Myocardial infarction is part of the spectrum of acute coronary syndromes which includes unstable angina, and myocardial infarction with or without ST-segment elevation.
These notes give an overview of the initial and long-term management of myocardial infarction with ST-segment elevation. For advice on the management of non-ST-segment elevation myocardial infarction and unstable angina, see section 2.6. The aims of management of ST-segment elevation myocardial infarction are to provide supportive care and pain relief, to promote reperfusion and to reduce mortality. Oxygen, diamorphine and nitrates can provide initial support and pain relief; aspirin and percutaneous coronary intervention or thrombolytics promote reperfusion; long-term use of aspirin, beta-blockers, ACE inhibitors, and statins help to reduce mortality further.
Initial managementOxygen should be administered if there is evidence of hypoxia, pulmonary oedema, or continuing myocardial ischaemia; hyperoxia should be avoided and particular care is required in patients with chronic obstructive airways disease.
The pain (and anxiety) of myocardial infarction is managed with slow intravenous injection of diamorphine ; an antiemetic such as metoclopramide (or, if left ventricular function is not compromised, cyclizine) by intravenous injection should also be given
Aspirin (chewed or dispersed in water) is given for its antiplatelet effect ; a dose of 300 mg is suitable. If aspirin is given before arrival at hospital, a note saying that it has been given should be sent with the patient. Clopidogrel, in a dose of 300 mg, should also be given
Patency of the occluded artery can be restored by percutaneous coronary intervention or by giving a thrombolytic drug , unless contra-indicated. Percutaneous coronary intervention is the preferred method and patients should receive a glycoprotein IIb/IIIa inhibitor (section 2.9) to reduce the risk of immediate vascular occlusion. In patients who cannot be offered percutaneous coronary intervention within 90 minutes of diagnosis, a thrombolytic drug should be administered. A low molecular weight heparin or fondaparinux should also be given to all patients; anticoagulant treatment should be continued for up to 8 days, or until percutaneous coronary intervention, or hospital discharge.
Nitrates are used to relieve ischaemic pain. If sublingual glyceryl trinitrate is not effective, intravenous glyceryl trinitrate or isosorbide dinitrate is given.
Early administration of some beta-blockers has been shown to be of benefit and should be given to patients without contra-indications.
ACE inhibitors , and angiotensin-II receptor antagonists if an ACE inhibitor cannot be used, are also of benefit to patients who have no contra-indications; in hypertensive and normotensive patients treatment with an ACE inhibitor, or an angiotensin-II receptor antagonist, can be started within 24 hours of the myocardial infarction and continued for at least 5–6 weeks (see below for long-term treatment).
All patients should be closely monitored for hyperglycaemia; those with diabetes or raised blood-glucose concentration should receive insulin.
Long-term management
These notes give an overview of the initial and long-term management of myocardial infarction with ST-segment elevation. For advice on the management of non-ST-segment elevation myocardial infarction and unstable angina, see section 2.6. The aims of management of ST-segment elevation myocardial infarction are to provide supportive care and pain relief, to promote reperfusion and to reduce mortality. Oxygen, diamorphine and nitrates can provide initial support and pain relief; aspirin and percutaneous coronary intervention or thrombolytics promote reperfusion; long-term use of aspirin, beta-blockers, ACE inhibitors, and statins help to reduce mortality further.
Initial managementOxygen should be administered if there is evidence of hypoxia, pulmonary oedema, or continuing myocardial ischaemia; hyperoxia should be avoided and particular care is required in patients with chronic obstructive airways disease.
The pain (and anxiety) of myocardial infarction is managed with slow intravenous injection of diamorphine ; an antiemetic such as metoclopramide (or, if left ventricular function is not compromised, cyclizine) by intravenous injection should also be given
Aspirin (chewed or dispersed in water) is given for its antiplatelet effect ; a dose of 300 mg is suitable. If aspirin is given before arrival at hospital, a note saying that it has been given should be sent with the patient. Clopidogrel, in a dose of 300 mg, should also be given
Patency of the occluded artery can be restored by percutaneous coronary intervention or by giving a thrombolytic drug , unless contra-indicated. Percutaneous coronary intervention is the preferred method and patients should receive a glycoprotein IIb/IIIa inhibitor (section 2.9) to reduce the risk of immediate vascular occlusion. In patients who cannot be offered percutaneous coronary intervention within 90 minutes of diagnosis, a thrombolytic drug should be administered. A low molecular weight heparin or fondaparinux should also be given to all patients; anticoagulant treatment should be continued for up to 8 days, or until percutaneous coronary intervention, or hospital discharge.
