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Myocardial Infarction
Optimising Drug Therapy

Optimising Pharmacological Therapy after Myocardial Infarction

Ensure patient is on:

Low dose aspirin.
  • Clopidogrel and warfarin are alternatives for aspirin allergic or intolerant patients.
  • There is evidence for additional benefit with the use of aspirin combined with clopidogrel or warfarin.

Beta-blockers.
  • Betablockers are recommended for all patients that have had a myocardial infarction and guidelines suggest these agents are continued indefinitely.
  • Patients with impaired left ventricular systolic function obtain larger benefits from beta-blocker therapy.
Ace-inhibitors
  • Patients with heart failure and significant left ventricular impairment obtain much larger benefits from ace-inhibitor therapy and it is imperative that the dose is rapidly increased to maximal tolerated dosages.
  • The benefits include less adverse left ventricular remodelling and fewer problems with heart failure, as well as reduction in overall mortality.
  • Trials such as HOPE and EUROPA also suggest that ace-inhibitors should be used in all patients, and not just those with significant left ventricular impairment. However, the PEACE trial findings suggest there are subgroups of patients that will not benefit from routine use of ace-inhibitor therapy.

Appropriate anti-anginal therapy. Use betablockers first, then nitrates and then calcium channel blockers.

Lipid modifying therapy.
  • If simvastatin is used, then patients should be on maximal dosages, almost regardless of the initial lipid profile.
  • Evidence continues to accumulate to support lower LDL cholesterol target levels.
Spirinolactone.
  • Patients with heart failure that are being treated with ace-inhibitors and betablockers should also be treated with spirinolactone 25mg daily.

It is likely that the patient will need to be reviewed on several occasions to adjust the dosage of medications, to monitor progress, and regularly check on serum electrolyte and creatinine levels. If there is concern, at each assessment, only change the dosage of one drug that might affect blood pressure or renal function.

Hitesh Patel, Cardiologist
28th November, 2004
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