1. Dual Antiplatelet Therapy (DAPT) Duration
1.1 Standard DAPT Duration After ACS
The default DAPT duration (aspirin + P2Y12 inhibitor) after ACS with PCI is 12 months, regardless of stent type. However, the optimal duration is increasingly individualized based on the balance of ischemic and bleeding risk.
| Scenario | Recommended DAPT Duration | Evidence/Rationale |
|---|
| ACS with PCI (standard risk) | 12 months (Class I, LOE A) | Default duration supported by landmark trials (PLATO, TRITON-TIMI 38, CURE) |
| ACS with PCI, high bleeding risk (HBR) | Shortened DAPT: 3-6 months, then aspirin or P2Y12 inhibitor monotherapy | ARC-HBR criteria define high bleeding risk; trials (TWILIGHT, TICO, STOPDAPT-2 ACS) support shorter DAPT in HBR patients |
| ACS with PCI, high ischemic risk, low bleeding risk | Extended DAPT: 12-36 months (or longer) | DAPT Study, PEGASUS-TIMI 54: prolonged DAPT reduced MI and stent thrombosis but increased bleeding |
| ACS managed medically (no PCI) | 12 months (Class I) | Same duration for medically managed ACS |
| ACS with CABG | Resume P2Y12 inhibitor as soon as feasible post-CABG (within 24-96 hours depending on bleeding status); continue for up to 12 months total from ACS event | Evidence supports DAPT after ACS regardless of revascularization strategy |
1.2 Shortened DAPT (< 12 Months) — When to Consider
The international cardiology guidelines committee and the cardiovascular intervention expert panel have endorsed shorter DAPT durations in patients at high bleeding risk:
ARC-HBR (Academic Research Consortium — High Bleeding Risk) Criteria:
| Major Criteria (any one = HBR) | Minor Criteria (any two = HBR) |
|---|
| Oral anticoagulation anticipated at discharge | Age ≥ 75 years |
| Severe or end-stage CKD (eGFR < 30) | Moderate CKD (eGFR 30-59) |
| Hemoglobin < 11 g/dL | Hemoglobin 11-12.9 g/dL (men) or 11-11.9 g/dL (women) |
| Spontaneous bleeding requiring hospitalization/transfusion in past 6 months | Spontaneous bleeding requiring hospitalization/transfusion > 6 months ago |
| Thrombocytopenia (platelet count < 100,000/μL) | Chronic NSAID or steroid use |
| Chronic bleeding diathesis | Any ischemic stroke at any time |
| Active malignancy (excluding non-melanoma skin cancer) within past 12 months | — |
| Prior spontaneous ICH at any time | — |
| Prior traumatic ICH within past 12 months | — |
| Brain AVM | — |
| Moderate or severe hepatic disease | — |
| Major surgery or major trauma within 30 days | — |
Shortened DAPT protocols:
| Duration | Post-DAPT Strategy | Supporting Trial |
|---|
| 1 month DAPT → P2Y12 monotherapy | Ticagrelor monotherapy (TWILIGHT-like design in very HBR) | Limited data; for extreme HBR |
| 3 months DAPT → P2Y12 monotherapy | Ticagrelor or clopidogrel monotherapy | TICO, TWILIGHT, GLOBAL LEADERS |
| 6 months DAPT → P2Y12 or aspirin monotherapy | Clopidogrel monotherapy or aspirin alone | SMART-CHOICE, STOPDAPT-2 |
1.3 Extended DAPT (> 12 Months) — When to Consider
| Indication for Extended DAPT | Duration | Agent | Evidence |
|---|
| High ischemic risk without high bleeding risk | 12-36 months | Continue ticagrelor 90 mg BID (or reduce to 60 mg BID per PEGASUS-TIMI 54) + aspirin 81 mg | DAPT Study: 30 months of DAPT reduced stent thrombosis and MI; PEGASUS-TIMI 54: ticagrelor 60 mg BID + aspirin beyond 12 months reduced CV death/MI/stroke vs aspirin alone in post-MI patients at 3-year follow-up |
| Prior MI (1-3 years post-event) with additional risk factors | Up to 36 months | Ticagrelor 60 mg BID + aspirin 81 mg | PEGASUS-TIMI 54; benefit greatest in first year post-MI, within 2 years of qualifying event; NNT ~77 for CV death/MI/stroke over 3 years; NNH ~100 for major bleeding |
| Recurrent ACS on DAPT | Individualized | Continue potent P2Y12 inhibitor; consider switching to alternative agent | Clinical judgment; may reflect clopidogrel resistance (switch to ticagrelor) or ongoing high-risk plaque biology |
