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PARADISE-MI Secondary Prevention Algorithm

  • Age (years)
  • Sex
  • Left ventricular ejection fraction (LVEF %)
  • Transient pulmonary congestion at presentation?
  • Killip class at presentation
  • STEMI without reperfusion?
  • At least one additional risk factor present?
    (age ≥70, eGFR <60, diabetes, prior MI, atrial fibrillation, LVEF <30%)
  • eGFR (mL/min/1.73 m2) — optional
  • Diabetes?
  • Atrial fibrillation present?
  • PARADISE-MI Secondary Prevention Algorithm — Explanation and Clinical Context
    PARADISE-MI was a multinational randomized trial that enrolled high-risk patients early after acute myocardial infarction if they had transient pulmonary congestion or LVEF ≤40% and at least one additional risk factor (age ≥70 years, eGFR <60 mL/min/1.73 m², diabetes, prior myocardial infarction, atrial fibrillation, LVEF <30%, Killip class ≥III, or STEMI without reperfusion). The trial randomized patients within days of the index AMI to sacubitril/valsartan (ARNI) or ramipril (ACE inhibitor); while the primary composite endpoint was not significantly reduced by ARNI compared with ACE inhibitor in the primary analysis, some secondary/total HF event analyses suggested benefit in HF outcomes. Therefore, when a post-MI patient matches the PARADISE-MI profile, ARNI may be considered as an option in appropriate clinical contexts, but decisions should be individualized, balancing contraindications, timing (ACE inhibitor washout), renal function, blood pressure, and guideline recommendations. Independent of PARADISE-MI, guideline-directed secondary prevention after myocardial infarction includes high-intensity statin therapy (LDL target <1.4 mmol/L / <55 mg/dL and ≥50% reduction), appropriate antiplatelet therapy, blood pressure control, smoking cessation, cardiac rehabilitation, and—when LVEF ≤40% or clinical HF is present—implementation of the core HFrEF therapies (ACEi/ARB/ARNI where appropriate, beta-blocker, MRA when indicated, and SGLT2 inhibitors according to HF/diabetes guidance).

    Reference:
    Jering KS, Claggett B, Pfeffer MA, et al. Prospective ARNI vs. ACE inhibitor trial to DetermIne Superiority in reducing heart failure Events after Myocardial Infarction (PARADISE-MI): design and baseline characteristics. Eur J Heart Fail. 2021;23(6):1040–1048. DOI:10.1002/ejhf.2191.
    European Society of Cardiology (ESC) Guidelines — management of acute coronary syndromes and long-term secondary prevention recommendations (key points on statin intensity, antithrombotic strategies, and HF therapy implementation).

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