ST elevation myocardial infarction secondary prevention: Difference between revisions

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{{ST elevation myocardial infarction}}
{{ST elevation myocardial infarction}}
'''For the chapter on [[Secondary Prevention of Coronary Artery Disease]] in general, click [[Secondary Prevention of Coronary Artery Disease|here]].'''<br>
'''For the chapter on [[Secondary Prevention of Coronary Artery Disease]] in general, click [[Secondary Prevention of Coronary Artery Disease|here]].'''<br>
{{CMG}}; '''Associate Editor:''' {{CZ}}
{{CMG}}; {{AE}} {{CZ}}


==Overview==
==Overview==
Patients are usually treated with several long-term medications following a ST elevation myocardial infarction with the goal of preventing secondary cardiovascular events such as further myocardial infarctions, [[congestive heart failure]] or [[cerebrovascular accident]] (CVA). Unless contraindicated, such medications may include:<ref>Smith A, Aylward P, Campbell T, ''et al.'' Therapeutic Guidelines: Cardiovascular, 4th edition. North Melbourne: Therapeutic Guidelines; 2003. ISSN 1327-9513</ref>
Identifying and, when present, treating [[Coronary heart disease risk factors|category I]] risk factors can be an optimal secondary prevention strategy in patients with [[STEMI]]. You can read more about general coronary heart disease secondary prevention [[Coronary heart disease secondary prevention|HERE]]


* [[Antiplatelet drug]] therapy such as [[aspirin]] and/or [[clopidogrel]] should be continued to reduce the risk of plaque rupture and recurrent myocardial infarction. Aspirin is first-line, owing to its low cost and comparable efficacy, with clopidogrel reserved for patients intolerant of aspirin. The combination of clopidogrel and aspirin may further reduce risk of cardiovascular events, however the risk of [[hemorrhage]] is increased.<ref name="pmid14504182">{{cite journal |author=Peters RJ, Mehta SR, Fox KA, ''et al'' |title=Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study |journal=Circulation |volume=108 |issue=14 |pages=1682–7 |year=2003 |month=October |pmid=14504182 |doi=10.1161/01.CIR.0000091201.39590.CB |url=}}</ref>
==Long-term Medical Therapy and Secondary Prevention==
Patients are usually treated with several long-term medications following a ST elevation myocardial infarction with the goal of preventing secondary cardiovascular events such as further myocardial infarctions, [[congestive heart failure]] or [[cerebrovascular accident]] ([[CVA]]). Unless contraindicated, such medications may include:<ref>Smith A, Aylward P, Campbell T, ''et al.'' Therapeutic Guidelines: Cardiovascular, 4th edition. North Melbourne: Therapeutic Guidelines; 2003. ISSN 1327-9513</ref>


* [[Beta blocker]] therapy such as [[metoprolol]] or [[carvedilol]] should be commenced.<ref name="pmid2858114">{{cite journal |author=Yusuf S, Peto R, Lewis J, Collins R, Sleight P |title=Beta blockade during and after myocardial infarction: an overview of the randomized trials |journal=Prog Cardiovasc Dis |volume=27 |issue=5 |pages=335–71 |year=1985 |pmid=2858114 |doi= |url=}}</ref> These have been particularly beneficial in high-risk patients such as those with [[left ventricle|left ventricular]] dysfunction and/or continuing cardiac [[ischaemia]].<ref name="pmid11356434">{{cite journal |author=Dargie HJ |title=Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial |journal=Lancet |volume=357 |issue=9266 |pages=1385–90 |year=2001 |month=May |pmid=11356434 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673600045608}}</ref> β-Blockers decrease mortality and morbidity. They also improve symptoms of cardiac ischemia in NSTEMI.
* [[Antiplatelet drug]] therapy such as [[aspirin]] and/or [[clopidogrel]] should be continued to reduce the risk of [[plaque rupture]] and [[recurrent myocardial infarction]]. Aspirin is first-line, owing to its low cost and comparable efficacy, with clopidogrel reserved for patients intolerant of aspirin. The combination of clopidogrel and aspirin may further reduce risk of cardiovascular events, however the risk of [[hemorrhage]] is increased.<ref name="pmid14504182">{{cite journal |author=Peters RJ, Mehta SR, Fox KA, ''et al'' |title=Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study |journal=Circulation |volume=108 |issue=14 |pages=1682–7 |year=2003 |month=October |pmid=14504182 |doi=10.1161/01.CIR.0000091201.39590.CB |url=}}</ref>


