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

Beta-blockers after myocardial infarction

The benefits of beta-blocker therapy in patients that have had myocardial infarction has been known for some time. These agents have been shown to be beneficial in the current era and provide additional benefits to patients that are on aspirin or ace-inhibitors, or those patients that have had thrombolytic therapy for ST-elevation myocardial infarction.

The only patients in whom I might wonder about the usefulness of beta-blocker therapy are those who have had recent onset angina or unstable angina with minor troponin elevation, and who are found to have single vessel disease that is treated with percutaneous intervention. If these patients do not have hypertension then one might question the value of long-term beta-blocker therapy on top of other established secondary prevention measures (low dose aspirin, lipid modifying therapy). However, there should be a low-threshold to commence therapy with beta-blockers for treatment of mild hypertension in these patients.

• Should be first-line agents for patients with angina and hypertension.
• After significant myocardial infarction these agents reduce risk of sudden death.
• Those patients with significant LV impairment or heart failure obtain large benefits from beta-blocker therapy, in addition to benefits obtained from ace-inhibitor therapy use.
• The CAPRICORN study showed that patients with significant left ventricular impairment after myocardial infarction obtained large benefits from use of carvedilol.
• It is appropriate for General Practitioners to use beta-blockers in patients with heart failure. These patients tolerate introduction of these agents provided we do not rapidly escalate the dosage.
• We should be prepared to use beta-blockers in patients with chronic obstructive airways disease related to smoking if these patients do not have much bronchospasm. These patients may not tolerate high-dose beta-blockers.

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