Which drugs should post-MI patients routinely receive?

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Clinical Inquiries

Which drugs should post-MI patients routinely receive?

J Fam Pract. 2010 September;59(9):527-529

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References

1. Collaborative overview of randomized trials of antiplatelet therapy: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of people. Antiplatelet Trialists’ Collaboration. BMJ. 1994;308:81-106.

2. Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Second International Study of Infarct Survival (ISIS-2) Collaborative Group. Lancet. 1988;2:349-360.

3. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502.

4. Chen ZM, Jiang LX, Chen YP, et al. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366:1607-1621.

5. Ray KK, Cannon CP, McCabe CH, et al. Early and late benefits of high-dose atorvastatin in patients with acute coronary syndromes: results from the PROVE IT-TIMI 22 trial. J Am Coll Cardiol. 2005;46:1405-1410.

6. Yusuf S, Peto R, Lewis J, et al. Beta-blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis. 1985;27:335-371.

7. Freemantle N, Cleland J, Young P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318:1730-1737.

8. Domanski MJ, Exner DV, Borkowf CB, et al. Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials. J Am Coll Cardiol. 1999;33:598-604.

9. Pitt B, White H, Nicolau J, et al. Eplerenone reduces mortality 30 days post-randomization following acute myocardial infarction in patients with left ventricular systolic dysfunction and heart failure. J Am Coll Cardiol. 2005;46:425-431.

10. Smith SC, Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006;113:2363-2372.

11. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction. J Am Coll Cardiol. 2007;50:e1-e157.

12. Antman EM, Hand M, Armstron PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51:210-247.

13. National Institute for Health and Clinical Excellence (NICE). Clinical guideline 48. Secondary prevention in primary and secondary care for patients following a myocardial infarction. London: NICE; 2007. Available at: http://guidance.nice.org.uk/CG48. Accessed March 7, 2010.

Eplerenone + ACE inhibitor benefit patients with post-MI heart failure
The selective aldosterone blocker eplerenone appears to benefit patients with a decreased ejection fraction post-MI. The EPHESUS study demonstrated that eplerenone, when added to an ACE inhibitor, reduced all-cause mortality (ARR=1.4%; NNT=71; 95% CI, 47-200; RR=0.69; 95% CI, 0.54-0.89) and sudden cardiac death (ARR=0.5%; NNT=200; 95% CI, 125-∞; RR=0.63; 95% CI, 0.40-1.00) up to 30 days in patients with post-MI heart failure. Benefits were also seen after 16 months of treatment.⁹

Recommendations

The American College of Cardiology (ACC) and American Heart Association (AHA) provide the following recommendations in their joint 2006 Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease:¹⁰

Low-dose aspirin should be used, as well as clopidogrel in combination with aspirin for up to 12 months after a non-ST elevation MI
ACE inhibitors or angiotensin receptor blockers should be considered in all patients, and an aldosterone antagonist should be prescribed for patients with a diminished ejection fraction post-MI
Beta-blockers should be used in all post-MI patients without contraindications.

The ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction recommend the same medication combinations.¹¹ So does the 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction, with the exception that clopidogrel in combination with aspirin is recommended for at least 14 days.¹²

FAST TRACK

Atorvastatin has been found to decrease the risk of death and recurrent acute coronary syndrome.

Similarly, the British National Institute for Clinical Excellence Clinical Guideline 48 recommends that all post-MI patients be offered a combination of an ACE inhibitor, aspirin with clopidogrel, a beta-blocker, and a statin.¹³

Acknowledgement
The opinions and assertions contained herein are the private views of the authors and should not be construed as official or as reflecting the views of the US Department of the Navy or the Department of Defense.

Evidence-based answers from the Family Physicians Inquiries Network