* [[ACE inhibitor]] therapy should be commenced 24–48 hours post-MI in hemodynamically-stable patients, particularly in patients with a history of MI, [[diabetes mellitus]], [[hypertension]], [[anterior]] location of infarct (as assessed by ECG), and/or evidence of left ventricular dysfunction. ACE inhibitors reduce mortality, the development of [[heart failure]], and decrease ventricular remodelling post-MI.<ref name="pmid1386652">{{cite journal |author=Pfeffer MA, Braunwald E, Moyé LA, ''et al'' |title=Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators |journal=N. Engl. J. Med. |volume=327 |issue=10 |pages=669–77 |year=1992 |month=September |pmid=1386652 |doi= |url=}}</ref>
* [[Beta blocker]] therapy such as [[metoprolol]] or [[carvedilol]] should be commenced.<ref name="pmid2858114">{{cite journal |author=Yusuf S, Peto R, Lewis J, Collins R, Sleight P |title=Beta blockade during and after myocardial infarction: an overview of the randomized trials |journal=Prog Cardiovasc Dis |volume=27 |issue=5 |pages=335–71 |year=1985 |pmid=2858114 |doi= |url=}}</ref> These have been particularly beneficial in high-risk patients such as those with [[left ventricular dysfunction]] and/or continuing cardiac [[ischaemia]].<ref name="pmid11356434">{{cite journal |author=Dargie HJ |title=Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial |journal=Lancet |volume=357 |issue=9266 |pages=1385–90 |year=2001 |month=May |pmid=11356434 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673600045608}}</ref> β-Blockers decrease mortality and morbidity. They also improve symptoms of cardiac ischemia in NSTEMI.


* [[Statin]] therapy has been shown to reduce mortality and morbidity post-MI.<ref name="pmid8801446">{{cite journal |author=Sacks FM, Pfeffer MA, Moye LA, ''et al'' |title=The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators |journal=N. Engl. J. Med. |volume=335 |issue=14 |pages=1001–9 |year=1996 |month=October |pmid=8801446 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=8801446&promo=ONFLNS19}}</ref><ref name="pmid9576424">{{cite journal |author=Sacks FM, Moyé LA, Davis BR, ''et al'' |title=Relationship between plasma LDL concentrations during treatment with pravastatin and recurrent coronary events in the Cholesterol and Recurrent Events trial |journal=Circulation |volume=97 |issue=15 |pages=1446–52 |year=1998 |month=April |pmid=9576424 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=9576424}}</ref>  The effects of statins may be more than their LDL lowering effects. The general consensus is that statins have [[Atheroma|plaque]] stabilization and multiple other ("pleiotropic") effects that may prevent myocardial infarction in addition to their effects on blood lipids.<ref name="pmid16226165">{{cite journal |author=Ray KK, Cannon CP |title=The potential relevance of the multiple lipid-independent (pleiotropic) effects of statins in the management of acute coronary syndromes |journal=J. Am. Coll. Cardiol. |volume=46 |issue=8 |pages=1425–33 |year=2005 |month=October |pmid=16226165 |doi=10.1016/j.jacc.2005.05.086 |url=}}</ref> A study by AJC by Herbert D. Aranow, et al. indicates that, for patients who underwent lipid-lowering therapy prior to having an acute myocardial infarction (AMI), infarct size was significantly less than for patients who had not received this earlier treatment. Data from 10,548 patients were collected from both the Global Use of Streptokinase or t-PA for Occluded Coronary Arteries (GUSTO) IIb (n=6,414) and the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Supression Using Integrilin Therapy (PURSUIT) (n=4,134) studies, with infarct size measured by patients' peak creatine kinase (CK) -MB levels. Patients who had lipid-lowering therapy had a median peak CK-MB of 4.2 times the upper limit of normal (ULN) compared to 5.2 times the ULN for those who were not pre-treated (p<0.0001). These results suggest a potential benefit of lipid-lowering therapy for patients at risk for an AMI. Noted limitations of the study include: the observational study design (both the potential effects of confounding variables and the "healthy-user bias" ); the lack of documented information differentiating between statin and nonstatin therapies; and the exclusion from analysis of patients who died during the index hospitalization.
* [[ACE inhibitor]] therapy should be commenced 24-48 hours post-MI in hemodynamically-stable patients, particularly in patients with a history of MI, [[diabetes mellitus]], [[hypertension]], anterior location of infarct (as assessed by EKG), and/or evidence of left ventricular dysfunction. ACE inhibitors reduce [[mortality]], the development of [[heart failure]], and decrease ventricular remodelling post-MI.<ref name="pmid1386652">{{cite journal |author=Pfeffer MA, Braunwald E, Moyé LA, ''et al'' |title=Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators |journal=N. Engl. J. Med. |volume=327 |issue=10 |pages=669–77 |year=1992 |month=September |pmid=1386652 |doi= |url=}}</ref>