Nitrates are used to relieve ischaemic pain. If sublingual glyceryl trinitrate is not effective, intravenous glyceryl trinitrate or isosorbide dinitrate is given.
Early administration of some beta-blockers has been shown to be of benefit and should be given to patients without contra-indications.
ACE inhibitors , and angiotensin-II receptor antagonists if an ACE inhibitor cannot be used, are also of benefit to patients who have no contra-indications; in hypertensive and normotensive patients treatment with an ACE inhibitor, or an angiotensin-II receptor antagonist, can be started within 24 hours of the myocardial infarction and continued for at least 5–6 weeks (see below for long-term treatment).
All patients should be closely monitored for hyperglycaemia; those with diabetes or raised blood-glucose concentration should receive insulin.
Long-term management
Long-term management involves the use of several drugs which should ideally be started before the patient is discharged from hospital.
Aspirin should be given to all patients, unless contra-indicated, at a dose of 75 mg daily. The addition of clopidogrel has been shown to reduce morbidity and mortality. For those intolerant of clopidogrel, and who are at low risk of bleeding, the combination of and aspirin should be considered. In those intolerant of both aspirin and clopidogrel, warfarin alone can be used. Warfarin should be continued for those who are already being treated for another indication, such as atrial fibrillation, with the addition of aspirin if there is a low risk of bleeding. The combination of aspirin with clopidogrel or warfarin increases the risk of bleeding.
Beta-blockers should be given to all patients in whom they are not contra-indicated. Acebutolol, metoprolol, propranolol, and timolol are suitable; for patients with left ventricular dysfunction, carvedilol, bisoprolol, or long-acting metoprolol may be appropriate
Diltiazem orverapamil can be considered if a beta-blocker cannot be used; however, they are contra-indicated in those with left ventricular dysfunction. Other calcium-channel blockers have no place in routine long-term management after a myocardial infarction.
An ACE inhibitor should be considered for all patients, especially those with evidence of left ventricular dysfunction. If an ACE inhibitor cannot be used, an angiotensin-II receptor antagonist may be used for patients with heart failure. A relatively high dose of either the ACE inhibitor or angiotensin-II receptor antagonist may be required to produce benefit.
Nitrates are used for patients with angina.
Eplerenone is licensed for use following a myocardial infarction in those with left ventricular dysfunction and evidence of heart failure.
Aspirin should be given to all patients, unless contra-indicated, at a dose of 75 mg daily. The addition of clopidogrel has been shown to reduce morbidity and mortality. For those intolerant of clopidogrel, and who are at low risk of bleeding, the combination of and aspirin should be considered. In those intolerant of both aspirin and clopidogrel, warfarin alone can be used. Warfarin should be continued for those who are already being treated for another indication, such as atrial fibrillation, with the addition of aspirin if there is a low risk of bleeding. The combination of aspirin with clopidogrel or warfarin increases the risk of bleeding.
Beta-blockers should be given to all patients in whom they are not contra-indicated. Acebutolol, metoprolol, propranolol, and timolol are suitable; for patients with left ventricular dysfunction, carvedilol, bisoprolol, or long-acting metoprolol may be appropriate
Diltiazem orverapamil can be considered if a beta-blocker cannot be used; however, they are contra-indicated in those with left ventricular dysfunction. Other calcium-channel blockers have no place in routine long-term management after a myocardial infarction.
An ACE inhibitor should be considered for all patients, especially those with evidence of left ventricular dysfunction. If an ACE inhibitor cannot be used, an angiotensin-II receptor antagonist may be used for patients with heart failure. A relatively high dose of either the ACE inhibitor or angiotensin-II receptor antagonist may be required to produce benefit.
Nitrates are used for patients with angina.
Eplerenone is licensed for use following a myocardial infarction in those with left ventricular dysfunction and evidence of heart failure.
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