Management After Myocardial Infarction

Nederlands tijdschrift voor geneeskunde, 1983

Heart, 2000

In the first five years of the 1990s, the role of angiotensin converting enzyme (ACE) inhibitors in the treatment of patients with myocardial infarction was investigated in a series of large controlled trials involving more than 100 000 patients (table 1). 1 The early use of ACE inhibitors after acute myocardial infarction (MI) has been investigated in four trials (CONSENSUS II, GISSI 3, ISIS 4, and CCS 1) involving more than 98 000 patients with treatment initiated within 24-36 hours from the onset of MI symptoms. 2-5 Five of the trials (SAVE, AIRE, TRACE, and SOLVD prevention and treatment trials) involving a total of over 11 000 patients investigated the eVects of late treatment with ACE inhibitors in patients with left ventricular dysfunction or failure. 6-10 Early unselected trials An overview of the early, unselected trials showed that 30 days after MI, patients allocated to ACE inhibitors had a significant reduction in mortality from 7.6% to 7.1% (p = 0.004), which corresponds to five lives saved per 1000 patients treated. 1 11 In addition, there was a significantly lower rate of non-fatal congestive heart failure episodes, with a reduction from 15.2% among patients allocated to control, to 14.6% among patients allocated to ACE inhibitors (p = 0.01). This corresponds to the prevention of six cases of non-fatal heart failure per 1000 patients treated. 1 11 Unexpectedly, the benefit of ACE inhibitors was achieved very early after the start of treatment; 239 fewer deaths were observed during the first 30 days in the group receiving ACE inhibitors than among those patients allocated to control. Of these 239 deaths, 200 were saved in the first week after the beginning of treatment and the onset of symptoms. This means that more than 80% of the benefit achieved with this strategy was achieved in the first week after the onset of MI symptoms. 1 Long term follow up data from the GISSI-3 trial show that the early benefit of ACE inhibitors was maintained over a long period of time.

Cardiovascular drugs and therapy / sponsored by the International Society of Cardiovascular Pharmacotherapy, 2002

To investigate the prescription pattern for cardiovascular drugs among patients discharged after an acute myocardial infarction (AMI) in hospitals that had participated in a corresponding study seven years earlier, and examine what the indications were for use of the different drugs. From 16 hospitals we drew a sample of patients who were discharged with a diagnosis of AMI during a three months period in 1999/2000. Physicians in each hospital obtained from the medical records the observed rate of use of cardiovascular drugs at discharge. The drug use was compared with findings from a corresponding sample drawn in 1993. The main indication for use of the different cardiovascular drugs was recorded for the 1999/2000 sample. 399 patients discharged alive were included in the first study and 767 in the second. The use of beta-blockers, ACE inhibitors and statins rose substantially during the period. For patients aged </=70 drug use in respectively 1993 and 1999/2000 was as follows: b...

Clinical Cardiology, 1994

Based on selected patient populations, several randomized trials have shown beta blockers to decrease mortality after acute myocardial infarction (AMI). The purpose of this study was to describe the use of beta blockers in various subsets of patients admitted to Sahlgren's Hospital between February 15, 1986, and November 9, 1987, with AMI, and the relation of AMI to other risk indicators for death and to a 1-year mortality rate. Beta blockers, mainly metoprolol, were prescribed for 66% of all survivors at discharge. They were more frequently prescribed for younger patients and for those with a previous history of AMI and hypertension, but less frequently for those with a history of congestive heart failure and diabetes mellitus. Patients for whom beta blockers were not prescribed had a 1-year mortality of 27% versus 11% for the rest (p < 0.001). Independent predictors of 1 -year mortality after discharge were age (p < 0.001 ), history of hypertension (p < 0.001 ), prescription of beta blockers at discharge (p < 0.001 ), congestive heart failure during hospitalization (p < 0.001), and a history of AMI (p < 0.01 ). P values were corrected for baseline differences. Beta blockers were not prescribed at discharge for one-third of survivors after AMI. This group had a very high mortality during the first year. When simultaneously considering various risk indicators for death, prescription of beta blockers at discharge was associated with an increased rate of survival.

Pharmacy World & Science, 2004

Aim: To determine guideline-related pharmaceutical care issues for the prevention of coronary heart disease in hospitalised patients admitted for myocardial infarction (MI). Methods: Consecutive patients admitted with a diagnosis of Q-wave MI to two large teaching hospitals were studied. Relevant patient medical and drug histories, co-morbidities and total cholesterol concentrations were recorded. Primary or secondary prevention treatment prior to admission was assessed using a data collection tool of 16 criteria developed from the Scottish Intercollegiate Guidelines Network (SIGN) guidelines. Main outcome measures: Frequency of adherence to defined clinical guideline criteria. Results: There were 167 patients reviewed (mean age 65 years, 111 males), representing possible candidates for primary prevention (n ϭ 98) or secondary prevention (n ϭ 69) based on absence or presence of past history of coronary heart disease (CHD), respectively. Possible primary prevention candidates: eight guideline-based criteria were developed from the SIGN guideline. There were 85 (87%) patients with a total cholesterol concentration available on admission of whom 56 (66%) had a predicted CHD risk Ն 15% and 10 (12%) had CHD risk Ն 30%. Of those with CHD risk Ն 15% 6 (11%) had been receiving an anti-platelet agent and of those with CHD risk Ն 30% only 1 (10%) was recorded as taking a statin. Of known hypertensives with CHD risk Ն 15%, 21% (5/24) were not recorded as having received treatment. Secondary prevention candidates: a further eight guideline-based criteria were developed from the SIGN guidelines. There were 42/65 (65%) candidates for aspirin documented as receiving it. There were 22/47 (47%) of those who had a total cholesterol Ն 5mmol/l and/or known history of hypercholesterolaemia receiving a statin (representing 76% of the known hypercholesterolaemic patients identified in the community). Of statin-treated patients with a cholesterol measured on admission, 44% (7/16) had cholesterol remaining Ն 5mmol/l. ␤-blocker use was 27/62 (44%) and ACE inhibitors use was 11/31 (36%) of those eligible. Sublingual GTN was recorded in 36/69 (52%). Conclusion: The study has identified opportunities for improved pharmaceutical care in primary and secondary CHD prevention among those destined to suffer an MI. Candidates for secondary prevention are potentially identifiable from community pharmacy patient medication records from which the contribution of pharmacists in primary care might be targeted. The findings were obtained during a period of evolution of the evidence-base and so they establish a baseline for future work.

BMC Cardiovascular Disorders, 2014

Background: Despite recommended pharmacotherapies the use of secondary prevention therapy after myocardial infarction (MI) remains suboptimal. Patients with diabetes mellitus (DM) have worse prognosis after MI compared to patients without DM and aggressive secondary prevention pharmacotherapy in this population is therefore warranted. We examined the changes in use of evidence-based secondary prevention pharmacotherapy in patients with and without DM discharged after first MI. Methods: All patients aged 30 years or older admitted with first MI in Denmark during 1997-2006 were identified by individual-level linkage of nationwide registries of hospitalizations. Univariate and multivariate logistic regression models were used to identify patient characteristics associated with initiation of acetylsalicylic acid, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, and clopidogrel within 90 days, and statins within 180 days of discharge, respectively. Results: A total of 78,230 patients were included, the mean age was 68.3 years (SD 13.0), 63.5% were men and 9,797 (12.5%) had diabetes. Comparison of claimed prescriptions in the period 1997-2002 and 2003-2006 showed significant (p < 0.001) increases in claims for acetylsalicylic acid (38.9% vs. 69.7%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (38.7% vs. 50.4%), β-blockers (69.2% vs. 77.9%), clopidogrel (16.7% vs. 66.3%), and statins (41.3% vs. 77.3%). During 2003-2006, patients with DM claimed significantly less acetylsalicylic acid (odds ratio [OR] 0.81 [95% confidence interval [CI] 0.74-0.88) and clopidogrel (OR 0.91 [95% CI 0.83-1.00]) than patients without DM. Conclusions: Despite sizeable increase in use of evidence-based secondary prevention pharmacotherapy after MI from 1997 to 2006, these drugs are not used in a substantial proportion of subjects and patients with DM received significantly less antiplatelet therapy than patients without DM. Increased focus on initiation of secondary prevention pharmacotherapy after MI is warranted, especially in patients with DM.

The American Journal of Cardiology, 2003

BMJ, 2005

All authors have been or are involved in clinical trials with angiotensin receptor blockers in cardiovascular disease and have received honorariums for speaking, consultancy fees, and research grants from pharmaceutical companies that market angiotensin receptor blockers. 1 Verma S, Strauss M. Angiotensin receptor blockers and myocardial infarction. BMJ 2004;329:1248-9. (27 November.) 2 Dickstein K, Kjekshus J, OPTIMAAL Steering Committee of the OPTIMAAL Study Group. Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Optimal trial in myocardial infarction with angiotensin II antagonist losartan.

European Heart Journal, 1997

Aims Many clinical trials conducted in the 1970s and early 1980s have shown that the long-term use of beta-blockers after an acute myocardial infarction significantly reduces mortality and reinfarction rates. This study assessed the impact of these findings in clinical practice. Methods We retrospectively analysed the beta-blocker prescriptions for 36 817 patients with acute myocardial infarction included in three large randomized clinical trials (Gruppo Italiano di Studio sulla Sopravvivenza nell'lnfarto Miocardico-GISSI, 1, 2 and 3), conducted by a highly representative sample (about 75%) of Italian coronary care units in 1984-85, 1988-89 and 1991-93. Results The prescription of beta-blockers at discharge increased gradually from 8-5% in 1984-85 to 250% in 1988-89 and to 31-4% in 1991-93. A similar trend was apparent for beta-blocker prescriptions 6 months after acute myocardial infarction. The strongest predictors of beta-blocker prescription are the presence of post-infarctual angina and a history of arterial hypertension. Besides the classical contraindications, advanced age, transitory cardiac failure or arrhythmias in the acute phase of acute myocardial infarction are important predictors of nonprescription. Conclusion The use of beta-blockers after acute myocardial infarction in Italy has increased more than threefold in the last decade, but they are still prescribed to too few patients, especially those at higher risk, for whom the expected benefit is greater.

The American Journal of Medicine, 2010

Background-Guidelines for the management of patients with acute myocardial infarction recommend the routine use of 4 effective cardiac medications: angiotensin converting enzyme (ACE) inhibitors, aspirin, β-blockers, and lipid lowering agents. Limited data are available, however, about the contemporary, and changing, use of these therapies, particularly from a population-based perspective. The study describes differences in the use of these medications during hospitalization for acute myocardial infarction according to age, sex, and period of hospitalization.