1.4 DAPT Score (Predicting Benefit of Extended DAPT)
| Variable | Points |
|---|
| Age ≥ 75 | -2 |
| Age 65-74 | -1 |
| Age < 65 | 0 |
| Current smoker | 1 |
| Diabetes | 1 |
| MI at presentation | 1 |
| Prior PCI or MI | 1 |
| Stent diameter < 3 mm | 1 |
| CHF or LVEF < 30% | 2 |
| Vein graft PCI | 2 |
| Paclitaxel-eluting stent | 1 |
Interpretation:
- Score ≥ 2: Extended DAPT (30 months) favored — greater reduction in ischemic events than increase in bleeding
- Score < 2: Extended DAPT may cause more bleeding harm than ischemic benefit; standard 12 months preferred
1.5 P2Y12 Monotherapy After Short DAPT
An emerging paradigm supported by recent trials involves early aspirin discontinuation (after 1-3 months of DAPT) with continuation of P2Y12 inhibitor monotherapy:
| Trial | Protocol | Finding |
|---|
| TWILIGHT | 3 months DAPT → ticagrelor monotherapy | Reduced bleeding (BARC 2/3/5) without increase in ischemic events at 1 year (in high-risk PCI patients excluding STEMI) |
| TICO | 3 months DAPT → ticagrelor monotherapy (ACS population) | Reduced net adverse clinical events (primarily driven by bleeding reduction) |
| GLOBAL LEADERS | 1 month DAPT → ticagrelor monotherapy (experimental) vs 12 months DAPT + aspirin (control) | No significant difference in primary endpoint; bleeding reduction with experimental strategy |
| STOPDAPT-2 ACS | 1-2 months DAPT → clopidogrel monotherapy | Met non-inferiority for net clinical outcome vs 12 months DAPT |
2. Statin Therapy for Secondary Prevention
2.1 Initiation and Intensity
High-intensity statin therapy is a Class I recommendation for all ACS patients, initiated within 24 hours of presentation regardless of baseline LDL level:
| Intensity | Statin and Dose | Expected LDL Reduction |
|---|
| High intensity (recommended for all ACS) | Atorvastatin 80 mg daily OR rosuvastatin 20-40 mg daily | ≥ 50% reduction from baseline |
| Moderate intensity (if high-intensity not tolerated) | Atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, pravastatin 40-80 mg | 30-49% reduction |
2.2 LDL Targets
| Guideline Source | LDL Target | Additional Threshold |
|---|
| North American cardiology guidelines | < 70 mg/dL (1.8 mmol/L) | If baseline LDL not at goal, achieve ≥ 50% reduction |
| European cardiology guidelines | < 55 mg/dL (1.4 mmol/L) AND ≥ 50% reduction from baseline | For patients with recurrent events within 2 years while on max statin: consider < 40 mg/dL |
2.3 Add-On Lipid-Lowering Therapy
| Agent | Dose | Indication | LDL Reduction | Evidence |
|---|
| Ezetimibe | 10 mg PO daily | LDL above target on max statin (Class I) | Additional 15-20% reduction | IMPROVE-IT: ezetimibe + simvastatin reduced CV events vs simvastatin alone post-ACS; NNT ~50 over 7 years |
| PCSK9 inhibitors | Evolocumab 140 mg SC q2wk (or 420 mg monthly); Alirocumab 75-150 mg SC q2wk | LDL above target despite max statin + ezetimibe (Class IIa) | Additional 50-60% reduction | FOURIER: evolocumab reduced CV events vs placebo in statin-treated patients; ODYSSEY OUTCOMES: alirocumab reduced CV events post-ACS |
| Bempedoic acid | 180 mg PO daily | Statin-intolerant patients or add-on to maximally tolerated statin + ezetimibe | 15-25% reduction | CLEAR Outcomes: bempedoic acid reduced CV events in statin-intolerant patients |
| Inclisiran | 284 mg SC at month 0, month 3, then q6 months | Add-on for inadequate LDL lowering; siRNA targeting PCSK9 synthesis | 50% reduction | ORION trials; long dosing interval improves adherence |
2.4 Statin Safety
| Concern | Management |
|---|
| Myalgias | Occur in 5-10%; check CK if severe; try dose reduction, alternative statin (rosuvastatin or pravastatin have lowest myalgia rates), every-other-day dosing, or switch to non-statin lipid therapy |
| Rhabdomyolysis | Very rare (< 0.01%); CK > 10× ULN with muscle symptoms; discontinue statin; IV hydration |
| Hepatotoxicity | Transaminase elevation > 3× ULN occurs in < 1%; routine LFT monitoring no longer recommended; check at baseline and as clinically indicated |
| New-onset diabetes | Small increased risk (HR 1.09-1.12); benefit of statin for CV risk far outweighs diabetes risk in ACS patients |
3. ACE Inhibitor and ARB Therapy
3.1 Indications After ACS
| Indication | Strength of Recommendation |
|---|
| LVEF ≤ 40% | Class I, LOE A |
| Anterior MI | Class I, LOE A |
| Heart failure symptoms | Class I, LOE A |
| Hypertension | Class I, LOE A |
| Diabetes | Class I, LOE A |
| Stable CKD | Class I, LOE A |
| All other post-ACS patients | Class IIa, LOE A (reasonable for all MI patients) |
3.2 Agent Selection and Dosing
| Agent | Starting Dose | Target Dose | Monitoring |
|---|
| Ramipril | 2.5 mg PO BID | 5 mg PO BID (or 10 mg daily) | K, creatinine at 1-2 weeks, then periodically |
| Lisinopril | 5 mg PO daily | 20-40 mg PO daily | Same |
| Enalapril | 2.5 mg PO BID | 10-20 mg PO BID | Same |
| Captopril | 6.25 mg PO TID | 50 mg PO TID | Same |
| Valsartan (ARB — for ACE-I intolerant) | 20 mg PO BID | 160 mg PO BID | Same |
| Candesartan (ARB alternative) | 4-8 mg PO daily | 32 mg PO daily | Same |
3.3 Key Trial Evidence
| Trial | Intervention | Finding |
|---|
| SAVE | Captopril post-MI with EF ≤ 40% | 19% reduction in mortality |
| AIRE | Ramipril post-MI with clinical HF | 27% reduction in mortality |
| TRACE | Trandolapril post-MI with EF ≤ 35% | 22% reduction in mortality |
| HOPE | Ramipril in high-risk patients (including prior MI) | 22% reduction in CV death/MI/stroke |
| VALIANT | Valsartan non-inferior to captopril post-MI with LV dysfunction | ARB validated as alternative to ACE-I |
3.4 Contraindications and Precautions
- Bilateral renal artery stenosis (or stenosis in solitary kidney)
- Serum potassium > 5.5 mEq/L
- Symptomatic hypotension (SBP < 100 mmHg)
- History of angioedema with ACE-I (use ARB with caution; cross-reactivity <5%)
- Pregnancy (absolute contraindication — teratogenic)
- Serum creatinine > 3.0 mg/dL (use with caution; expect 10-15% rise in creatinine which is acceptable; discontinue if > 30% rise)
4. Beta-Blocker Therapy After ACS
4.1 Indications and Duration
| Indication | Duration | Strength |
|---|
| Post-MI with LVEF ≤ 40% or heart failure | Indefinitely (at least 3 years; lifetime in HFrEF) | Class I, LOE A |
| Post-MI with preserved EF (LVEF > 40%), no HF | At least 1 year; benefit of indefinite therapy debated; may be discontinued after 1 year if no other indication | Class IIa, LOE B (recent evidence suggests less long-term benefit than previously believed in the era of modern reperfusion — ABYSS trial, REDUCE-AMI trial) |
| Hypertension | As needed for BP control | Class I |
4.2 Evidence in the Modern Reperfusion Era
The traditional evidence for beta-blockers post-MI (ISIS-1, MIAMI, Norwegian Timolol trial, CAPRICORN) was generated before routine primary PCI and contemporary pharmacotherapy. Recent evidence has challenged the long-term benefit of beta-blockers in post-MI patients with preserved ejection fraction:
| Trial | Population | Key Finding |
|---|
| REDUCE-AMI (2024) | Post-MI, EF ≥ 50%, early PCI | Long-term beta-blocker therapy did NOT reduce the composite of death or new MI compared to no beta-blocker at median 3.5 years follow-up |
| ABYSS (2024) | Stable post-MI on beta-blocker ≥ 6 months | Discontinuation of beta-blocker was non-inferior to continuation for the composite of death, MI, stroke, or hospitalization for CV reason at 1 year |
| CAPRICORN | Post-MI, EF ≤ 40% | Carvedilol reduced all-cause mortality; remains the key evidence for beta-blockers in HFrEF post-MI |
Clinical implication: Beta-blockers remain clearly indicated for post-MI patients with reduced EF or heart failure. For patients with preserved EF treated with modern reperfusion therapy, the benefit of long-term beta-blockade is less certain, and discontinuation after 1 year may be reasonable.
