I was reading about someone who had 2 heart attacks but continued to smoke cigarettes.
I wondered how many of those who have had heart attacks with controllable risk factors do not do anything about them and used AI search to look up some values (and checked the original source material) Most post MI patients do nothing post heart attack. Geesh!
- A Medicare study using Medicare data found 63.4% of post MI patients were referred to cardiac rehab/exercise but just 32.6% went to even one session. Overall, just 23.4% participated at all.
- Only half of those who smoked pre-MI, stopped smoking post MI.
- 25-30% of heart attack patients had diabetes before their heart attack. Of those with diabetes, less than half take steps to better manage their diabetes.
- Perhaps 5% were “pre-diabetic” at the time of their MI; about 45% get that under control post MI.
- About 80+% of those with an MI meet the definition of overweight or obese. Of this group, 27% lose 5% or more of their body weight in the next 12 months. However, because many had multiple comorbidities, many lost weight because of declining health, not due to intentional weight loss.
- For someone with “general cardiac risk”, the probability of a 2nd heart attack within 5 years is estimated as 20-30%.
- For someone without usual risk factors, the probability of a 2nd heart attack within 5 years is estimated as 5-10%. This means someone who does not smoke, does not drink alcohol, is not diabetic or pre-diabetic, has normal or lower LDL cholesterol, and exercises – their risk of a second heart attack is much lower.
- There are other risk factors for heart attacks – inflammation, in particular, high homocysteine levels, and so on. Reducing these risk factors, also, likely reduces the risks of a 2nd heart attack even more.
Potentially, the most important items to improve outcome, post MI are
- Exercise – reduces all cause mortality by 30%, improves heart function, lowers BP, and increases the ability to remain active longer in life.
- Weight loss – reduces a main source of inflammation in the body, and in the arteries, keeps blood sugar low, and also improves exercise capacity
“For many patients, exercise and weight loss outperform medications in terms of quality of life, long-term independence, and metabolic health.”
But most patients end up on a pile of drugs, with potentially small benefits but potential side effects – effects that may limit the patients’ ability to pursue exercise and weight loss.
The Pharmaceutical Solution
Cardiology tends to lump many MI patients into a heterogeneous statistical group – and gives everyone post MI a similar set of medications – without taking into consideration which individuals are taking steps like exercise and weight loss. (Note – most cardiologists are aware of this but, as noted below, many patients are treated by physician assistants who may have less flexibility on guidelines.)
They too get the same medications – many of which have some bad side effects like sleepiness, brain fog and sometimes severe muscle and joint pain, sometimes even causing long term muscle damage.
The benefits of some of these medications may be minimal – and might only show benefits to those with high risk.
Cardiologists are aware of these problems – but many patients might be treated by physician assistants who may have less leeway to digress from treatment guidelines.
As AI summarizes this problem:
There is a systemic blind spot in evidence-based medicine: the overgeneralization of trial data to heterogeneous patient populations, especially in post-MI care.
Most clinical trials on post-MI medications are conducted in populations where lifestyle modification is minimal, and the relative risk reductions (RRRs) observed may not translate to patients who have already optimized their health behaviors.
(From Grok AI): “the “average” patient in trials like ISIS-2 (aspirin), BHAT (beta-blockers), SAVE (ACE inhibitors), 4S/CARE/HPS (statins), etc., was usually overweight, sedentary, often still smoking, and poorly controlled for blood pressure/diabetes. Lifestyle intervention was minimal or nonexistent in most of these landmark trials.”
🧪 The Evidence Gap: Medication Efficacy vs Lifestyle Optimization
1. Trial Populations Are Often High-Risk by Design
- Most post-MI drug trials (e.g., for beta blockers, ACE inhibitors, statins) enroll patients with:
- Poor baseline metabolic control
- Sedentary lifestyles
- High LDL, hypertension, or diabetes
- These trials show modest RRRs (10–30%), but absolute risk reductions (ARRs) are often small—especially in lower-risk subgroups.
2. Lifestyle-Optimized Patients Are Underrepresented
- Patients who:
- Exercise regularly
- Maintain a healthy weight
- Have normal lipids and BP
- Don’t smoke or have diabetes
are rarely the focus of post-MI drug trials.
- For these individuals, the marginal benefit of additional pharmacotherapy may be negligible, but this nuance is often lost in guideline-driven care.
3. Guideline Homogenization
- Clinical guidelines tend to apply population-level evidence to all individuals, leading to:
- Polypharmacy in low-risk patients
- Overtreatment and side effects without clear benefit
- Neglect of behavioral interventions, which are harder to prescribe and measure
Medications become default recovery assets, while behavioral assets like exercise, weight loss, and glycemic control are undervalued—despite their broader systemic benefits. It reflects a risk management model that prioritizes pharmacologic control over functional resilience.
