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

Warfarin for Secondary Prevention

A number of studies have examined the use of warfarin for secondary prevention. In some studies “low-dose warfarin” plus low dose aspirin was compared with aspirin alone. Other studies compared “theurapeutic” dose warfarin plus aspirin with aspirin alone. Warfarin has also been compared directly with low dose aspirin.

• Warfarin is an alternative for patients that can not take low dose aspirin
• Warfarin alone may be superior to low dose aspirin alone
• Low dose warfarin plus low dose aspirin it not better than low dose aspirin alone
• Theurapeutic dose warfarin plus low dose aspirin may be superior to low dose aspirin alone or to warfarin alone
• There is no comparision to date of aspirin with clopidogrel vs aspirin with theurapeutic dose warfarin.

The use of warfarin for secondary prevention has not been widely accepted, presumably because of the need for regular monitoring and the increased risk of bleeding. However, we should consider the use of warfarin plus low dose aspirin in some high risk patients who continue to have events despite use of all appropriate secondary prevention measures.

References:
CLINICIAN UPDATE. Oral Anticoagulation for Acute Coronary Syndromes. Circulation 2002:1270-1274