After a Heart Attack

Once you’ve had a heart attack or other major heart problem needing hospital care, the chance that you will experience other heart problems is high. In such cases, your doctor may combine some of the medications we have discussed in here to minimize your risk of additional heart problems in the future.

If you have had a heart attack, the American Heart Association/American College of Cardiology guidelines recommend that you take the following medications:

  • Aspirin, 75 to 325 mg per day (if you have a medical reason not to take aspirin, you should take clopidogrel, 75 mg daily instead).
  • Clopidogrel, along with aspirin, every day for nine months, starting the day you leave the hospital if you’ve had a heart attack that is called a non-ST segment-elevation heart attack (a distinction based on the ECG).
  • a beta-blocker (unless you have a medical reason not to).
  • A statin, especially if your LDL cholesterol is still over 100 mg/dL.
  • An ACE inhibitor.
  • An aldosterone blocker (e.g., spironolactone or eplerenone) for patients with abnormal heart function and symptoms of heart failure (e.g., shortness of breath, swelling of the legs). This therapy should be used with caution if you have kidney problems or a propensity to high potassium levels.

As it turns out, the medications that have been shown to help protect a person who has just had a heart attack from having another one are almost the same as those that have been proven to benefit people with heart disease over the long term.

Post–Heart Attack Medication Combinations

Aspirin and Clopidogrel One main difference between the guidelines for treating any patient with heart disease and those for treating a patient who has just had a heart attack is the recommendation to take both clopidogrel and aspirin for nine months after certain types of heart attacks.

A large clinical study showed that heart attack patients with a certain ECG pattern (a non-ST segment elevation something you can ask your doctor about) who were given both clopidogrel and aspirin for nine months after they left the hospital had a 20 percent lower risk of having another heart attack, stroke, or dying when compared with patients who took only aspirin during that period.

Patients who took the clopidogrel-and-aspirin combination did have a higher risk of bleeding, but the overall benefits of this treatment outweighed the risk.

A new study also shows that taking both clopidogrel and aspirin for one year after undergoing angioplasty or stenting (a procedure done to widen a narrowed coronary artery) lowered the risk of having a heart attack, stroke, or dying by 27 percent without significantly increasing the risk of bleeding.

These results have not yet been translated into mainstream practice, but they do serve to highlight the potential importance of using clopidogrel and aspirin together in certain situations.

Aspirin and Warfarin An alternative approach for people who have just had a heart attack is the combination of warfarin and aspirin. Recent clinical studies suggest that taking warfarin plus aspirin for a year or more after having a heart attack may reduce your risk of subsequent heart attack or stroke, or of dying, compared with taking aspirin alone.

The combination therapy does carry with it an increased risk of bleeding, but the researchers in favor of this combined approach believe that this risk is heavily outweighed by the potential benefit. The newest studies suggest that the warfarin dose needed to gain this benefit over aspirin is slightly higher than the dose that has been used in the past to treat people with only heart disease.

In light of this, and because of the increased risk of bleeding, doctors will probably continue to be cautious about prescribing warfarin. However, warfarin plus aspirin may be a good option for people who have a high risk of forming blood clots. You should know that it is still unclear if warfarin plus aspirin is better than clopidogrel plus aspirin.

More research in this area will help doctors and patients to better understand the role of warfarin in treating people just after a heart attack. In the meantime, clopidogrel may be favored because it does not require the monitoring that is essential when using warfarin.