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Prevention of cardiovascular events
Patients with
stable and unstable angina should be given advice and
treatments
to reduce their
cardiovascular
risk.
The
importance of
life-style changes,
especially stopping
smoking,
should be emphasised.
Patients should take
aspirin indefinitely in a dose of 75 mg daily. In patients
with
non-ST-segment
elevation
acute
coronary
syndrome,
a combination of
aspirin and clopidogrel
(section 2.9) is given for up to 12 months;
most benefit
occurs during the first
3 months.
An ACE inhibitor
(section 2.5.5.1) and a statin (section 2.12) should also
be given.
Management of ST-segment elevation
myocardial infarction
Local guidelines for the management of myocardial
infarction should be followed where they exist
These notes give an overview of
the initial
and long-
term management
of
myocardial
infarction with ST-
segment
elevation.
For advice on the management
of
non-ST-segment
elevation myocardial
infarction and
unstable angina,
see above.
The aims of
management
of
ST-segment
elevation myocardial
infarction are to
provide supportive care and pain relief,
to promote
reperfusion and to reduce mortality.
Oxygen,
nitrates,
and diamorphine or morphine can provide initial
sup-
port and pain relief; aspirin and percutaneous coronary
intervention or thrombolytics promote reperfusion; anti-
coagulants help to reduce re-occlusion and systemic
embolisation;
long-term use of
aspirin,
beta-blockers,
ACE inhibitors,
and statins help to reduce mortality
further.
Initial management
Oxygen (section 3.6) should be
administered if there is evidence of hypoxia, pulmonary
oedema, or continuing myocardial ischaemia; hyperoxia
should be avoided and particular
care is required in
patients with chronic obstructive airways disease.
The pain (and anxiety) of myocardial infarction is man-
aged with slow intravenous injection of diamorphine or
morphine (section 4.7.2);
an antiemetic such as meto-
clopramide (or,
if
left
ventricular function is not com-
promised,
cyclizine)
by intravenous
injection should
also be given (section 4.6).
Aspirin (chewed or dispersed in water) is given for its
antiplatelet
effect
(section 2.9);
a dose of
300 mg is
suitable.
If
aspirin is given before arrival
at hospital,
a
note saying that it has been given should be sent with
the patient. Clopidogrel, in a dose of 300 mg (or 600 mg
[unlicensed]
if
used prior
to percutaneous
coronary
intervention), should also be given (section 2.9). Prasu-
grel, in a dose of 60 mg, is an alternative to clopidogrel
in certain patients undergoing percutaneous coronary
intervention (see NICE guidance,
p.
150).
Patency of
the occluded artery can be restored by
percutaneous
coronary intervention or
by giving a
thrombolytic drug (section 2.10.2), unless contra-indi-
cated.
Percutaneous coronary intervention is the pre-
ferred method;
a glycoprotein IIb/IIIa inhibitor (sec-
tion 2.9)
can be used to reduce the risk of
immediate
vascular
occlusion
in
intermediate-
and
high-risk
patients.
Patients
undergoing percutaneous
coronary
intervention should also receive either
unfractionated
heparin or a low molecular weight heparin (e.g.
enoxa-
parin); bivalirudin (section 2.8.1) is an alternative to the
combination of
a glycoprotein IIb/IIIa inhibitor plus a
heparin.
In patients who cannot
be offered percuta-
neous coronary intervention within 90 minutes of diag-
nosis, a thrombolytic drug should be administered along
with either
unfractionated heparin (for
maximum 2
days), a low molecular weight heparin (e.g. enoxaparin),
or
fondaparinux.
See section 2.9 for
the use of
anti-
platelet drugs in patients undergoing coronary stenting.
Patients who do not receive reperfusion therapy (with
percutaneous coronary intervention or a thrombolytic)
should be treated with either fondaparinux, enoxaparin,
or
unfractionated heparin.
Prescribers should consult
product literature and local protocols (where they exist)
for details of anticoagulant dose and duration.
Nitrates (section 2.6.1)
are used to relieve ischaemic
pain.
If
sublingual
glyceryl
trinitrate is not
effective,
intravenous glyceryl
trinitrate or isosorbide dinitrate is
given.
Early administration of
some beta-blockers (section
2.4)
has been shown to be of
benefit
and should be
given to patients without contra-indications.
ACE inhibitors
(section 2.5.5.1),
and angiotensin-II
receptor antagonists (section 2.5.5.2) if an ACE inhibitor
cannot be used, are also of benefit to patients who have
no contra-indications;
in hypertensive and normoten-
sive patients treatment
with an ACE inhibitor,
or
an
angiotensin-II receptor antagonist, can be started within
24 hours of the myocardial infarction and continued for
at least 5–6 weeks (see below for long-term treatment).
All patients should be closely monitored for hyperglyc-
aemia;
those with diabetes
or
raised blood-glucose
concentration should receive insulin.
Long-term management
Long-term management
following ST-segment
elevation myocardial
infarction
involves the use of
several
drugs which should ideally
be started before the patient is discharged from hospital.
Aspirin (section 2.9)
should be given to all
patients,
unless contra-indicated,
at a dose of
75 mg daily.
The
addition of clopidogrel (section 2.9) has been shown to
reduce morbidity and mortality.
For those intolerant of
clopidogrel,
and who are at
low risk of
bleeding,
the
combination of
warfarin (section 2.8.2)
and aspirin
should be considered. In those intolerant of both aspirin
and clopidogrel,
warfarin alone can be used.
Warfarin
should be continued for those who are already being
treated for another indication, such as atrial fibrillation,
with the addition of
aspirin if
there is a low risk of
bleeding.
The combination of
aspirin with clopidogrel
or warfarin increases the risk of bleeding. See section 2.9
for details of
antiplatelet
drug duration following cor-
onary stenting.
Beta-blockers
(section 2.4)
should be
given to all
patients in whom they are not
contra-indicated.
Ace-
butolol,
metoprolol,
propranolol,
and timolol
are suita-
ble; for patients with left ventricular dysfunction, carve-
dilol,
bisoprolol,
or
long-acting metoprolol
may be
appropriate (section 2.5.5).
Diltiazem [unlicensed] or verapamil (section 2.6.2) can
be considered if
a beta-blocker cannot
be used;
how-
ever, they are contra-indicated in those with left ventri-
cular dysfunction. Other calcium-channel blockers have
no place in routine long-term management after a myo-
cardial infarction.
156
2.10.1 Management of stable angina and acute coronary syndromes
BNF 61
2
Cardiovascular system