Benefits are greatest with overt heart failure but extend to asymptomatic left ventricular systolic dysfunction and preserved left ventricular function. ACE inhibitors should be considered in all patients with acute coronary syndrome.
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Use caution in hypovolaemia or hypotension because ACE inhibition may worsen hypotension and impair coronary perfusion.
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Listed ACE inhibitor regimens are enalapril 10 mg twice daily or ramipril 2.5–5 mg twice daily.
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For ACE inhibitor intolerance, better-tolerated alternatives include valsartan 40–160 mg twice daily or candesartan 4–16 mg daily.
Mineralocorticoid receptor antagonists
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Patients with acute myocardial infarction, an ejection fraction below 35%, and either pulmonary oedema or diabetes mellitus benefit from an additional mineralocorticoid receptor antagonist.
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Listed options are eplerenone 25–50 mg daily or spironolactone 25–50 mg daily.
Lipid lowering
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All patients should receive an HMG CoA reductase inhibitor after acute coronary syndrome, irrespective of serum cholesterol concentration; atorvastatin 80 mg daily is the example given.
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If statins alone do not adequately lower total or LDL cholesterol, additional options include ezetimibe, fibrates, anion exchange resins and injectable PCSK9 inhibitors. The stated LDL cholesterol target is ≤ 2.0 mmol/L.
Smoking, diet and exercise
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Five-year mortality is twice as high among patients who continue smoking as among those who quit at the time of their acute coronary syndrome.
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Smoking cessation is described as the most effective contribution patients can make to their future. Supportive advice and pharmacological treatment improve cessation success.
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Ideal body weight, a Mediterranean-style diet, regular exercise, and good control of hypertension and diabetes may improve long-term outlook.