A 62-year-old man with anterior STEMI, now day 2 post-primary PCI, is found on echo to have an LV ejection fraction of 32% and anterior wall akinesis. He has no symptoms of heart failure at rest. According to current guidelines, which therapy should be initiated before discharge to reduce mortality?

• A Implantable cardioverter-defibrillator (ICD)
• B ACE inhibitor/ARB plus beta-blocker plus aldosterone antagonist ✓
• C Sacubitril/valsartan
• D Amiodarone for prevention of sudden cardiac death

Explanation

Post-MI LV dysfunction (EF <40%) warrants ACE inhibitor (or ARB if intolerant), beta-blocker, and aldosterone antagonist — all have Class I evidence for mortality reduction post-MI. An ICD is indicated for primary prevention of SCD only if EF remains ≤35% after at least 40 days post-MI and 3 months of optimal medical therapy — not at day 2. Sacubitril/valsartan is now guideline-recommended for HFrEF but not universally started at 48 hours post-MI. Amiodarone does not reduce mortality in post-MI patients with LV dysfunction.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.