Heart Failure Prevention Post–Myocardial Infarction: 5 Things to Know

Musa A. Sharkawi, MBBCh; Ajar Kochar, MD, MHS

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May 28, 2020

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2. The timely introduction and gradual uptitration of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are fundamental to reducing post-MI morbidity and mortality.

ACE inhibitors reduce patient mortality, readmissions for HF, and reinfarction when initiated post-MI; however, early initiation (ie, within the first 24 hours of MI symptom onset) of these drugs is critical to achieve maximum patient benefit. A prospective systematic overview of four randomized trials of ACE inhibitor use in STEMI demonstrated that 40% of the 30-day survival benefit occurred on the first day of treatment.

For patients who are intolerant to ACE inhibitors, ARBs are an alternative treatment. Specifically, valsartan was shown to be noninferior to captopril in patients with ejection fraction (EF) ≤ 35% post-MI in the VALIANT trial.

Contraindications to consider prior to administering ACE inhibitors or ARBs include renal failure and drug allergy. The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Guideline for the Management of ST-Elevation Myocardial Infarction recommend that an ACE inhibitor should be given "within the first 24 hours to all patients with STEMI with anterior location, HF, or EF less than or equal to 0.40%, unless contraindicated."

3. While beta-blockers are an integral part of post-MI treatment, early introduction of these drugs can be harmful to patients with post-MI HF.

Long-term treatment with beta-blockers post-MI reduces the risk for reinfarction and death by approximately 20%-25% after a mean of 2 years. Beta-blockers, which reduce myocardial oxygen consumption by lowering the heart rate, afterload, and myocardial contractility, have an important role in reducing ventricular arrhythmias and possibly even infarct size.

Although long-term beta-blocker use has been shown to reduce the risk for hospitalization by approximately 40% in patients with HF, early administration during the first 24 hours post-MI is associated with a higher rate of cardiogenic shock and death in patients with HF when compared with placebo.

Patients for whom the use of beta-blockers was initially contraindicated in the first 24 hours following STEMI should be reevaluated to determine later eligibility for this therapy. Initially starting short-acting beta-blockers can make titration easier, with a preference for the long-term use of extended-release carvedilol, or metoprolol in those patients with HF or LV systolic dysfunction.

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