vaccination (DO NOT EDIT)
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction 
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction 
- ↑ Smith A, Aylward P, Campbell T, et al. Therapeutic Guidelines: Cardiovascular, 4th edition. North Melbourne: Therapeutic Guidelines; 2003. ISSN 1327-9513
- ↑ Peters RJ, Mehta SR, Fox KA, et al (October 2003). "Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study". Circulation 108 (14): 1682–7. doi:10.1161/01.CIR.0000091201.39590.CB. PMID 14504182.
- ↑ Yusuf S, Peto R, Lewis J, Collins R, Sleight P (1985). "Beta blockade during and after myocardial infarction: an overview of the randomized trials". Prog Cardiovasc Dis 27 (5): 335–71. PMID 2858114.
- ↑ Dargie HJ (May 2001). "Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial". Lancet 357 (9266): 1385–90. PMID 11356434.
- ↑ Pfeffer MA, Braunwald E, Moyé LA, et al (September 1992). "Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators". N. Engl. J. Med. 327 (10): 669–77. PMID 1386652.
- ↑ Sacks FM, Pfeffer MA, Moye LA, et al (October 1996). "The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators". N. Engl. J. Med. 335 (14): 1001–9. PMID 8801446.
- ↑ Sacks FM, Moyé LA, Davis BR, et al (April 1998). "Relationship between plasma LDL concentrations during treatment with pravastatin and recurrent coronary events in the Cholesterol and Recurrent Events trial". Circulation 97 (15): 1446–52. PMID 9576424.
- ↑ Ray KK, Cannon CP (October 2005). "The potential relevance of the multiple lipid-independent (pleiotropic) effects of statins in the management of acute coronary syndromes". J. Am. Coll. Cardiol. 46 (8): 1425–33. doi:10.1016/j.jacc.2005.05.086. PMID 16226165.
- ↑ Keating GM, Plosker GL (2004). "Eplerenone : a review of its use in left ventricular systolic dysfunction and heart failure after acute myocardial infarction". Drugs 64 (23): 2689–707. PMID 15537370.
- ↑ (August 1999) "Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico". Lancet 354 (9177): 447–55. PMID 10465168.
- ↑ Leaf A, Albert CM, Josephson M, et al (November 2005). "Prevention of fatal arrhythmias in high-risk subjects by fish oil n-3 fatty acid intake". Circulation 112 (18): 2762–8. doi:10.1161/CIRCULATIONAHA.105.549527. PMID 16267249.
- ↑ Brouwer IA, Zock PL, Camm AJ, et al (June 2006). "Effect of fish oil on ventricular tachyarrhythmia and death in patients with implantable cardioverter defibrillators: the Study on Omega-3 Fatty Acids and Ventricular Arrhythmia (SOFA) randomized trial". JAMA 295 (22): 2613–9. doi:10.1001/jama.295.22.2613. PMID 16772624.
- ↑ Raitt MH, Connor WE, Morris C, et al (June 2005). "Fish oil supplementation and risk of ventricular tachycardia and ventricular fibrillation in patients with implantable defibrillators: a randomized controlled trial". JAMA 293 (23): 2884–91. doi:10.1001/jama.293.23.2884. PMID 15956633.
- ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 14.9 Antman EM, Hand M, Armstrong PW, et al (January 2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078.
- ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (August 2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation 110 (9): e82–292. PMID 15339869.