* The [[aldosterone antagonist]] agent [[eplerenone]] has been shown to further reduce risk of cardiovascular death post-MI in patients with heart failure and left ventricular dysfunction, when used in conjunction with standard therapies above.<ref name="pmid15537370">{{cite journal |author=Keating GM, Plosker GL |title=Eplerenone : a review of its use in left ventricular systolic dysfunction and heart failure after acute myocardial infarction |journal=Drugs |volume=64 |issue=23 |pages=2689–707 |year=2004 |pmid=15537370 |doi= |url=}}</ref>
* [[Statin]] therapy has been shown to reduce mortality and [[morbidity]] post-MI.<ref name="pmid8801446">{{cite journal |author=Sacks FM, Pfeffer MA, Moye LA, ''et al'' |title=The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators |journal=N. Engl. J. Med. |volume=335 |issue=14 |pages=1001–9 |year=1996 |month=October |pmid=8801446 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=8801446&promo=ONFLNS19}}</ref><ref name="pmid9576424">{{cite journal |author=Sacks FM, Moyé LA, Davis BR, ''et al'' |title=Relationship between plasma LDL concentrations during treatment with pravastatin and recurrent coronary events in the Cholesterol and Recurrent Events trial |journal=Circulation |volume=97 |issue=15 |pages=1446–52 |year=1998 |month=April |pmid=9576424 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=9576424}}</ref>  The effects of statins may be more than their [[LDL]] lowering effects. The general consensus is that statins have [[Atheroma|plaque]] stabilization and multiple other ("pleiotropic") effects that may prevent myocardial infarction in addition to their effects on blood lipids.<ref name="pmid16226165">{{cite journal |author=Ray KK, Cannon CP |title=The potential relevance of the multiple lipid-independent (pleiotropic) effects of statins in the management of acute coronary syndromes |journal=J. Am. Coll. Cardiol. |volume=46 |issue=8 |pages=1425–33 |year=2005 |month=October |pmid=16226165 |doi=10.1016/j.jacc.2005.05.086 |url=}}</ref> A study by AJC by Herbert D. Aranow, et al. indicates that, for patients who underwent lipid-lowering therapy prior to having an acute myocardial infarction (AMI), infarct size was significantly less than for patients who had not received this earlier treatment. Data from 10,548 patients were collected from both the Global Use of Streptokinase or t-PA for Occluded Coronary Arteries (GUSTO) IIb (n=6,414) and the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Supression Using Integrilin Therapy (PURSUIT) (n=4,134) studies, with infarct size measured by patients' peak creatine kinase (CK) -MB levels. Patients who had lipid-lowering therapy had a median peak CK-MB of 4.2 times the upper limit of normal (ULN) compared to 5.2 times the ULN for those who were not pre-treated (p<0.0001). These results suggest a potential benefit of lipid-lowering therapy for patients at risk for an AMI. Noted limitations of the study include: the observational study design (both the potential effects of confounding variables and the "healthy-user bias" ); the lack of documented information differentiating between statin and nonstatin therapies; and the exclusion from analysis of patients who died during the index hospitalization.
* [[Omega-3 fatty acid]]s, commonly found in fish, have been shown to reduce mortality post-MI.<ref name="pmid10465168">{{cite journal |author= |title=Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico |journal=Lancet |volume=354 |issue=9177 |pages=447–55 |year=1999 |month=August |pmid=10465168 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673699070725}}</ref>  While the mechanism by which these fatty acids decrease mortality is unknown, it has been postulated that the survival benefit is due to electrical stabilization and the prevention of [[ventricular fibrillation]].<ref name="pmid16267249">{{cite journal |author=Leaf A, Albert CM, Josephson M, ''et al'' |title=Prevention of fatal arrhythmias in high-risk subjects by fish oil n-3 fatty acid intake |journal=Circulation |volume=112 |issue=18 |pages=2762–8 |year=2005 |month=November |pmid=16267249 |doi=10.1161/CIRCULATIONAHA.105.549527 |url=}}</ref>  However, further studies in a high-risk subset have not shown a clear-cut decrease in potentially fatal arrhythmias due to omega-3 fatty acids.<ref name="pmid16772624">{{cite journal |author=Brouwer IA, Zock PL, Camm AJ, ''et al'' |title=Effect of fish oil on ventricular tachyarrhythmia and death in patients with implantable cardioverter defibrillators: the Study on Omega-3 Fatty Acids and Ventricular Arrhythmia (SOFA) randomized trial |journal=JAMA |volume=295 |issue=22 |pages=2613–9 |year=2006 |month=June |pmid=16772624 |doi=10.1001/jama.295.22.2613 |url=}}</ref><ref name="pmid15956633">{{cite journal |author=Raitt MH, Connor WE, Morris C, ''et al'' |title=Fish oil supplementation and risk of ventricular tachycardia and ventricular fibrillation in patients with implantable defibrillators: a randomized controlled trial |journal=JAMA |volume=293 |issue=23 |pages=2884–91 |year=2005 |month=June |pmid=15956633 |doi=10.1001/jama.293.23.2884 |url=}}</ref>
 
