Secondary prevention post myocardial infarction


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Antiplatelet therapy

a. aspirin (or clopidogrel if true intolerance to aspirin)

b. aspirin and clopidogrel (or ticagrelor or prasugrel)

Initiate on suspecting a type 1 myocardial infarction (Acute coronary syndrome). Be very cautious about prescribing dual anti-platelets in patients with bradycardias or AV block as clopidogrel causes major problems if a subsequent permanent pacemaker is warranted

a.  continue aspirin or clopidogrel indefinitely

b.  continue single antiplatelet indefinitely and stop second antiplatelet agent after duration advised by local specialist.


eg bisoprolol

Initiate unless patient:  

  • remains hypotensive
  • remains bradycardic
  • is receiving verapamil
  • has heart block or unstable cardiac failure
  • has proven bronchospasm.

If not started immediately, initiate as soon as possible (up to 28 days post- MI) if patient is no longer bradycardic or hypotensive and has no other contra-indications.

ACE inhibitors*

eg perindopril erbumine

Initiate within 24 hours of MI.

Monitor U&Es.

Avoid with potassium-sparing diuretics or potassium supplements.

Measure U&Es 1 to 2 weeks after initiation, after dosage increase and at least annually thereafter.

Lipid-lowering therapy

eg atorvastatin 80mg daily

Indicated in all patients, irrespective of cholesterol level.

Consider drug interactions, see BNF.

Follow up in accordance with the lipid-lowering guidance.

If side-effects occur consider a lower dose or alternative statin.   Review dose annually.

Eplerenone or spironolactone

Initiate if left ventricular dysfunction.

Monitor U&Es.

Continue lifelong.

Monitor U&Es 1 week after starting and annually thereafter if stable.

*In normotensive, non-diabetic, NSTEMI patients with preserved LV function, the potential benefit of beta-blockers and ACE inhibitors is small with a high NNT and therefore it may be decided by the cardiologist not to prescribe these treatments in such patients.

Patient group/treatment



Diabetes mellitus or if blood glucose greater than 11mmol/L on admission.

If type 2 diabetes discontinue oral hypoglycaemic agents and for all patient groups give 24 hours of intravenous insulin according to Integrated Care guidance (opposite), aiming for a blood glucose of 7 to 10mmol/L.

Better control of blood glucose indefinitely. Refer to Management of Hyperglycaemia in Acute MI guidance in the Raigmore Hospital Integrated Care Pathway for Acute Coronary Syndromes.


Hypertension following myocardial infarction.

Initiate antihypertensive treatment.

Follow up, monitor and adjust therapy to obtain target BP.


Abbreviation Meaning
ACE inhibitors Angiotensin-converting-enzyme inhibitors
MI Myocardial Infarction
U+Es Urea and Electrolytes
NSTEMI Non-ST-elevation myocardial infarction
LV Left ventricle
NNT Number needed to treat
BP Blood Pressure

Last reviewed: 29 April 2022

Next review: 29 April 2025

Author(s): Department of Cardiology

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Consultant Cardiologist and Clinical Lead

Document Id: TAM137