Post Myocardial Infarction Medications

Aka: Post Myocardial Infarction Medications

1. See Also
   1. Cardiac Risk Management
2. Medications: Antihypertensives
   1. Beta Blocker
      1. Start within hours to days of Myocardial Infarction
      2. Taken for life following CAD diagnosis
      3. Contraindications: Following ST Elevation MI
         1. Includes general contraindications (see below)
         2. Delayed management of STEMI
         3. Signs of Heart Failure, low output state or risk of Cardiogenic Shock
            1. Age over 70 years
            2. Heart Rate <60 or over 110
            3. Systolic Blood Pressure <120 mmHg
      4. Contraindications: General
         1. Overt Congestive Heart Failure
         2. Bradycardia (Heart Rate under 60)
         3. Acute exacerbation of Asthma
         4. Second degree Heart Block or PR interval > 0.24 seconds (relative contraindication)
      5. Preferred Beta Blockers after Myocardial Infarction
         1. Metoprolol
         2. Timolol
         3. Propranolol
         4. Carvedilol (if decreased ejection fraction)
   2. ACE Inhibitor (or Angiotensin Receptor Blocker if unable to take ACE Inhibitor)
      1. Indications (Consider in all patients following Myocardial Infarction)
         1. Left Ventricular Ejection Fraction <40%
         2. Hypertension
         3. Diabetes Mellitus
         4. Chronic Kidney Disease
      2. Started day 2 following Myocardial Infarction
         1. May be detrimental if given in first 24 hours
      3. Efficacy: Very significant benefit
         1. Lower overall mortality
         2. Lower Cardiovascular death
         3. Lower sudden death
         4. Lower sudden Congestive Heart Failure
      4. References
         1. Kober (1995) N Engl J Med 333:1670-6
3. Medications: Miscellaneous
   1. Aspirin and/or Clopidogrel (used together following ST Elevation MI)
      1. See Antiplatelet Therapy for Vascular Disease
   2. AntiHyperlipidemic (HMG-CoA Reductase Inhibitors)
      1. Prescribe a Statin drug in patients discharged post-Myocardial Infarction
      2. Lowers risk of recurrent symptomatic ischemic event
      3. MIRACL study started Lipitor within 96 hours of ACS
      4. Schwartz (2001) JAMA 285:1711-8
   3. Magnesium oral supplementation
      1. Appears to improve Angina and Exercise tolerance
      2. Shechter (2003) Am J Cardiol 91:517-21
4. Medications: Antianginals
   1. Nitroglycerin: Long Acting Nitrates
      1. No evidence that prolongs life
5. Medications: Specific indications
   1. Warfarin (Coumadin)
      1. Coumadin with Aspirin does not lower mortality rate
         1. Does lower recurrent MI and CVA risk
         2. Rothberg (2005) Ann Intern Med 143:241-50
      2. Indications
         1. Thrombophlebitis
         2. Large antero-apical Myocardial Infarction
         3. Mural thrombus
         4. Left Ventricular Ejection Fraction under 25%
   2. Implantable Defibrillator Indications
      1. Ejection Fraction <30%
6. Management: Comorbid Major Depression
   1. Major Depression significantly increases mortality
   2. Treat comorbid Major Depression aggressively
   3. See Myocardial Infarction Stabilization for prognosis
   4. References
      1. Bush (2001) Am J Cardiol 88:337-41
7. Medications: Contraindicated
   1. NSAIDS are contraindicated (esp. post-STEMI)
      1. Acute
         1. NSAIDS are absolutely contraindicated in acute post-STEMI period
         2. Increased risk of mortality, reinfarction, Heart Failure and myocardial rupture post-STEMI
      2. Long-term
         1. Consider NSAIDs as a medication allergy in post-STEMI patients
         2. Choose non-NSAID agents first: Acetaminophen, Tramadol
         3. Consider non-acetylated Salicylates (Exercise caution due to peptic ulcer risk)
            1. Aspirin
            2. Salsalate
         4. If pain refractory to non-NSAIDAnalgesics
            1. Use non-cox2 selective agents (e.g. Naprosyn) sparingly
8. References
   1. Antman (2008) Circulation 117(2): 296-329