* The [[aldosterone antagonist]] agent [[eplerenone]] has been shown to further reduce risk of cardiovascular death post-MI in patients with [[heart failure]] and [[left ventricular dysfunction]], when used in conjunction with standard therapies above.<ref name="pmid15537370">{{cite journal |author=Keating GM, Plosker GL |title=Eplerenone : a review of its use in left ventricular systolic dysfunction and heart failure after acute myocardial infarction |journal=Drugs |volume=64 |issue=23 |pages=2689–707 |year=2004 |pmid=15537370 |doi= |url=}}</ref>
* [[Omega-3 fatty acid]]s, commonly found in fish, have been shown to reduce mortality post-MI.<ref name="pmid10465168">{{cite journal |author= |title=Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico |journal=Lancet |volume=354 |issue=9177 |pages=447–55 |year=1999 |month=August |pmid=10465168 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673699070725}}</ref>  While the mechanism by which these fatty acids decrease mortality is unknown, it has been postulated that the survival benefit is due to electrical stabilization and the prevention of [[ventricular fibrillation]].<ref name="pmid16267249">{{cite journal |author=Leaf A, Albert CM, Josephson M, ''et al'' |title=Prevention of fatal arrhythmias in high-risk subjects by fish oil n-3 fatty acid intake |journal=Circulation |volume=112 |issue=18 |pages=2762–8 |year=2005 |month=November |pmid=16267249 |doi=10.1161/CIRCULATIONAHA.105.549527 |url=}}</ref>  However, further studies in a high-risk subset have not shown a clear-cut decrease in potentially fatal [[arrhythmia]]s due to omega-3 fatty acids.<ref name="pmid16772624">{{cite journal |author=Brouwer IA, Zock PL, Camm AJ, ''et al'' |title=Effect of fish oil on ventricular tachyarrhythmia and death in patients with implantable cardioverter defibrillators: the Study on Omega-3 Fatty Acids and Ventricular Arrhythmia (SOFA) randomized trial |journal=JAMA |volume=295 |issue=22 |pages=2613–9 |year=2006 |month=June |pmid=16772624 |doi=10.1001/jama.295.22.2613 |url=}}</ref><ref name="pmid15956633">{{cite journal |author=Raitt MH, Connor WE, Morris C, ''et al'' |title=Fish oil supplementation and risk of ventricular tachycardia and ventricular fibrillation in patients with implantable defibrillators: a randomized controlled trial |journal=JAMA |volume=293 |issue=23 |pages=2884–91 |year=2005 |month=June |pmid=15956633 |doi=10.1001/jama.293.23.2884 |url=}}</ref>
* Reducing excess weight and exercising regularly.
* Reducing excess weight and exercising regularly.
* Keeping BP and diabetes under check.
* Keeping blood pressure and diabetes under check.
* Following a diet low in cholesterol (<200 mg daily) and saturated fat.
* Following a diet low in [[cholesterol]] (<200 mg daily) and saturated fat.
* Increasing HDL- Patients with low HDL  [A lipoprotein that transports cholesterol in the blood; composed of a high proportion of protein and relatively little cholesterol] (<35 mg/dl) are encouraged to exercise regularly and to take medications to increase HDL levels.
* Increasing [[HDL]]- Patients with low HDL  [A [[lipoprotein]] that transports cholesterol in the blood; composed of a high proportion of protein and relatively little cholesterol] (<35 mg/dl) are encouraged to exercise regularly and to take medications to increase HDL levels.
 
