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← Cardiology indexChapter sections
Role and principlesAssessment and patient selectionBaseline assessmentInterventionsMedicines and treatment safetyTargets, monitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Secondary prevention after myocardial infarction

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull

Role and principles

Build and monitor the UK post-MI package that reduces recurrent atherothrombotic events, heart failure and preventable treatment harm.

Secondary prevention begins in hospital and must leave hospital as a reconciled, dated plan: indication, dose, intended duration, monitoring and who will titrate. The plan differs when there is atrial fibrillation, recent PCI, bleeding or LV thrombus.

NICE separates lifelong vascular protection from time-limited therapy. Aspirin, lipid lowering and ACE inhibition are generally long term; the second antiplatelet and some beta-blocker use require planned review.

Cardiac rehabilitation links prescribing with exercise, education, risk-factor change and psychological recovery and should be offered irrespective of age.

Key points

  • After MI, the core package is antiplatelet therapy, high-intensity lipid lowering, an ACE inhibitor (or ARB if intolerant), appropriate beta-blockade, lifestyle support and cardiac rehabilitation.
  • Aspirin 75 mg daily is normally continued indefinitely; dual antiplatelet therapy is usually continued for up to 12 months, but the chosen P2Y12 inhibitor and duration depend on ACS strategy, bleeding risk and any anticoagulation indication.
  • Offer atorvastatin 80 mg unless a lower dose is justified; NICE secondary-prevention targets are LDL cholesterol 2.0 mmol/L or less, or non-HDL cholesterol 2.6 mmol/L or less.
  • Start and titrate an ACE inhibitor once clinically and haemodynamically stable; check BP, renal function and electrolytes before treatment and 1–2 weeks after initiation or dose change.
  • Early MRA therapy is for recent MI with clinical heart failure plus LV systolic dysfunction, not for every uncomplicated MI.
  • Beta-blocker duration is clearest when LV systolic dysfunction or another indication persists; NICE advises discussing stopping after 12 months when LVEF is preserved and there is no other indication.
  • Smoking cessation, Mediterranean-style eating, physical activity, weight, BP, diabetes, psychosocial health and medicine adherence are active treatments, not discharge footnotes.

Assessment and patient selection

High recurrent-ischaemic risk

Multivessel disease, diabetes, CKD, recurrent MI, complex PCI or prior stent thrombosis may favour more intensive antithrombotic/lipid strategies after bleeding assessment.

High bleeding risk

Prior bleeding, anaemia, frailty, CKD, low body weight, anticoagulation and interacting medicines require an individual antithrombotic plan rather than automatic 12-month DAPT.

Post-MI LV dysfunction

Clinical heart failure or reduced LVEF changes beta-blocker, MRA and device follow-up; document LVEF before discharge or arrange timely imaging.

Statin intolerance or inadequate response

Confirm adherence and reversible causes, use the maximum tolerated statin, then follow NICE escalation to ezetimibe and further lipid-lowering options where criteria are met.

Psychosocial and access barriers

Depression, fear of exertion, work or transport problems, language needs and health beliefs commonly undermine rehabilitation and adherence unless explicitly addressed.

Baseline assessment

  1. 01
    Lipid profileFirst step
    Why
    Establish baseline and assess response to high-intensity therapy.
    Interpretation and limitations
    Repeat at about 2–3 months after starting or changing therapy; for secondary prevention aim for LDL-C ≤2.0 mmol/L or non-HDL-C ≤2.6 mmol/L under NICE NG238.
  2. 02
    U&E, creatinine/eGFR and potassium
    Why
    Safely start and titrate ACE inhibitor/ARB and MRA.
    Interpretation and limitations
    Check at baseline and 1–2 weeks after initiation or increments; respond to significant creatinine or potassium change through the current NICE heart-failure/renal route.
  3. 03
    Blood pressure and pulse
    Why
    Guide ACE inhibitor and beta-blocker titration and identify hypotension or bradycardia.
    Interpretation and limitations
    Assess symptoms and postural BP, not a single seated value alone.
  4. 04
    Echocardiography
    Why
    Quantify LVEF and detect wall-motion abnormality, valve complications or thrombus.
    Interpretation and limitations
    Reduced LVEF determines heart-failure therapy and later ICD/CRT reassessment after optimisation.
  5. 05
    HbA1c, smoking status, weight/BMI and renal profile
    Why
    Find modifiable cardiometabolic risk and comorbidity.

