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 and with significant left ventricular impairment

Beta-blockers had been shown in early trials to reduce mortality after myocardial infarction. Subsequently, pharmacological therapy after myocardial infarction, particularly for those after large infarction, also included ace-inhibitor therapy.

The CAPRICORN trial enrolled patients within ten days of myocardial infarction if they had an ejection fraction under 40 percent, and who were expected to be on ace-inhibitor therapy. Not all patients had heart failure. This placebo controlled trial was done when there was emerging evidence for the benefits of beta-blocker therapy in those with heart failure.

This trial was designed to determine with greater certainty that beta-blocker therapy was still efficacious in this era in high risk patients that are treated with aspirin or anticoagulants and with ace-inhibitors.

Over 1800 patients were randomised. Mortality from all causes was lower in the carvedilol group than in the placebo group (12% vs 15%, p=0.03), after a mean follow-up of only 1.3 years.

Thus, only 33 high risk patients need be treated for 1.3 years to prevent one death.