4.3 Agent Selection
| Agent | Starting Dose | Target Dose | Notes |
|---|
| Metoprolol succinate (extended-release) | 25 mg PO daily | 200 mg PO daily | Preferred in HFrEF (MERIT-HF trial) |
| Carvedilol | 3.125-6.25 mg PO BID | 25 mg PO BID (50 mg BID if > 85 kg) | Combined alpha/beta-blocker; preferred in HFrEF (CAPRICORN, COPERNICUS); beneficial in diabetes (no worsening of insulin sensitivity) |
| Bisoprolol | 1.25 mg PO daily | 10 mg PO daily | Preferred in HFrEF (CIBIS-II); highly beta-1 selective |
5. Aldosterone Antagonist Therapy
5.1 Indications After ACS
Aldosterone antagonists (mineralocorticoid receptor antagonists — MRAs) are indicated post-ACS when BOTH of the following are present:
- LVEF ≤ 40% (documented within the first 3-14 days post-MI)
- Heart failure symptoms OR diabetes mellitus
Additionally:
- Already receiving therapeutic doses of ACE inhibitor (or ARB) AND beta-blocker
- Serum potassium < 5.0 mEq/L
- eGFR > 30 mL/min/1.73m²
5.2 Agent and Dosing
| Agent | Starting Dose | Target Dose | Monitoring |
|---|
| Eplerenone | 25 mg PO daily | 50 mg PO daily | Serum potassium and creatinine at 3 days, 1 week, then monthly for 3 months, then q3 months |
| Spironolactone | 12.5-25 mg PO daily | 25-50 mg PO daily | Same monitoring; watch for gynecomastia (less with eplerenone) |
5.3 Key Trial Evidence
| Trial | Intervention | Finding |
|---|
| EPHESUS | Eplerenone post-MI with EF ≤ 40% + HF or DM | 15% reduction in all-cause mortality; 13% reduction in CV death/hospitalization for CV events |
| RALES | Spironolactone in severe HF (EF ≤ 35%, NYHA III-IV) | 30% reduction in mortality |
| EMPHASIS-HF | Eplerenone in mild HF (EF ≤ 35%, NYHA II) | 37% reduction in CV death or HF hospitalization |
5.4 Hyperkalemia Prevention
- Do NOT initiate if K ≥ 5.0 mEq/L
- Avoid concurrent use of potassium supplements (reassess need)
- Monitor closely in CKD, diabetes, and elderly
- Hold if K > 5.5 mEq/L; discontinue if K > 6.0 mEq/L
- Avoid combining with other potassium-sparing diuretics (triamterene, amiloride)
6. Additional Secondary Prevention Measures
6.1 Comprehensive Secondary Prevention Checklist
| Category | Intervention | Target |
|---|
| Antiplatelet | Aspirin 81 mg daily indefinitely + P2Y12 inhibitor per DAPT duration plan | As above |
| Statin | High-intensity statin | LDL < 70 mg/dL (< 55 per European guidelines) |
| Blood pressure | ACE-I/ARB + beta-blocker ± additional agents | < 130/80 mmHg (for most patients) |
| Diabetes | Individualized glycemic control; consider GLP-1 RA or SGLT2 inhibitor (CV benefit) | HbA1c < 7% (individualized) |
| Smoking cessation | Counseling at every visit + pharmacotherapy (varenicline, bupropion, NRT) | Complete cessation |
| Weight management | Dietary counseling; calorie restriction if BMI > 25; consider GLP-1 RA for obesity | BMI < 25 kg/m² (ideal); waist circumference < 40 in (M), < 35 in (F) |
| Physical activity | 150 min/week moderate aerobic + 2 sessions/week resistance training | Cardiac rehab enrollment |
| Diet | Mediterranean or DASH-style dietary pattern; reduce sodium (< 2,300 mg/day, ideally < 1,500 mg); increase fruits, vegetables, whole grains, fish; limit saturated fat, trans fat, added sugars | — |
| Influenza vaccination | Annual influenza vaccination | Class I recommendation (associated with reduced CV events in post-MI patients) |
| Depression screening | Screen for depression post-MI (PHQ-2/PHQ-9); treat if identified | Mental health optimization |
6.2 SGLT2 Inhibitors in Post-ACS Care
Sodium-glucose cotransporter 2 (SGLT2) inhibitors have demonstrated cardiovascular benefit beyond glucose lowering and are increasingly incorporated into post-ACS secondary prevention:
| Agent | Dose | CV Indication | Evidence |
|---|
| Empagliflozin | 10 mg PO daily | HFrEF (with or without diabetes); post-MI with EF ≤ 40% | EMPEROR-Reduced: reduced CV death and HF hospitalization in HFrEF; EMPA-REG OUTCOME: reduced CV death in T2DM with established CVD |
| Dapagliflozin | 10 mg PO daily | HFrEF and HFpEF (with or without diabetes) | DAPA-HF: reduced CV death and worsening HF; DECLARE-TIMI 58: reduced HF hospitalization in T2DM with CVD |
Post-ACS role: SGLT2 inhibitors should be initiated in all post-MI patients with HFrEF (EF ≤ 40%) regardless of diabetes status. They should also be considered for post-MI patients with diabetes and additional risk factors.
