NICE produced guidelines on the management of patients following a myocardial infarction (MI) in 2013. Some key points are listed below

All patients should be offered the following drugs:

• dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
• ACE inhibitor
• beta-blocker
• statin

Some selected lifestyle points:

• diet: advise a Mediterranean style diet, switch butter and cheese for plant oil based products. Do not recommend omega-3 supplements or eating oily fish
• exercise: advise 20-30 mins a day until patients are 'slightly breathless'
• sexual activity may resume 4 weeks after an uncomplicated MI. Reassure patients that sex does not increase their likelihood of a further MI. PDE5 inhibitors (e.g, sildenafil) may be used 6 months after a MI. They should however be avoided in patient prescribed either nitrates or nicorandil

Most patients who've had an acute coronary syndrome are now given dual antiplatelet therapy (DAPT). Clopidogrel was previously the second antiplatelet of choice. Now ticagrelor and prasugrel (also ADP-receptor inhibitors) are more widely used. NICE now recommend:

• post acute coronary syndrome (medically managed): add ticagrelor to aspirin, stop ticagrelor after 12 months
• post percutaneous coronary intervention: add prasugrel or ticagrelor to aspirin, stop the second antiplatelet after 12 months
• this 12 month period may be altered for people at a high-risk of bleeding or those who at high-risk of further ischaemic events

Aldosterone antagonists

• patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment (e.g. eplerenone) should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy