» ACUTE MYOCARDIAL INFARCTION Immediate ma practitioners) i) Ambulance ii) Aspirin Analgesia nagement (general Arrange “blue-light” emergency ambulance if acute myocardial infarction (AMI) suspected. For patients with known ischaemic heart disease advise 999 call if chest pain, unresponsive to GTN, has been present for >15 minutes. In the absence of a CLEAR contraindication, give 300 mg aspirin to chew immediately. Use iv opiates (e.g. 2.5 to 5 mg diamorphine, 5 to 10 mg morphine). Avoid im injections because of risk of bleeding after thrombolysis. Hospital management i) Asp ii) Fibrinolytic therapy Beta blocker iv) Angiotensin converting enzyme (ACE) itors Diabetes only Post discharge i) smoking ii) Aspirin Beta-blocker iv) ACE inhibitor v) Lipids vi) Exercise vii) Other risk factors Give at least 300 mg aspirin to chew immediately, if it has not already been given. In the absence of a CLEAR contraindication (eg recent history of major trauma, active peptic ulceration, Gl bleed or stroke) give iv fibrinolytic therapy without delay to all patients with ST elevation left bundle branch block not known to be old who present within 12 hrs of the onset of symptoms. (see Figure 1) In the absence of a clear contraindication, give iv beta-blocker on admission (e.g. atenolol 5 mg) and continue oral beta-blocker for at least 1 year. In the absence of a clear contraindication (eg_ persistent systolic BP <100 mmHg) start angiotensin converting enzyme (ACE) inhibitors. Consider insulin-glucose infusion followed by intensive subcutaneous insulin in patients with insulin and non-insulin dependent diabetes mellitus admitted with AMI (NB beware falling potassium). (see Appendix 1) Discourage smoking. A combination of GP advice, nicotine replacement therapy, nurse follow-up and written information can be effective in motivated smokers. Continue low dose aspirin orally (je 75 to 150 mg per day) indefinitely. In the absence of a CLEAR contraindication, continue oral beta- blocker for at least 1 year. Titrate to recommended post myocardial infarction dosage. In patients over 55, diabetics or with Q waves or confirmed LV dysfunction continue long term. Dietary modification can reduce serum cholesterol by about 5%. In doses that reduce cholesterol by 20 to 30%, simvastatin and pravastatin have been shown to reduce mortality after AMI by about 25 to 30% over 5 years. It is plausible, but unproven, that this is a class effect common to all statins. Encourage regular aerobic exercise (eg swimming/jogging), avoiding exhaustion, and angina. Discourage anaerobic exercise (eg heavy gardening). Identify and treat other risk factors - eg hypertension, diabetes.Acute Myocardial Infat jeneral practioners, Intervention Evidence ‘Summary of benefits/risks Call ambulance ASAP World-wide systematic Mortality benefits of fibrinolytic overview of randomised controlled trials, demonstrates benefits of early fibrinolytic therapy. UK observational studies demonstrate that delay ‘ean be reduced by calling ‘an ambulance before GP hhas attended patient in person, ‘therapy reduced by about 2 lives/1000 infarctshhour delay. (see graph, reprinted with permission from Lancet 1994; 343 311-22.) Amaertate narra Pease SE Key references brinol Therapy Tai (FT labotatve rounding for Aibvinolte therpy in suspected acute myocar nfarco: colaborative renew of eatly morality and major tmorbiyrest rom al andomised ‘lal of mare than 1000 pation Lancet t994;3enth22 Aad RAS, Bond, uke Patients with pected myocardial Infareton: effect of mode of wansport tn admiion time to coronary care unit Brien Pract 093; 42008 Aspirin (at least 300mg World-wide systematic cally) (note: after overview of randomised discharge low dose aspirin is sufficient Le. 75 to 150 mg see below) ‘Aspirin started immediately and continued for one month reduces vascular events (MI, stroke or vascular death) by 29% (95% Cl 65% to 77%), preventing 38 vascular deaths per 1000 patients treated (Number needed to ‘reat, (NNT) = 26). Further substantial reduct vascular events accrue if aspirin is continued for at least a few years. Serious bleeding is rare. “Antiplatelet Walt Collaboration (APD. Collaborative overview of Fandomised thal of antiplatelet ‘therapy Prevention of death, Inyecatdial infarction, and strake by prolonged antiplatelet therapy in Waious categories. BND 1994; 3088 106. ‘Analgesia ‘Acute Myocardi Infarction: hospital Aspi World-wide systematic i) initaly a least 300mg Overview of randomised orally (fot previously controlled trials. iver) iiMlow dose aspirin (ie. 75 to 150mg) ued indefinitely Fibrinolytic therapy World-wide systematic (see Figure 1) overview of randomised controlled trials involving 58,600 patients. 'V opiates relieve pain, reduce anxiety and help treat acute left ventricular failure. ‘Avoid intra-muscular injections because of bleeding after fibrinolytic therapy. Aspirin started immediately and continued for one month reduces vascular events (Ml, stroke or vascular death) by about 29 (95% C173 to 3536), saving approximately 38 lives per 1000 patients treated (NNT=26). Further substantial reduc vascular events (death, and stroke) accrue if as for atleast a few years. Serious bleeding is rare. Seta rain ae: siete mes, ae i aa infarcts/hour de ted ae eee akeisy nausea Seal moral acl eles disabling and 1 “r nino eters or Antiplatelet Walt Collaboration Collaborative overview of randomised ‘ale of antiplatelet therapy Frevention of death myocardial Infarction, and stroke by prolonged antiplatelet therapy in various ‘ategores BM) 1934, 308:81-06, Fibrinolytic Therapy Talis