6.3 GLP-1 Receptor Agonists
| Agent | CV Benefit Trial | Key Finding |
|---|
| Liraglutide | LEADER | Reduced CV death, MI, stroke in T2DM with CVD |
| Semaglutide (SC) | SUSTAIN-6, SELECT | Reduced MACE in T2DM with CVD; SELECT: reduced MACE in overweight/obese patients without diabetes |
| Dulaglutide | REWIND | Reduced MACE in T2DM with CVD risk factors |
Post-ACS role: GLP-1 RAs should be considered for post-ACS patients with T2DM and/or obesity (BMI ≥ 27 with CV risk factors) as they provide both metabolic and cardiovascular benefit.
7. Cardiac Rehabilitation
7.1 Referral and Enrollment
Cardiac rehabilitation (CR) is a Class I recommendation for all patients after ACS (STEMI, NSTEMI, or UA with revascularization). Despite strong evidence, CR is significantly underutilized — only 20-35% of eligible patients participate.
| Phase | Timing | Components |
|---|
| Phase I (inpatient) | During hospitalization | Early mobilization; education on disease, medications, risk factors, symptoms requiring return; discharge planning |
| Phase II (outpatient — supervised) | Begin within 2-4 weeks of discharge; typical duration 12 weeks (36 sessions) | Supervised exercise training (aerobic + resistance); nutrition counseling; smoking cessation support; psychosocial assessment; medication optimization; ongoing risk factor education |
| Phase III (maintenance) | After completing Phase II; indefinite | Independent or community-based exercise; ongoing risk factor modification; periodic reassessment |
7.2 Exercise Prescription
| Parameter | Recommendation |
|---|
| Aerobic exercise | 3-5 sessions/week; 20-60 min/session; 50-80% of maximal heart rate (initially lower, progress gradually) |
| Resistance training | 2-3 sessions/week; 8-10 exercises; 1-3 sets of 10-15 repetitions; 40-60% of 1 repetition maximum |
| Flexibility | Stretching before and after exercise sessions |
| Initial evaluation | Symptom-limited exercise test to determine safe exercise intensity; ECG monitoring during early sessions |
| Activity restrictions | Avoid heavy lifting (> 30 lbs) and strenuous activity for 2-4 weeks post-PCI; 6-8 weeks post-CABG (sternal precautions) |
7.3 Evidence for Cardiac Rehabilitation
- Mortality reduction: 20-25% reduction in CV mortality (meta-analyses)
- Rehospitalization: 18-25% reduction
- Quality of life: Significant improvement in physical function, depression, anxiety
- Return to work: Faster and more successful return to employment
- Cost-effectiveness: CR is highly cost-effective ($4,950/QALY gained — comparable to aspirin post-MI)
7.4 Barriers and Solutions
| Barrier | Solutions |
|---|
| Low referral rates | Automatic/systematic referral at discharge (liaison model); bedside enrollment before discharge |
| Transportation/access | Home-based CR programs (validated in trials — non-inferior to center-based); telehealth CR; hybrid models |
| Cost/insurance | Most insurance covers Phase II CR; expand awareness of coverage |
| Underrepresentation of women, elderly, minorities | Targeted outreach; culturally sensitive programs; flexible scheduling |
8.1 Core ACS Quality Measures
| Measure | Target | Source |
|---|
| Door-to-balloon time ≤ 90 min (PCI-capable) | ≥ 75% of STEMI cases | National quality reporting |
| Door-to-needle time ≤ 30 min (fibrinolysis) | ≥ 75% of fibrinolysis cases | National quality reporting |
| Aspirin at arrival | 100% (unless documented contraindication) | Core measure |
| Aspirin at discharge | 100% (unless documented contraindication) | Core measure |
| P2Y12 inhibitor at discharge | 100% of ACS patients with PCI (unless documented contraindication) | Core measure |
| Statin at discharge | 100% (high-intensity for ACS; unless documented contraindication) | Core measure |
| ACE-I/ARB at discharge for LVEF ≤ 40% | 100% (unless documented contraindication) | Core measure |
