The intervention that offers the greatest cardiovascular risk reduction for this patient is to start an ACE inhibitor for secondary prevention after myocardial infarction (MI) and to reduce systolic blood pressure. ACE inhibitors have been shown to decrease both cardiovascular and all-cause mortality in patients with chronic ischemic heart disease, especially in those patients with prior MI, left ventricular systolic dysfunction, or heart failure. Guidelines from the American College of Physicians/American College of Cardiology Foundation/American Heart Association recommend a treatment goal of 140/90 mm Hg or below in patients with stable ischemic coronary heart disease. Although previous guidelines recommended treatment to reduce blood pressure to below 130/80 mm Hg, there is limited evidence to show a benefit of doing so, with the potential for adverse consequences owing to overtreatment of blood pressure in these patients. The 2014 Eighth Joint National Committee (JNC-8) report does not provide specific recommendations for treatment of patients with established atherosclerotic disease, although the recommended threshold for treatment for all patients younger than 60 years is also 140/90 mm Hg. Therefore, this patient would be expected to benefit from therapy to decrease her blood pressure to at least 140/90 mm Hg or below.

While there is observational evidence from the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico) Prevention study that patients with prior MI who take fish oil have a 20% reduction in mortality rate, the current American College of Cardiology/American Heart Association guidelines do not currently provide recommendations for use of fish oil after MI. Fish oil is effective in reducing triglyceride levels; however, this patient's triglyceride levels are normal.

Recently released guidelines recommend treatment of patients with established atherosclerotic disease with a high-intensity statin with a goal of lowering the LDL cholesterol level to less than 50% of the baseline level but without treatment to a specific LDL cholesterol level. As this patient has had the expected decrease in LDL cholesterol level on her present regimen, the addition of another agent for managing dyslipidemia, such as niacin, would not be appropriate.

Although moderate alcohol consumption (approximately one to three drinks daily) is associated with a lower risk of coronary heart disease, excessive alcohol intake accounts for approximately 4% of cases of dilated cardiomyopathy. However, reducing this patient's current level of alcohol consumption will not reduce her risk of a future cardiovascular event.