Interventions

01First-lineBefore dischargeFirst stepFirst lineAny confirmed MI+
  1. 1Reconcile aspirin plus the indicated P2Y12 inhibitor, recording the intended DAPT end/review date and any anticoagulant interaction.
  2. 2Start atorvastatin 80 mg unless a lower intensity is justified, and start ACE inhibition once stable; add beta-blocker when appropriate.
  3. 3Assess LVEF; add an MRA through the post-MI heart-failure route when clinical HF and LV systolic dysfunction are present.
  4. 4Refer directly to cardiac rehabilitation and provide smoking, diet, activity, driving, work and safety-net advice.
02Second-lineEarly optimisationSecond lineFirst weeks after discharge+

Medicines and treatment safety

Lifelong single-antiplatelet backbone after MI unless aspirin intolerance or an anticoagulation-led alternative plan applies.

Aspirin

75 mg orally once daily long term after the acute loading phase.

Active bleeding, aspirin hypersensitivity and peptic-ulcer risk; review gastroprotection and interactions. Do not duplicate over-the-counter aspirin/NSAIDs.

P2Y12 inhibition with low-dose aspirin; agent and duration are determined by ACS/PCI and bleeding risk.

Ticagrelor

After a 180 mg loading dose, 90 mg orally twice daily for up to 12 months in ACS when selected; 60 mg twice daily is the separate extended-treatment dose for eligible high-risk patients beyond 1 year.

Active bleeding or previous intracranial haemorrhage; dyspnoea, bradyarrhythmia and CYP3A interactions. Do not extrapolate the 90 mg regimen beyond its intended period.

High-intensity lipid lowering for secondary prevention regardless of baseline cholesterol.

Atorvastatin

80 mg orally once daily; use a lower dose only when interactions, adverse-effect risk or preference makes 80 mg unsuitable.

Check interactions, pregnancy potential and muscle/liver symptoms; unexplained severe muscle pain or weakness needs urgent CK/renal assessment.

Targets, monitoring and follow-up

  • Bleeding, bruising, haemoglobin where indicated and the documented stop/review date for dual antiplatelet therapy.
  • BP, pulse and postural symptoms during ACE-inhibitor and beta-blocker titration.
  • Creatinine/eGFR and potassium before and 1–2 weeks after ACE inhibitor/ARB/MRA initiation or dose increase.
  • Lipid profile about 2–3 months after starting or changing treatment, then at clinically appropriate review.
  • LVEF after recovery/optimised therapy when initial systolic dysfunction may confer ICD or CRT eligibility.
  • Smoking, activity, diet, weight, HbA1c where relevant, mood, rehabilitation participation and medicine adherence.

Special situations

Dates prevent harm

The discharge summary should state why each antithrombotic is prescribed and when it must be reviewed or stopped.

NICE and ESC lipid targets differ

For a UK NICE pathway use LDL-C ≤2.0 mmol/L or non-HDL-C ≤2.6 mmol/L; do not silently substitute a more aggressive European target in an NHS plan.

Beta-blockers are not one-size-fits-all

Ongoing benefit is clearest with LVEF reduction or another indication; preserved-LVEF use needs a planned 12-month review under NICE.

MRA is phenotype-specific

Post-MI eplerenone is triggered by clinical heart failure plus LV systolic dysfunction and safe renal/potassium status.

Rehabilitation is treatment

Referral alone is insufficient: check contact, start and completion, and address access barriers with alternative delivery modes.

Common pitfalls

  1. 01

    Discharging on DAPT without naming the agent, indication and review/stop date.

  2. 02

    Using a low-dose statin by default instead of atorvastatin 80 mg or documenting why not.

  3. 03

    Starting or titrating ACE inhibitor/MRA without planned renal and potassium checks.

  4. 04

    Continuing a beta-blocker indefinitely after an uncomplicated MI with preserved LVEF without reviewing indication.

  5. 05

    Treating cardiac-rehabilitation referral as completed care without confirming uptake.

Practice

Two practice questions

Your practice draft is saved in this browser.

Question 1 of 2
0 correct
CardiologyOriginal SBA

Long-term antiplatelet backbone

A patient is 14 months after an uncomplicated MI, has completed the agreed dual-antiplatelet course and has no anticoagulation indication or aspirin intolerance. Which antiplatelet plan is the standard NICE route?