| Beta-blocker at discharge | 100% of MI patients (unless documented contraindication) | Core measure |
| Smoking cessation counseling | 100% of tobacco users | Core measure |
| Cardiac rehabilitation referral | 100% of eligible patients | Core measure (newer) |
| 12-lead ECG within 10 minutes | ≥ 90% of suspected ACS | Performance benchmark |
8.2 Systems of Care Optimization
| Strategy | Impact |
|---|
| STEMI receiving center certification | Standardized protocols, volume requirements, quality reporting |
| Prehospital STEMI activation | Reduces D2B by 15-20 min; associated with lower mortality |
| Single-call cath lab activation | Eliminates intermediate steps; ED physician or EMS can activate directly |
| Standardized STEMI protocol | Checklist-driven approach reduces variability and errors |
| Real-time D2B feedback | Performance dashboards with case-level review |
| Regional STEMI systems | Coordinated networks of EMS, non-PCI hospitals, and PCI centers with standardized transfer protocols |
| Standardized chest pain protocols | Validated pathways (HEART Pathway, 0/1h hs-cTn) reduce unnecessary admissions and improve throughput |
| Metric | Benchmark |
|---|
| STEMI in-hospital mortality (risk-adjusted) | < 7% |
| STEMI 30-day readmission rate | < 12% |
| NSTEMI in-hospital mortality | < 5% |
| Median D2B time | < 60 min (aspirational < 45 min) |
| Percentage of STEMI patients receiving primary PCI | > 90% |
| DAPT adherence at 1 year | > 80% |
| CR referral rate | > 70% (aspirational) |
9. Transition of Care and Outpatient Follow-Up
9.1 Discharge Planning Checklist
| Component | Details |
|---|
| Medication reconciliation | Complete review of all discharge medications; ensure DAPT, statin, beta-blocker, ACE-I/ARB are prescribed with clear duration instructions |
| Patient education | Disease education; medication adherence; symptom recognition (when to call 911 vs. when to call cardiologist); activity restrictions; dietary counseling |
| Follow-up appointments | Cardiologist follow-up within 1-2 weeks; PCP within 1 month; CR enrollment within 2-4 weeks |
| Echocardiography | If not performed during admission, schedule within 2-4 weeks for LVEF assessment (determines ACE-I/ARB, beta-blocker, MRA, ICD decisions) |
| Driving restrictions | State-specific; generally no driving for 1-2 weeks after uncomplicated PCI; 4-6 weeks after complicated MI or CABG; longer for commercial driving license |
| Return to work | Individualized; sedentary work: 1-2 weeks post-uncomplicated PCI; physical labor: 4-8 weeks; guided by functional capacity and stress testing |
| Sexual activity | May resume when able to climb 2 flights of stairs without symptoms (typically 1-2 weeks post-uncomplicated PCI; 6-8 weeks post-CABG); PDE-5 inhibitors: withhold for 24-48 hours of nitrate use |
| ICD evaluation | For patients with LVEF ≤ 35% — reassess EF at 40 days post-MI and 3 months post-revascularization before ICD decision (allow time for recovery) |
9.2 Long-Term Follow-Up Schedule
| Timeframe | Key Assessments |
|---|
| 1-2 weeks | Cardiology visit: wound check (if PCI/CABG), medication review, symptom assessment, CR enrollment |
| 1 month | PCP visit: BP, labs (lipid panel, renal function, K if on ACE-I/MRA), medication adherence |
| 3 months | Repeat echocardiography (if EF reduced at discharge); fasting lipid panel; HbA1c if diabetic; reassess DAPT plan |
| 6 months | Lipid panel; reassess DAPT duration; CR completion; functional assessment |
| 12 months | DAPT decision (continue, de-escalate, or stop P2Y12); annual lipid panel; stress testing if symptoms recur; reassess all secondary prevention measures |
| Annually | Ongoing: lipid panel, BP, HbA1c, weight, smoking status, depression screening, medication adherence, influenza vaccination, exercise counseling |
References