Secondary prevention of myocardial infarction (MI) Drug therapy

1
Secondary prevention of myocardial infarction
(MI)Drug therapy
2
Prophylaxis for patients who have experienced an
MI NICE Clinical Guideline 43. May 2007

• ACE-Is should be offered to all patients early
  after presentation with acute MI
• Titrate at every 1-2 weeks to max tolerated or
  target dose
• Continue indefinitely, whether or not symptomatic
• Routine use of ARB alone or ARB ACE-I not
  recommended
• Similar recommendations for patients with proven
  MI in the past

3
Prophylaxis for patients who have experienced an
MI NICE Clinical Guideline 43. May 2007

• Aspirin should be offered to all patients after
  an MI unless contraindicated
• Clopidogrel not recommended as first line
  monotherapy
• Non-STEMI ACS
• Consider aspirin clopidogrel as in NICE TA 80
• STEMI
• Dont use aspirin clopidogrel routinely, but if
  started, continue for at least 4 weeks
• Aspirin hypersensitivity
• Consider clopidogrel monotherapy (see NICE TA 90)
• Dyspepsia or aspirin-induced bleeding ulcer
• Low dose aspirin PPI (see NICE CG 17
  Dyspepsia)

4
Prophylaxis for patients who have experienced an
MI NICE Clinical Guideline 43. May 2007

• Beta blockers should be offered to all patients
  early after an acute MI
• Irrespective of LV function or whether or not
  LVSD is symptomatic
• If patient has LVSD, clinicians may prefer to
  use a beta blocker licensed for use in heart
  failure
• Initiate as soon as patient is clinically stable
  and titrate upwards
• After a proven MI in the past
• Patients with LVSD should be offered a
  beta-blocker
• Patients with heart failure should be treated
  according to NICE CG 5 Chronic Heart Failure
• Patients with preserved LV function and
  asymptomatic beta-blocker only if increased
  risk of further CV events or other compelling
  indications

5
Prophylaxis for patients who have experienced an
MI NICE Clinical Guideline 43. May 2007

• High intensity warfarin (INRgt3) should not be
  considered as an alternative to aspirin first
  line
• Patients unable to tolerate either aspirin or
  clopidogrel
• Consider moderate intensity warfarin (INR 2-3)
  for up to 4 years, possibly longer
• Patients with acute MI who are intolerant to
  clopidogrel and have low risk of bleeding
• Consider moderate intensity warfarin (INR 2-3)
  plus aspirin
• Patients already treated for another indication
• Continue warfarin
• Consider adding aspirin to moderate intensity
  warfarin (INR 2-3) in patients at low risk of
  bleeding
• Warfarin plus clopidogrel not routinely
  recommended

6
Prophylaxis for patients who have experienced an
MI NICE Clinical Guideline 43. May 2007

• Calcium channel blockers should not be routinely
  used to reduce CV risk after an MI
• If beta-blockers are contraindicated or need to
  be discontinued
• Consider diltiazem or verapamil in patients
  without pulmonary congestion or LVSD unlicensed
  use
• Calcium channel blockers may be used to treat
  hypertension or angina in patients who are stable
• In patients with heart failure
• Amlodipine is preferred
• Avoid verapamil, diltiazem and short-acting
  dihydropyridine agents (NICE CG 5 Chronic Heart
  Failure)

7
Prophylaxis for patients who have experienced an
MI NICE Clinical Guideline 43. May 2007

• Aldosterone antagonists should be initiated in
  patients with acute MI and symptoms/signs of
  heart failure or LVSD
• Initiate within 3-14 days of the MI, preferably
  after ACE-I
• Patients already being treated for another
  indication should continue with it or an
  alternative licensed for early post-MI treatment
• In patients with proven MI in the past and heart
  failure due to LVSD, treat in line with NICE CG 5
  Chronic Heart Failure

8
NICE CV risk and lipids and guidanceNICE
Clinical Guideline 67. May 2008

• For secondary prevention, lipid modification
  therapy should be offered and should not be
  delayed by management of modifiable risk factors
• Perform blood tests and clinical assessment and
  treat comorbidities and secondary causes of
  dyslipidaemia
• Statin therapy is recommended for adults with
  clinical evidence of CVD
• Fibrates, nicotinic acid or ion-exchange resins
  may be considered in people not able to tolerate
  statins
• The decision whether to initiate statin therapy
  should be made after an informed discussion about
  the risks and benefits of statin treatment
• Take into account additional factors such as
  comorbidities and life expectancy

9
NICE CV risk and lipids and guidanceNICE
Clinical Guideline 67. May 2008

• Initiate treatment for secondary prevention of
  CVD with simvastatin 40mg. If there are potential
  drug interactions, or simvastatin 40mg is
  contraindicated, choose a lower dose or
  alternative preparation such as pravastatin
• In people taking statins for secondary
  prevention, consider increasing to simvastatin
  80mg or a drug of similar efficacy and
  acquisition cost if a total cholesterol of less
  than 4 mmol/litre or an LDL cholesterol of less
  than 2 mmol/litre is not attained
• Any decision to offer a higher intensity statin
  should take into account the patient's informed
  preference, comorbidities, multiple drug therapy,
  and the benefits and risks of treatment