FT) Eglaboraiv Group, nation for tmyocaial infarct: collaborative overview of early mortality and major ‘moray res from al vandomied ‘al of more than 1000 patient. nce 1994 34351122 Baigent c, collins R, Appleby Peta. Isis: T0searsurvvalin a randomised comparison of intravenous, $etokinae orl iin, bath of vr among patients with Sate myocar infarction, aM 998, Siena, I beta blockade overview of randomised controlled trials and later international mult centre randomised controlled tral Ea nano eta oad reds sreton Sintacien i iesched Sa Sityby seundiee Gok G56 90" the retbereft maintained untl at ea ear Weta blockade isaac with only minor increas nthe we Sada Tonsigfieant increase Bock: ISS‘ Collaborative Group, Randomised ‘al of intravenourstenelol among 16027 (ages of suspected acute myocardial Infarction: Bist Lancet 19651 57-66 Yosut 5, Peto R Lewis, Collins, Sleight Pr Beta blockade during and afer ‘myocardial infarction: an overview ofthe Fandomised vials. Prog Cardiovasc is 1805327:35-71,Intervention ACE inhibitors Evidence International multi- centre overview of randomised controlled tials (for ACE-inhibitors started within 36 hours of infarct) and. international multi- centre randomised controlled trials for ACE inhibitors started 3 to 7 days after infarction.) Summary of benefits/risks ‘Among all patients treated with an ACE inhibitor within 36h of onset of symptoms ‘of M30 day all cause mortality was reduced by 7% (95% C12 to 11%), corresponding to an absolute reduction in all use mortality at one month of 5/1000 ‘QNT=200), Benefits are greatest in patients with heart failure, LV dysfunction or extensive C-wave infarction. 80% of ‘the deaths avoided were in the fist week. ‘Among patients with clinical evidence of heat failure or echocardiographic evidence of impaired LV function, treatment with an ‘ACE inhibitor started after 3-7 days reduces all cause mortality at 12 months by approximately 60/1000 (NNT=18). Key references ‘ACEinhibitor Myocardial Infarction Collaborative Group. Indications for [ACEinhibtors nthe early treatment of faute myocardial infarction: systematic veriew of individual data from {00,000 patients in randomised tas, Greulation 1996 7.20212. The AIRE study Etec of ramipril on mortality and morbty of unions of {este myocardial infarction with lal idence of hear falure- Lancet issnzerazr8 The TRACE study: A clinical tril ofthe Angiotensn-converting enzyme inhibitor trandolapri in patents with lett ventricular dysfunction ater ‘myocardial infarction. N Engl) Med ise5 a2 1670-6 Diabetics ONLY Insulin-glucose infusion in patients with diabetes ‘mellitus. (see Appendix 1) ‘Acute myocardi Intervention smoking cessa Randomised controlled trial infarction: post discharge Evidence Observational studies demonstrate mortality and morbidity benefits ‘of smoking cessation Randomised trials and overviews of randomised controlled trials demonstrate the effectiveness of nicotine replacement therapy and brief individual (tather than group) advice from GPs. Further follow up by nurses and counselling. supplemented by written information in promoting smoking cessation may help in selected patients. ‘Among 620 patients with insulin and, rnon-insulin dependant diabetes mellitus and AMI randomised to at least 24 hours insulin-glucose infusion followed by at least 3 months intensive sub-cutaneous insulin 4x. daily, mortality, after mean follow-up of 3.4 years (range 1.6 to 5.6 years), ‘was 33% (102 deaths) compared to 4496 (138 deaths) (Relative Risk 0.72, 195% C1 0.55 to 0.92) in the controls, treated, NNT=9. Summary of benefitsirisks After 9 years of smoking cessation Cardiovascular risks of ex-smokers approximate risks of felong non- ‘Smoking cessation is most likely in motivated patients, receiving initial advice from doctors, follow-up by nurses and nicotine replacement. ‘ypical1 year smoking cessation rates range from <196 in ner-intervention. control groups to 11% (NNT=10) following brief advice from doctors, written information, nurse follow -up {and nicotine replacement therapy. ‘Among 584 smokers with ischaemic disease, there was no increase in cardiovascular events over 24 weeks in those randomised to transdermal nicotine (16/284, 5.496) compared to Placebo (23/280, 7.986). Malmberg for the DIGAMI Study ‘Group. Prospective randomised study ‘of intensive Insln treatment on long term sunival after acute myocardial infarction inpatients with dlabetes smeltus, BMI 1997; 314: 15125. Key references Doll Peto R. Mortality in relation to roking: 20 year: observing on male Sian dott BM 157s 2900595 Kotte BatitaR, De Bs G Beka M. ‘Atbter of suecetlmoking Intervent in medal pacts a meta. Shales of 39 controled wale JAMA ‘bad Zoee9 9. “Tang, Law M, Wald, How effective is retin replacement therapy in heb People sop snking? BA oSe SD, Slag) Mant, Foe G, Lodge M, Meta- rls of eficc of rcatne replacement ‘Terapies nsmaling easton. Lana 134, 3 Bo. IKREGP Research Group, Randomised til of ‘cotine paths general prac: eas Stone year BM 364 30814767 Jesoph AM, Norman SM, Fey LH eta. The salt of tansdermal ntine oan ad to Solio casatlonn patents with cardiac (Asa, New Engl Med 956 335 1928 Aspirin 5 t0 325 mg aaly ‘Overview of randomised controlled trials. Aspirin prevents around 40 serious vascular events (death, myocardial infarction and stroke) per 1000 treated (NNT=25) in the first two years after AMI. Serious adverse effects attributable to aspirin are rare. ‘Ariat Tals! Colaboration, Celdbrative overew of randoméed ‘Ga of atsatalt therapy Prevention Staesth mjocrdal fatto and sake ae cago of patent Sas ios,