* "Among patients with a recent myocardial infarction, colchicine at a dose of 0.5 mg daily led to a significantly lower risk of ischemic cardiovascular events than placebo". <ref name="pmid31733140">{{cite journal| author=Tardif JC, Kouz S, Waters DD, Bertrand OF, Diaz R, Maggioni AP et al.| title=Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction. | journal=N Engl J Med | year= 2019 | volume= | issue= | pages= | pmid=31733140 | doi=10.1056/NEJMoa1912388 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31733140 }} </ref> In a [[randomized controlled trial]] of patients after myocardial infarction, the [[relative risk ratio]] of [[colchicine 0.5 mg once daily]], as compared to [[placebo]], for ischemic cardiovascular events was 0.77 and the [[relative risk reduction]] was 22.5%. In populations similar to those in this study which had a rate of risk as measured by the ischemic cardiovascular events of 7.1% without treatment, the [[number needed to treat]] is 63. <ref name="pmid31733140"/>
=ACC / AHA Guidelines- Recommendations for Secondary Prevention (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>=
 
==ACC / AHA Guidelines- Recommendations for Smoking (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
 
 
===2007 Goal===
 
*Complete cessation, no exposure to environmental [[tobacco]] smoke
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Status of [[tobacco]] use should be asked about at every visit. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Every [[tobacco]] user and family members who smoke should be advised to quit at every visit. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' The [[tobacco]] user’s willingness to quit should be assessed. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' The [[tobacco]] user should be assisted by [[counseling]] and developing a plan for quitting.  ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Follow-up, referral to special programs, or [[pharmacotherapy]] (including [[nicotine replacement]] and pharmacological treatment) should be arranged.  ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' Exposure to environmental [[tobacco]] smoke at work and home should be avoided. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|}
 
==ACC / AHA Guidelines- Recommendations for Blood Pressure Control (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
 
===2007 Goal===
 
*Less than 140/90 mm Hg or less than 130/80 if patient has [[diabetes]] or chronic [[kidney disease]]
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For patients with [[blood pressure]] greater than or equal to 140/90 mm Hg (or greater than or equal to 130/80 mm Hg for patients with [[diabetes]] or chronic [[kidney disease]]), it is recommended to initiate or maintain lifestyle modification—weight control; increased physical activity; [[alcohol]] moderation; [[sodium]] reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products.  ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For patients with [[blood pressure]] greater than or equal to 140/90 mm Hg (or greater than or equal to 130/80 mm Hg for patients with [[diabetes]] or chronic [[kidney disease]]), it is useful as tolerated, to add [[blood pressure medication]], treating initially with [[beta blockers]] and/or [[ACE inhibitors]], with the addition of other drugs such as [[thiazide]]s as needed to achieve goal [[blood pressure]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])<nowiki>"</nowiki>
|}


==ACC / AHA Guidelines- Recommendations for Lipid Management (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
==2007 Update of 2004 ACC / AHA Guidelines for the management of ST Segment Elevation Myocardial Infarction - Recommendations for Secondary Prevention (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==


{{cquote|
===Aspirin (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>===
===2007 Goal===
 
*[[LDL-C]] substantially less than 100 mg per dL (If [[triglyceride]]s are greater than or equal to 200 mg per dL, [[non–HDL-C]] should be less than 130 mg per dL.)
 
