Myocardial Infarction: Secondary Prevention

A 55-year-old man is admitted following an anterior myocardial infarction. Which of the following drugs is least likely to reduce mortality in the long-term?
A. Atorvastatin
B. Atenolol
C. Ramipril
D. Aspirin
E. Isosorbide mononitrate

Answer:
E. Isosorbide mononitrate

Discussion: Isosorbide mononitrate may be important in managing symptoms yet it has no proven mortality benefit following a myocardial infarction

Myocardial infarction: secondary prevention
NICE produced guidelines on the management of patients following a myocardial infarction (MI) in 2013. Some key points are listed below

All patients should be offered the following drugs:
 dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
 ACE inhibitor
 beta-blocker
 statin

Some selected lifestyle points:
 diet: advise a Mediterranean style diet, switch butter and cheese for plant oil based products. Do not recommend omega-3 supplements or eating oily fish
 exercise: advise 20-30 mins a day until patients are 'slightly breathless'
 sexual activity may resume 4 weeks after an uncomplicated MI. Reassure patients that sex does not increase their likelihood of a further MI. PDE5 inhibitors (e.g, sildenafil) may be used 6 months after a MI. They should however be avoided in patient prescribed either nitrates or nicorandil

Clopidogrel
 since clopidogrel came off patent it is now much more widely used post-MI
 STEMI: the European Society of Cardiology recommend dual antiplatelets for 12 months. In the UK this means aspirin + clopidogrel
 non-ST segment elevation myocardial infarction (NSTEMI): following the NICE 2013 Secondary prevention in primary and secondary care for patients following a myocardial infarction guidelines clopidogrel should be given for the first 12 months

Aldosterone antagonists
 patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment (e.g. eplerenone) should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy