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Secondary prevention of myocardial infarction (MI) Drug therapy

Secondary prevention of myocardial infarction (MI) Drug therapy. 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

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Secondary prevention of myocardial infarction (MI) Drug therapy

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  1. Secondary prevention of myocardial infarction (MI)Drug therapy

  2. Prophylaxis for patients who have experienced an MINICE 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 MINICE 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 • Don’t 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 MINICE 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 MINICE Clinical Guideline 43. May 2007 • High intensity warfarin (INR>3) 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 MINICE 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 MINICE 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

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