For pts who have not already undergone coronary angiography and PCI, submaximal exercise testing should be performed prior to or soon after discharge. A positive test in certain subgroups (angina at a low workload, a large region of provocable ischemia, or provocable ischemia with a reduced LVEF) suggests need for cardiac catheterization to evaluate myocardium at risk of recurrent infarction. Beta blockers (e.g., metoprolol, 25-200 mg daily) should be prescribed routinely for at least 2 years following acute MI, unless contraindications present (asthma, active heart failure, bradycardia). Continue oral antiplatelet agents (e.g., aspirin 81-325 mg daily and a P2Y12 platelet receptor antagonist) to reduce incidence of reinfarction. If LVEF ≤40%, an ACE inhibitor or ARB (if ACE inhibitor is not tolerated) should be used indefinitely. Consider addition of aldosterone antagonist (see “Heart Failure,” above).

Modification of cardiac risk factors must be encouraged: discontinue smoking; control hypertension, diabetes, and serum lipids (typically atorvastatin 80 mg daily in immediate post-MI period—see Chap. 178. Hypercholesterolemia and Hypertriglyceridemia); and pursue graduated exercise.