Choose one answer, then submit
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG185: Acute coronary syndromesPost-MI medicines, lifestyle and rehabilitation.
  • NICE NG238: Cardiovascular risk and lipid modificationSecondary-prevention statin intensity and UK lipid targets.
  • NICE CKS: MI secondary preventionPrimary-care implementation and monitoring.
  • Ramipril 2.5 mg tablets SmPCLicensed post-MI dosing and cautions.
  • Eplerenone 25 mg tablets SmPCLicensed post-MI HF dosing and potassium monitoring.
  • Ticagrelor 90 mg tablets SmPCACS dosing and duration.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
Interpretation and limitations
Use results to activate NICE diabetes, hypertension, CKD and stop-smoking pathways rather than merely record them.
1
Review symptoms, adherence, bleeding, BP, pulse, renal function and potassium; titrate ACE inhibitor and beta-blocker toward tolerated evidence-based doses.
  • 2Ensure rehabilitation contact and address practical or psychological barriers; re-offer if attendance lapses.
  • 3Clarify chest-pain action plan and avoid non-prescribed NSAIDs; check gastroprotection need where bleeding risk is increased.
  • 4Arrange repeat ventricular-function assessment when reduced LVEF could lead to device therapy.
    • 03Third-lineLipid and antithrombotic escalationThird lineEscalationTarget not reached or competing thrombotic/bleeding risks+
    1. 1Repeat lipid profile after about 2–3 months; confirm adherence and maximum tolerated statin.
    2. 2Add ezetimibe and use NICE technology-appraisal routes for further therapy when targets remain unmet and eligibility is satisfied.
    3. 3For AF, LV thrombus or another anticoagulation indication, obtain a cardiology-led combined antithrombotic plan with explicit stop dates.
    4. 4Consider extended ticagrelor only for eligible high-risk people beyond one year after MI after bleeding-risk review under NICE TA420.
    04EscalationLong-term reviewEscalationAt least annual review or earlier deterioration+
    1. 1Review angina, dyspnoea, exercise tolerance, mood, smoking, BP, lipids, glycaemia, renal function and adherence.
    2. 2Continue aspirin, statin and ACE inhibitor long term unless contraindicated; reassess each drug's indication and tolerance.
    3. 3At 12 months, review the P2Y12 inhibitor and beta-blocker plan rather than allowing time-limited medicines to continue unintentionally.
    4. 4Re-refer for cardiology assessment with recurrent angina, heart failure, arrhythmia, syncope or treatment-limiting adverse effects.
    ACE-inhibitor secondary prevention after MI; the exact dose shown is the licensed ramipril post-MI-with-heart-failure schedule.

    Ramipril

    NICE recommends starting an ACE inhibitor once haemodynamically stable after MI. The cited ramipril SmPC's licensed post-MI regimen specifically applies when clinical heart-failure signs are present: start after 48 hours at 2.5 mg orally twice daily for 3 days (1.25 mg twice daily if 2.5 mg is not tolerated), then double at 1–3-day intervals toward 5 mg twice daily.

    Check BP, creatinine/eGFR and potassium; contraindicated in pregnancy and previous ACE-inhibitor angioedema. Avoid ACE inhibitor plus ARB.

    Reduces adrenergic drive; strongest long-term indication is LV systolic dysfunction, heart failure, angina or arrhythmia.

    Bisoprolol

    If treating stable systolic HF, start 1.25 mg orally once daily and stepwise titrate to 10 mg once daily as tolerated; a post-MI dose without HF is individualised to heart rate, BP and indication.

    Do not start during shock or acute decompensation; bradycardia, AV block, asthma and hypotension require assessment. Avoid abrupt withdrawal.

    MRA for recent MI with LV systolic dysfunction and clinical heart failure in addition to standard therapy.

    Eplerenone

    25 mg orally once daily, usually started 3–14 days after MI, titrating to 50 mg once daily within about 4 weeks if potassium and renal function allow; with creatinine clearance 30–60 mL/min, the cited SmPC starts 25 mg on alternate days.

    Do not start if potassium >5.0 mmol/L or eGFR is below 30 mL/min/1.73 m². Measure potassium before treatment, within the first week and at 1 month after starting or changing dose, then periodically; reduce or withhold according to potassium and review interacting potassium-raising drugs.