Secondary Prevention After Myocardial Infarction: Bridging Evidence to Practice
DOI:
https://doi.org/10.58931/cct.2025.129Abstract
Management of acute coronary syndrome (ACS) has advanced significantly over the past years, with various strategies shown to improve patient survival and reduce cardiovascular (CV) adverse events. An expanding body of literature supports the efficacy of both pharmacologic and non-pharmacologic approaches after acute myocardial infarction (MI). This review aims to provide a comprehensive overview of the secondary prevention strategies after acute MI in the modern era, with a particular focus on recent guidelines and their application in Canadian healthcare practice.
References
Rao SV, O’Donoghue ML, Ruel M, Rab T, Tamis-Holland JE, Alexander JH, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;151(13):e771–e862. doi:10.1161/cir.0000000000001309 DOI: https://doi.org/10.1161/CIR.0000000000001328
Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2023;148(9):e9–e119. doi:10.1161/cir.0000000000001168 DOI: https://doi.org/10.1161/CIR.0000000000001183
Rabi DM, McBrien KA, Sapir-Pichhadze R, Nakhla M, Ahmed SB, Dumanski SM, et al. Hypertension Canada’s 2020 Comprehensive Guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children. Can J Cardiol. 2020;36(5):596–624. doi:10.1016/j.cjca.2020.02.086 DOI: https://doi.org/10.1016/j.cjca.2020.02.086
Pearson GJ, Thanassoulis G, Anderson TJ, Barry AR, Couture P, Dayan N, et al. 2021 Canadian Cardiovascular Society Guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in adults. Can J Cardiol. 2021;37(8):1129–1150. doi:10.1016/j.cjca.2021.03.016 DOI: https://doi.org/10.1016/j.cjca.2021.03.016
Stone JA, Houlden RL, Lin P, Udell JA, Verma S. Cardiovascular protection in people with diabetes. Can J Diabetes. 2018;42 Suppl 1:S162–s169. doi:10.1016/j.jcjd.2017.10.024 DOI: https://doi.org/10.1016/j.jcjd.2017.10.024
Bainey KR, Marquis-Gravel G, Belley-Côté E, Turgeon RD, Ackman ML, Babadagli HE, et al. Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol. 2024;40(2):160–181. doi:10.1016/j.cjca.2023.10.013 DOI: https://doi.org/10.1016/j.cjca.2024.05.001
Choi KH, Park YH, Lee JY, Jeong JO, Kim CJ, Yun KH, et al. Efficacy and safety of clopidogrel versus aspirin monotherapy in patients at high risk of subsequent cardiovascular event after percutaneous coronary intervention (SMART-CHOICE 3): a randomised, open-label, multicentre trial. Lancet. 2025;405(10486):1252–1263. doi:10.1016/s0140-6736(25)00449-0 DOI: https://doi.org/10.1016/S0140-6736(25)00449-0
Eikelboom JW, Connolly SJ, Bosch J, Dagenais GR, Hart RG, Shestakovska O, et al. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med. 2017;377(14):1319–1330. doi:10.1056/NEJMoa1709118 DOI: https://doi.org/10.1056/NEJMoa1709118
Bainey KR, Welsh RC, Connolly SJ, Marsden T, Bosch J, Fox KAA, et al. Rivaroxaban plus aspirin versus aspirin alone in patients with prior percutaneous coronary intervention (COMPASS-PCI). Circulation. 2020;141(14):1141–1151. doi:10.1161/circulationaha.119.044598 DOI: https://doi.org/10.1161/CIRCULATIONAHA.119.044598
Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41(1):111–188. doi:10.1093/eurheartj/ehz455 DOI: https://doi.org/10.1093/eurheartj/ehz455
Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344(8934):1383–1389. DOI: https://doi.org/10.1016/S0140-6736(94)90566-5
