TAM (Treatments and Medicines) NHS Highland
| Abbreviation | Meaning |
| ACE inhibitors | Angiotensin-converting-enzyme inhibitors |
| MI | Myocardial Infarction |
| U+Es | Urea and Electrolytes |
| NSTEMI | Non-ST-elevation myocardial infarction |
| LV | Left ventricle |
| NNT | Number needed to treat |
| BP | Blood Pressure |
Secondary prevention post myocardial infarction (Guidelines)
Warning
|
Treatment |
Immediate |
Maintenance |
|
Antiplatelet therapy a. aspirin (or clopidogrel if true intolerance to aspirin) b. aspirin and clopidogrel (or ticagrelor or prasugrel) |
Initiate on suspecting a type 1 myocardial infarction (Acute coronary syndrome). Be very cautious about prescribing dual anti-platelets in patients with bradycardias or AV block as clopidogrel causes major problems if a subsequent permanent pacemaker is warranted |
a. continue aspirin or clopidogrel indefinitely b. continue single antiplatelet indefinitely and stop second antiplatelet agent after duration advised by local specialist. |
|
Beta-blocker* eg bisoprolol |
Initiate unless patient:
|
If not started immediately, initiate as soon as possible (up to 28 days post- MI) if patient is no longer bradycardic or hypotensive and has no other contra-indications. |
|
ACE inhibitors* eg perindopril erbumine |
Initiate within 24 hours of MI. Monitor U&Es. |
Avoid with potassium-sparing diuretics or potassium supplements. Measure U&Es 1 to 2 weeks after initiation, after dosage increase and at least annually thereafter. |
|
Lipid-lowering therapy eg atorvastatin 80mg daily |
Indicated in all patients, irrespective of cholesterol level. Consider drug interactions, see BNF. |
Follow up in accordance with the Lipid lowering therapy in the prevention/treatment of atherosclerosis guidance If side-effects occur consider a lower dose or alternative statin. Review dose annually. |
|
Eplerenone or spironolactone |
Initiate if left ventricular dysfunction. Monitor U&Es. |
Continue lifelong. Monitor U&Es 1 week after starting and annually thereafter if stable. |
*In normotensive, non-diabetic, NSTEMI patients with preserved LV function, the potential benefit of beta-blockers and ACE inhibitors is small with a high NNT and therefore it may be decided by the cardiologist not to prescribe these treatments in such patients.
|
Patient group/treatment |
Immediate |
Maintenance |
|
Diabetes mellitus or if blood glucose greater than 11mmol/L on admission. |
If type 2 diabetes discontinue oral hypoglycaemic agents and for all patient groups give 24 hours of intravenous insulin according to Integrated Care guidance (opposite), aiming for a blood glucose of 7 to 10mmol/L. |
Better control of blood glucose indefinitely. Refer to Management of Hyperglycaemia in Acute MI guidance in the Raigmore Hospital Integrated Care Pathway for Acute Coronary Syndromes.
|
|
Hypertension following myocardial infarction. |
Initiate antihypertensive treatment. |
Follow up, monitor and adjust therapy to obtain target BP. |