Myocardial Infarction – Medical Treatment at Discharge
Antiplatelet and anticoagulant treatment
Aspirin in doses between 75 and 325 mg has shown a 25% decrease in death and re-infarction in patients who have suffered a myocardial re-infarction. For patients with high thromboembolic risk it is used the combination of aspirin and oral anticoagulants (to maintain the INR between 2 and 3). If patients have increased risk of bleeding may be associated with oral anticoagulants and clopidogrel on a short time. Triple combination aspirin, clopidogrel and oral anticoagulants show an acceptable ratio between risk and benefit (as long as short-term clopidogrel is associated with decreased risk of bleeding). If a patient requires oral anticoagulation, should be avoided pharmacologically active stents. Clopidogrel is administered on average 9 months after myocardial infarction (3-12 months).
Therapy with beta-blockers
Following the studies it was concluded that beta-blockers should be administered long-term for all patients with post myocardial infarction. They have proven that it reduces mortality by 20-25% and re-infarction.
Angiotensin-converting enzyme inhibitors and receptor blockers of angiotensin 2 (RBA)
Use of ACE inhibitors in patients with myocardial infarction complicated by systolic dysfunction (ejection fraction <40%) showed a reduction in mortality and the incidence of Cerebral Vascular Accident. If no contraindications, ACE inhibitors are strongly indicated in cases that were presented with heart failure in the acute phase of stroke. RBA have not shown superiority over ACE, but can be used if ACE inhibitors are not tolerated (cough, angioedema, etc.).
Eplerenone has been shown to have an additional benefit if associated to standard therapy in patients with myocardial infarction, heart failure and left ventricular dysfunction, reducing morbidity and mortality. Eplerenone has indications in post myocardial infarction patients with left ventricular dysfunction, heart failure, diabetes, the condition being creatinine value to be less than 2.5 mg% in men and less than 2 mg% in women and potassium lower 5 mEq /L. Initiating therapy with 25 mg dose will then be increased to the target dose of 50 mg. Pay attention to the amount of serum potassium.
Statins reduce ischemic events and reduce mortality in cases of ischemic heart disease. Indicated in all patients with myocardial infarction and will be initiated as early as possible. The target values for a total cholesterol is < 175 mg%, for LDL <100 mg%. It will be administered regardless of the cholesterol values.
Have no benefit if they are administered. It is used for patients who still have angina.
Calcium channel blockers
It will be used if beta-blockers are contraindicated. Verapamil and diltiazem prevent re-infarction and death. It will be administered prudently to those who have left ventricular dysfunction.
Fats will represent less than 30% of calories and saturated fats are less than a third. If body mass index is higher than 30 it is recommended weight loss and decrease in abdominal circumference below 102 cm in men and 88 cm in women.
All patients with coronary artery disease or who have survived a heart attack will have the flu shot.
It is indicated in cases of cardiac failure NYHA III or IV it is symptomatic although optimal therapy, ejection fraction less than 35%, dilated left ventricle, sinus rhythm and a wide QRS >120 Ms.
Implantation of cardiac defibrillators
It is indicated in patients who have an ejection fraction less than 40% and spontaneous non-sustained ventricular tachycardia and sustained monomorphic. It is advisable to those with ejection fraction <30% after myocardial infarction suffered at least 40 days ago.
smoking cessation (can use nicotine replacement therapy, antidepressants, nicotine patches);
diet, weight control (increased consumption of fruits and vegetables, grains, fish, reduced fat, reduced salt intake);
physical activity: 30 minutes of moderate exercise 5 days a week (improves endothelial function, progression of coronary lesions, thrombogenic risk decreases, the improvement of collateral circulation);
blood pressure control (<130/80 mmHg);
Associated diabetes control (objective is to obtain a glycated hemoglobin below 6.5 mg %)
Lipid control: the use of statins.