Schwartz GG, Olsson AG, Ezekowitz MD, Ganz P, Oliver MF, Waters D, et al. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. Jama. 2001;285(13):1711–1718. doi:10.1001/jama.285.13.1711 DOI: https://doi.org/10.1001/jama.285.13.1711
Sabatine MS, Giugliano RP, Keech AC, Honarpour N, Wiviott SD, Murphy SA, et al. Evolocumab and clinical outcomes in patients with cardiovascular disease. N Engl J Med. 2017;376(18):1713–1722. doi:10.1056/NEJMoa1615664 DOI: https://doi.org/10.1056/NEJMoa1615664
Schwartz GG, Steg PG, Szarek M, Bhatt DL, Bittner VA, Diaz R, et al. Alirocumab and cardiovascular outcomes after acute coronary syndrome. N Engl J Med. 2018;379(22):2097–2107. doi:10.1056/NEJMoa1801174 DOI: https://doi.org/10.1056/NEJMoa1801174
O’Donoghue ML, Giugliano RP, Wiviott SD, Atar D, Keech A, Kuder JF, et al. Long-term evolocumab in patients with established atherosclerotic cardiovascular disease. Circulation. 2022;146(15):1109–1119. doi:10.1161/circulationaha.122.061620 DOI: https://doi.org/10.1161/CIRCULATIONAHA.122.061620
Cannon CP, Blazing MA, Giugliano RP, McCagg A, White JA, Theroux P, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372(25):2387–2397. doi:10.1056/NEJMoa1410489 DOI: https://doi.org/10.1056/NEJMoa1410489
Nissen SE, Lincoff AM, Brennan D, Ray KK, Mason D, Kastelein JJP, et al. Bempedoic Acid and cardiovascular outcomes in statin-intolerant patients. N Engl J Med. 2023;388(15):1353–1364. doi:10.1056/NEJMoa2215024 DOI: https://doi.org/10.1056/NEJMoa2215024
Wright RS, Raal FJ, Koenig W, Landmesser U, Leiter LA, Vikarunnessa S, et al. Inclisiran administration potently and durably lowers LDL-C over an extended-term follow-up: the ORION-8 trial. Cardiovasc Res. 2024;120(12):1400–1410. doi:10.1093/cvr/cvae109 DOI: https://doi.org/10.1093/cvr/cvae109
Bhatt DL, Steg PG, Miller M, Brinton EA, Jacobson TA, Ketchum SB, et al. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019;380(1):11–22. doi:10.1056/NEJMoa1812792 DOI: https://doi.org/10.1056/NEJMoa1812792
Sayah, Neila et al. “Icosapent ethyl following acute coronary syndrome: the REDUCE-IT trial.” European heart journal vol. 45,13 (2024): 1173-1176. doi:10.1093/eurheartj/ehad889 DOI: https://doi.org/10.1093/eurheartj/ehad889
Opie LH. The new trials: AIRE, ISIS-4, and GISSI-3. Is the dossier on ACE inhibitors and myocardial infarction now complete? Cardiovasc Drugs Ther. 1994;8(3):469–472. doi:10.1007/bf00877924 DOI: https://doi.org/10.1007/BF00877924
Pfeffer MA, Claggett B, Lewis EF, Granger CB, Køber L, Maggioni AP, et al. Angiotensin receptor-neprilysin inhibition in acute myocardial infarction. N Engl J Med. 2021;385(20):1845–1855. doi:10.1056/NEJMoa2104508 DOI: https://doi.org/10.1056/NEJMoa2104508
Pitt B, Williams G, Remme W, Martinez F, Lopez-Sendon J, Zannad F, et al. The EPHESUS trial: eplerenone in patients with heart failure due to systolic dysfunction complicating acute myocardial infarction. Eplerenone Post-AMI Heart Failure Efficacy and Survival Study. Cardiovasc Drugs Ther. 2001;15(1):79–87. doi:10.1023/a:1011119003788 DOI: https://doi.org/10.1023/A:1011119003788
Jolly SS, d’Entremont MA, Pitt B, Lee SF, Mian R, Tyrwhitt J, et al. Routine spironolactone in acute myocardial infarction. N Engl J Med. 2025;392(7):643–652. doi:10.1056/NEJMoa2405923 DOI: https://doi.org/10.1056/NEJMoa2405923