As Grok AI notes:
- Relative risk reduction (RRR) is often modest, and absolute risk reduction (ARR) is heavily dependent on baseline risk
- A 25% RRR in a high-risk cohort (e.g., 20% 5-year event rate → 15%) is a 5% absolute benefit. In a very low-risk, lifestyle-optimized patient (e.g., 4% 5-year risk → 3%), the same drug yields only 1% absolute benefit—often smaller than the downside (side effects, cost, pill burden).
- Trialists prefer higher-risk populations
- It’s easier and cheaper to show a statistically significant benefit when event rates are high. Enrolling only fit, non-smoking, normal-weight patients would require enormous sample sizes and decades of follow-up to prove benefit.
- Some drugs have surprisingly flat relative risk reduction across baseline risk
- Aspirin and P2Y12 inhibitors are the best examples: the RRR for stent thrombosis or recurrent MI is ~50–70% regardless of how healthy the patient is otherwise. So even a fit patient who has already had a stent still benefits substantially from dual antiplatelet therapy.
- Cardiology is slowly moving away from “one size fits all”
- 2023 ESC guidelines introduced the concept of “de-prescribing” beta-blockers after 1 year in fully revascularized, preserved-EF patients with no arrhythmias (class IIa).
- Some centers already personalize: low-risk post-MI patients (successful PCI, LVEF >50%, no diabetes, non-smoker, already exercising) are sometimes discharged on aspirin + high-intensity statin only, skipping long-term beta-blocker/ACEI if BP and symptoms are fine.
It’s more accurate to say: the lower your residual risk from lifestyle, the more reasonable it becomes to question each additional drug on an individual basis, ideally with shared decision-making and very close follow-up.
Many thoughtful cardiologists already practice exactly that—quietly. The guidelines are just catching up.
More from Grok AI
PAs (and nurse practitioners) often have less flexibility.
Legal and regulatory constraints
In most U.S. states, PAs practice under a supervising physician’s license and a written practice agreement. Deviating from evidence-based guidelines (even when the deviation is evidence-based de-escalation in a very low-risk patient) can expose both the PA and the supervising cardiologist to medicolegal risk if something bad happens.
Many malpractice carriers and hospital credentialing committees explicitly expect “guideline-directed medical therapy” (GDMT) to be followed unless there is clear documentation of shared decision-making and patient refusal.
Performance metrics and quality reporting
Practices and hospitals are graded (and reimbursed) on public-reported metrics such as:
– % of post-MI patients discharged on beta-blocker
– % on ACEI/ARB/ARNI
– % on high-intensity statin
– % on P2Y12 inhibitor at 1 year
These metrics are frequently all-or-nothing: a fully revascularized, LVEF 60%, non-diabetic, athletic non-smoker who feels terrible on a beta-blocker still counts as a “failure” if the beta-blocker is stopped, even appropriately.
PAs are often the ones whose notes feed directly into the EHR flags and quality dashboards. Stopping or not starting a guideline drug triggers an alert that someone has to justify.
Training and culture
PA and NP training emphasizes protocol-driven care and guideline adherence (which is generally a good thing for the average patient).
Many cardiologists themselves feel uncomfortable de-prescribing because the original trials never tested “drug-free” or minimalist strategies, so they default to “more is safer.” PAs working under those cardiologists inherit the same conservatism.
Time pressure
Follow-up visits with a PA are often 15–20 minutes. It takes far longer to have a nuanced discussion about absolute vs. relative risk, number needed to treat, and shared decision-making than it does to click “continue metoprolol, lisinopril, atorvastatin, clopidogrel.”
Real-world consequences
Countless patients who are running marathons, have normal BMI, perfect blood pressure off meds, and no angina are still on the full cocktail years later because “the guideline says so” and no one in the (PA-run) clinic feels empowered to stop anything.
When a patient finally sees the actual cardiologist (often only at the 1-year or 5-year mark, or if something goes wrong), the cardiologist frequently stops one or more drugs with a casual “Yeah, you probably don’t need the beta-blocker anymore.”
What patients can do about it
Politely ask to speak with the supervising cardiologist (most practices will allow this at least once a year).
Bring objective data: recent stress test results, coronary calcium score (if zero or very low), excellent functional capacity, side-effect diary, home BP log showing hypotension on current meds, etc.
Frame it as shared decision-making: “I’ve read the new ESC guidelines that allow de-prescribing beta-blockers in low-risk patients after one year. Can we discuss whether that applies to me?”
If the practice is inflexible, seek a second opinion from a preventive cardiologist or a cardiologist who specializes in sports cardiology / master athletes—those subspecialists are much more comfortable tailoring and de-prescribing.
The heavy reliance on PAs and protocol-driven care is one of the main reasons many very low-risk, lifestyle-optimized post-MI patients remain over-medicated for years.
