How should I assess the risk of recurrent myocardial infarction in a patient with a history of MI?

Assessing the risk of recurrent myocardial infarction (MI) in a patient with a history of MI involves a comprehensive clinical evaluation and use of risk stratification tools.

First, use predicted 6-month mortality to categorise the risk of future adverse cardiovascular events, as this correlates with the risk of recurrent MI. Risk categories range from lowest (≤1.5%) to highest (>9.0%) based on data from the Myocardial Ischaemia National Audit Project (MINAP) database. This risk assessment should be recorded in the patient's care record and guide clinical management decisions, balancing treatment benefits against risks ¹.

Second, offer a cardiological assessment to consider coronary revascularisation if not previously performed, taking into account comorbidities, as this can influence recurrent MI risk ¹.

Third, assess for clinical heart failure and left ventricular ejection fraction (LVEF), as reduced LVEF (<35%) and heart failure increase risk and may indicate need for device therapy ¹.

Fourth, evaluate and manage modifiable risk factors including hypertension, hyperglycaemia, lipid levels, and lifestyle factors such as smoking, diet, and exercise ¹.

Fifth, review and optimise secondary prevention pharmacotherapy including ACE inhibitors, beta-blockers, statins, and antiplatelet therapy, as these reduce recurrent MI risk ¹.

Finally, consider bleeding risk assessment to balance antithrombotic therapy benefits and risks ¹.