Myocardial Infarction
Optimising Drug Therapy

• Check List for Drug Therapy

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• Clopidogrel
• Clopidogrel alone only slightly better than aspirin alone
• Clopidogrel with aspirin better than aspirin alone after an acute coronary event
• Clopidogel with aspirin probably is better than aspirin alone in stable coronary disease

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• Warfarin
• Warfarin- instead of (or as well as) aspirin for secondary prevention

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• Beta-blockers
• After MI
• After large MI
• In heart failure

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• ACE-inhibitors
• After MI
• After large MI
• Use maximal dosages in heart failure
• For most patients after MI

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• Aldosterone antagonists
• Spirinolactone in heart failure

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• Lipid modifying therapy after MI

Ace-inhibitors after Myocardial Infarction.

The evidence in favour of ace-inhibitor therapy after myocardial infarction is compelling.

• Patients with significant left ventricular impairment or with heart failure get large benefits from these agents- these agents reduce mortality, reduce admissions to hospital with heart failure, and reduce adverse left ventricular remodelling after infarction.
• There is evidence that maximal ace-inhibitor therapy provides additional benefits to moderate dosage ace-inhibitor therapy.
• However, there will be some patients in whom we wish to start beta-blocker therapy but whose systolic blood pressue is just on 90mmHg. If these patients are on the maximal dose of ace-inhibitor, I think it is reasonable to reduce the dose of ace-inhibitor therapy to enable use of beta-blockers.
• There is evidence that all patients with atherosclerotic disease should be on ace-inhibitor therapy, including those with good LV systolic function.