===Recommendations===
 
1. Starting dietary therapy is recommended for all patients. Reduce intake of [[saturated fat]]s (to less than 7% of total calories), [[trans fatty acid]]s, and [[cholesterol]] (to less than 200 mg per day). ''(Class I Recommendation; Level of Evidence: B)''
 
2. Adding plant [[stanol]]/[[sterol]]s (2 g per day) and/or viscous [[fiber]] (greater than 10 g per day) is reasonable to further lower [[LDL-C]]. ''(Class IIa Recommendation; Level of Evidence: A)''
 
3. Promotion of daily physical activity and weight management is recommended. ''(Class I Recommendation; Level of Evidence: B)''
 
4. It may be reasonable to encourage increased consumption of [[omega-3 fatty acid]]s in the form of fish or in capsules (1 g per day) for risk reduction. For treatment of elevated [[triglyceride]]s, higher doses are usually necessary for risk reduction. (Class IIb Recommendation; Level of Evidence: B)''
 
5. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. ''(Class I Recommendation; Level of Evidence: A)'' For hospitalized patients, initiation of [[lipid-lowering medication]] is indicated as recommended below before discharge according to the following schedule:
:* [[LDL-C]] should be less than 100 mg per dL. ''(Class I Recommendation; Level of Evidence: A)''
:* Further reduction of [[LDL-C]] to less than 70 mg per dL is reasonable. ''(Class IIa Recommendation; Level of Evidence: A)''
:* If baseline [[LDL-C]] is greater than or equal to 100 mg per dL, [[LDL-lowering drug therapy]] should be initiated. ''(Class I Recommendation; Level of Evidence: A)''
:* If on-treatment [[LDL-C]] is greater than or equal to 100 mg per dL, intensifying [[LDL-lowering drug therapy]] (may require LDL-lowering drug combination) is recommended. ''(Class I Recommendation; Level of Evidence: A)''
:* If baseline [[LDL-C]] is 70 to 100 mg per dL, it is reasonable to treat to [[LDL-C]] less than 70 mg per dL. ''(Class IIa Recommendation; Level of Evidence: B)''
:* If [[triglyceride]]s are greater than or equal to 150 mg per dL or HDL-C is less than 40 mg per dL, weight management, physical activity, and [[smoking cessation]] should be emphasized. ''(Class I Recommendation; Level of Evidence: B)''
:* If [[triglyceride]]s are 200 to 499 mg per dL, [[non–HDL-C]] target should be less than 130 mg per dL. (Class I Recommendation; Level of Evidence: B)''
:* If [[triglyceride]]s are 200 to 499 mg per dL, further reduction of [[non–HDL-C]] to less than 100 mg per dL is reasonable. ''(Class IIa Recommendation; Level of Evidence: B)''
 
6. Therapeutic options to reduce [[non–HDL-C]] include:
:* More intense [[LDL-C–lowering therapy]] is indicated. ''(Class I Recommendation; Level of Evidence: B)''
:* [[Niacin]] (after [[LDL-C–lowering therapy]]) can be beneficial. ''(Class IIa Recommendation; Level of Evidence: B)''
:* [[Fibrate therapy]] (after [[LDL-C–lowering therapy]]) can be beneficial. ''(Class IIa Recommendation; Level of Evidence: B)''
 
7. If [[triglyceride]]s are greater than or equal to 500 mg per dL, therapeutic options indicated and useful to prevent [[pancreatitis]] are [[fibrate]] or [[niacin]] before [[LDL-lowering therapy]]; and treat [[LDL-C]] to goal after [[triglyceride-lowering therapy]]. Achieving [[non–HDL-C]] less than 130 mg per dL is recommended. ''(Class I Recommendation; Level of Evidence: C)''}}
 
==ACC / AHA Guidelines- Recommendations for Physical Activity (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
 
===2007 Goal===
 
* 30 minutes, 7 days per week (minimum 5 days per week)


{|class="wikitable"
{|class="wikitable"
Line 106: Line 34:
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Advising medically supervised programs ([[cardiac rehabilitation]]) for high-risk patients (e.g., recent [[acute coronary syndrome]] or [[revascularization]], [[HF]]) is recommended.  ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For all post-[[PCI]] [[STEMI]] [[stent]]ed patients without [[aspirin resistance]], [[aspirin allergy|allergy]], or increased risk of bleeding, [[aspirin]] 162 mg to 325 mg daily should be given for at least 1 month after [[BMS]] implantation, 3 months after [[sirolimus-eluting stent]] implantation, and 6 months after [[paclitaxel-eluting stent]] implantation, after which long-term [[aspirin]] use should be continued indefinitely at a dose of 75 mg to 162 mg daily.  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.'''For all patients, encouraging 30 to 60 minutes of moderate-intensity aerobic activity is recommended, such as brisk walking on most—preferably all—days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, and household work).  ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
|}
|}


