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Secondary prevention after a heart attack: first 90 days

  • Evaluation & Diagnosis
secondary prevention after a heart attack

The first three months after an acute myocardial infarction (AMI) are decisive. During this period, drugs are adjusted, lifestyle changes are initiated and early risks are detected. Here you will find a practical plan -aligned to AHA/ACC/ESC guidelines- to reduce the risk of a new event. To individualize it, request a Clinical cardiology consultation.

Short notice: This guide is informative and does not replace your medical plan. Customize each step with your cardiologist.

Clinical objectives for the first 90 days

  • Prevent recurrence (thrombosis, re-infarction, decompensation).
  • Optimize treatment (antiplatelet agents, high-intensity statins, cardioprotectors).
  • Start and complete Cardiac rehabilitation.
  • Achieve goals: LDL-C, blood pressure, weight, and glycemic control if diabetes is present.
  • Tobacco cessation with pharmacological and behavioral support.
  • Educate and empower: recognize warning signs and maintain adherence.

Practical Timeline (0-90 days)

Day 0 to 14: stabilization and start-up

  • Antiaggregation: after acute coronary syndrome with stenting, it is usually indicated aspirin + P2Y12 (eg, ticagrelor or clopidogrel). Typical duration 12 months; in high bleeding risk, abbreviated regimens or early transition to monotherapy may be considered.
  • Statins: high intensity (atorvastatin 40-80 mg or rosuvastatin 20-40 mg).
  • IECA/ARA-II: if there is ventricular dysfunction, diabetes or hypertension.
  • Beta-blocker: initiate/continue (especially with LVEF ≤ 50 %, angina or arrhythmias); chronic need reassessed thereafter.
  • Mineralocorticoid antagonist: consider if LVEF ≤ 40 % with diabetes or HF.
  • Cardiac rehabilitation: initial evaluation and first session when you are clinically stable.
  • Safe physical activity: walking 5-10 min, 1-2 times/day, and progress according to tolerance.
  • Tobacco: stop smoking now; combine counseling and drugs if there are no contraindications.
  • Appointments: follow-up in 1-2 weeks to check symptoms, pressure and adherence.

Depending on your evolution, monitoring may be requested as follows 24-hour Holter (ECG) and/or 24 h MAP (ambulatory blood pressure) to fine-tune arrhythmia and pressure control.

Weeks 2 to 6: fine adjustment

  • Lipids: profile at 4-12 weeks after statin initiation/adjustment. Practical goal: LDL-C < 70 mg/dL and/or ≥ 50 % reduction; if not achieved, add ezetimibe and assess PCSK9 at high risk.
  • Blood pressure: target < 130/80 mmHg if tolerated; adjust with objective data (ideal with 24 h MAP (ambulatory blood pressure)).
  • Cardiac rehabilitation: consolidate 3 sessions/week (or hybrid/home modality), plus education on nutrition, stress and adherence.
  • Exercise: progress to 20-30 min of moderate aerobic activity, 5 days/week; consider Stress test to customize intensities.
  • Nutrition: cardioprotective pattern (Mediterranean type), reduce ultra-processed foods, sugars and salt; prioritize fiber, fish, legumes and olive oil.
  • Alarm symptoms: typical chest pain, progressive dyspnea, sustained palpitations, syncope → immediate consultation.

If there were relevant changes, it can be indicated Transthoracic echocardiography to assess LVEF and remodeling.

Weeks 6 to 12: consolidation and 1-year plan

  • Drug review: confirm tolerance and goals; if LDL-C remains ≥ 70 mg/dL with high statin + ezetimibe, discuss PCSK9.
  • Long-term beta-blocker: if LVEF is normal and there is no other indication (angina or arrhythmias), evaluate continue vs. reduce according to individual risk and recent evidence.
  • Cardiac rehabilitation: complete the program and define the maintenance plan.
  • Return to work and sports: decide together; if you resume formal training, consider Pre-sports Cardiovascular Evaluation.
  • Follow-up: 3 month consultation to close this block and set goals for the next quarter.

Medication: key points

  • Double antiplatelet therapy (DAPT): 12 months after stenting is common; abbreviated strategies (3-6 months) or monotherapy with P2Y12 may be options at high bleeding risk.
  • High-intensity statins: cornerstone; if you do not reach goals, add ezetimibe; if elevation persists, assess PCSK9.
  • SGLT2 post-AMI: are not routinely recommended just for having had an AMI in the absence of diabetes or HF; the current evidence is neutral on mortality/early HF.
  • Vaccines: annual flu vaccine; discuss pneumococcus according to age and comorbidities.

Lifestyle with clinical impact

  • Zero tobacco: counseling + pharmacotherapy increase success after acute coronary syndrome.
  • Physical activity: progressive and supervised within the Cardiac rehabilitation.
  • Sleep and stress: sleep hygiene and management techniques (breathing, brief therapy, psychosocial support).
  • Nutrition: Mediterranean pattern, controlled portions, focus on LDL and glycemic control if diabetes is present.
  • Alcohol: avoid or limit; drinking “for the heart” is not recommended.

Useful studies and follow-up (as appropriate)

Warning signs (go to the emergency room)

Unrelenting oppressive chest pain, severe dyspnea, syncope, sustained palpitations with dizziness, sudden edema or rapid weight gain (> 2 kg in 3 days).

Closing: what success looks like 90 days from now

  • Full adherence to medication.
  • Assistance and completion of cardiac rehabilitation.
  • LDL-C at goal and controlled BP.
  • Tobacco-free.
  • Sustainable exercise and diet plan.
  • Scheduled follow-up and reinforced education.

References

Rao, S. V., et al. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes. Circulation. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001309
Virani, S. S., et al. (2023). 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001168
Vrints, C., et al. (2024). 2024 ESC Guidelines for the management of chronic coronary syndromes. European Heart Journal, 45(36), 3415-3537. https://academic.oup.com/eurheartj/article/45/36/3415/7743115
Anderson, L., et al. (2023). Exercise-based cardiac rehabilitation for coronary heart disease. European Heart Journal, 44(6), 452-489. https://academic.oup.com/eurheartj/article/44/6/452/7028725
Brown, T. M., et al. (2024). Core Components of Cardiac Rehabilitation Programs. Circulation. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001289
Silvain, J., et al. (2024). Beta-Blocker Interruption or Continuation after Myocardial Infarction (ABYSS). New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa2404204
Butler, J., et al. (2024). Empagliflozin after Acute Myocardial Infarction (EMPACT-MI). New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa2314051
James, S., et al. (2024). Dapagliflozin in Myocardial Infarction without Diabetes or Heart Failure (DAPA-MI). NEJM Evidence. https://evidence.nejm.org/doi/full/10.1056/EVIDoa2300286
Lloyd-Jones, D. M., et al. (2022). ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering. Journal of the American College of Cardiology. https://www.jacc.org/doi/10.1016/j.jacc.2022.07.006
Hernandez, A. F., et al. (2024). Effect of Empagliflozin on Heart Failure Outcomes After Acute Myocardial Infarction. Circulation. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.124.069217
Naziri, A., et al. (2025). Smoking Cessation Strategies After Acute Coronary Syndrome. Journal of Clinical Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC11856351/
The Joint Commission (2023). CCCIP-05: Attendance at least one cardiac rehabilitation session within 90 days of discharge. https://manual.jointcommission.org/releases/TJC2023B/MIF0406.html

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