Yndigegn T, Lindahl B, Mars K, Alfredsson J, Benatar J, Brandin L, et al. Beta-blockers after myocardial infarction and preserved ejection fraction. N Engl J Med. 2024;390(15):1372–1381. doi:10.1056/NEJMoa2401479 DOI: https://doi.org/10.1056/NEJMoa2401479
Silvain J, Cayla G, Ferrari E, Range G, Puymirat E, Delarche N, et al. Beta-Blocker interruption or continuation after myocardial infarction. N Engl J Med. 2024;391(14):1277–1286. doi:10.1056/NEJMoa2404204 DOI: https://doi.org/10.1056/NEJMoa2404204
Ali MU, Mancini GBJ, Fitzpatrick-Lewis D, Lewis R, Jovkovic M, Zieroth S, et al. The effectiveness of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists on cardiorenal outcomes: systematic review and meta-analysis. Can J Cardiol. 2022;38(8):1201–1210. doi:10.1016/j.cjca.2022.05.011 DOI: https://doi.org/10.1016/j.cjca.2022.05.011
Mancini GBJ, O’Meara E, Zieroth S, Bernier M, Cheng AYY, Cherney DZI, et al. 2022 Canadian Cardiovascular Society Guideline for Use of GLP-1 receptor agonists and SGLT2 inhibitors for cardiorenal risk reduction in adults. Can J Cardiol. 2022;38(8):1153–1167. doi:10.1016/j.cjca.2022.04.029 DOI: https://doi.org/10.1016/j.cjca.2022.10.008
Lincoff AM, Brown-Frandsen K, Colhoun HM, Deanfield J, Emerson SS, Esbjerg S, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med. 2023;389(24):2221–2232. doi:10.1056/NEJMoa2307563 DOI: https://doi.org/10.1056/NEJMoa2307563
McGuire, Darren K et al. “Oral Semaglutide and Cardiovascular Outcomes in High-Risk Type 2 Diabetes.” The New England journal of medicine vol. 392,20 (2025): 2001-2012. doi:10.1056/NEJMoa2501006 DOI: https://doi.org/10.1056/NEJMoa2501006
Tardif JC, Kouz S, Waters DD, Bertrand OF, Diaz R, Maggioni AP, et al. Efficacy and safety of low-dose colchicine after myocardial infarction. N Engl J Med. 2019;381(26):2497–2505. doi:10.1056/NEJMoa1912388 DOI: https://doi.org/10.1056/NEJMoa1912388
Jolly SS, d’Entremont MA, Lee SF, Mian R, Tyrwhitt J, Kedev S, et al. Colchicine in acute myocardial infarction. N Engl J Med. 2025;392(7):633–642. doi:10.1056/NEJMoa2405922 DOI: https://doi.org/10.1056/NEJMoa2405922
Gibson CM, Bahit MC, Mehran R, Mehta SR, Lamee RA, Goto S, et al. Oral factor xia inhibitor milvexian after a recent acute coronary syndrome: rationale and design of the phase 3 (Librexia ACS). Am Heart J. 2025;285:21–28. doi:10.1016/j.ahj.2025.02.011 DOI: https://doi.org/10.1016/j.ahj.2025.02.011
Cho L, Nicholls SJ, Nordestgaard BG, Landmesser U, Tsimikas S, Blaha MJ, et al. Design and rationale of Lp(a)HORIZON trial: assessing the effect of lipoprotein(a) lowering with pelacarsen on major cardiovascular events in patients with CVD and elevated Lp(a). Am Heart J. 2025;287:1–9. doi:10.1016/j.ahj.2025.03.019 DOI: https://doi.org/10.1016/j.ahj.2025.03.019
Solomon SD, McMurray JJV, Vaduganathan M, Claggett B, Jhund PS, Desai AS, et al. Finerenone in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2024;391(16):1475–1485. doi:10.1056/NEJMoa2407107 DOI: https://doi.org/10.1056/NEJMe2410904
d’Aiello A, Filomia S, Brecciaroli M, Sanna T, Pedicino D, Liuzzo G. Targeting inflammatory pathways in atherosclerosis: exploring new opportunities for treatment. Curr Atheroscler Rep. 2024;26(12):707–719. doi:10.1007/s11883-024-01241-3 DOI: https://doi.org/10.1007/s11883-024-01241-3

Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Canadian Cardiology Today

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.