Line 117: Line 41:
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Encouraging resistance training 2 days per week may be reasonable. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) '' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients for whom the [[physician]] is concerned about risk of bleeding lower-dose 75 mg to 162 mg of [[aspirin]] is reasonable during the initial period after [[stent]] implantation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}


==ACC / AHA Guidelines- Recommendations for Weight Management (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
===Clopidogrel (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>===
 
===2007 Goals===
 
* [[BMI]]: 18.5 to 24.9 kg/m2
* Waist circumference: Men less than 40 inches (102 cm), women less than 35 inches (89 cm)


{|class="wikitable"
{|class="wikitable"
Line 131: Line 50:
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' It is useful to assess [[BMI]] and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a [[BMI]] between 18.5 and 24.9 kg/m2. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For all post-[[PCI]] patients who receive a [[DES]], [[clopidogrel]] 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-[[PCI]] patients receiving a [[BMS]], clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For all [[STEMI]] patients not undergoing [[stent]]ing (medical therapy alone or [[PTCA]] without [[stent]]ing), treatment with clopidogrel should continue for at least 14 days. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' If waist circumference (measured horizontally at the [[iliac crest]]) is 35 inches (89 cm) or greater in women and 40 inches (102 cm) or greater in men, it is useful to initiate lifestyle changes and consider treatment strategies for [[metabolic syndrome]] as indicated.  ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
|}
 
==ACC / AHA Guidelines- Recommendations for Diabetes Management (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
 
===2007 Goal===
 
*[[HbA1c]] less than 7%
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' It is recommended to initiate lifestyle and [[pharmacotherapy]] to achieve near-normal [[HbA1c]].  ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Beginning vigorous modification of other risk factors (e.g., physical activity, weight management, [[blood pressure]] control, and [[cholesterol]] management as recommended above) is beneficial. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Coordination of [[diabetic]] care with the patient’s [[primary care physician]] or [[endocrinologist]] is beneficial.  ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
|}
 
==ACC / AHA Guidelines- Recommendations for Antiplatelet Agents/Anticoagulants: Aspirin (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For all post-[[PCI]] [[STEMI]] [[stent]]ed patients without [[aspirin resistance]], [[aspirin allergy|allergy]], or increased risk of bleeding, [[aspirin]] 162 mg to 325 mg daily should be given for at least 1 month after [[BMS]] implantation, 3 months after [[sirolimus-eluting stent]] implantation, and 6 months after [[paclitaxel-eluting stent]] implantation, after which long-term [[aspirin]] use should be continued indefinitely at a dose of 75 mg to 162 mg daily.  ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
|}
|}


Line 168: Line 59:
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients for whom the [[physician]] is concerned about risk of bleeding lower-dose 75 mg to 162 mg of [[aspirin]] is reasonable during the initial period after [[stent]] implantation. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) '' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Long-term maintenance therapy (e.g., 1 year) with [[clopidogrel]] (75 mg per day orally) is reasonable in [[STEMI]] patients regardless of whether they undergo reperfusion with [[fibrinolytic therapy]] or do not receive [[reperfusion therapy]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}


==ACC / AHA Guidelines- Recommendations for Antiplatelet Agents/Anticoagulants: Clopidogrel (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
===Warfarin (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>===


{|class="wikitable"
{|class="wikitable"
Line 177: Line 68:
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For all post-[[PCI]] patients who receive a [[DES]], [[clopidogrel]] 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-[[PCI]] patients receiving a [[BMS]], [[clopidogrel]] should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Managing [[warfarin]] to an [[INR]] equal to 2.0 to 3.0 for paroxysmal or chronic [[atrial fibrillation]] or [[atrial flutter|flutter]] is recommended, and in post-[[MI]] patients when clinically indicated (e.g., [[atrial fibrillation]], [[left ventricular thrombus]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For all [[STEMI]] patients not undergoing [[stent]]ing (medical therapy alone or [[PTCA]] without [[stent]]ing), treatment with [[clopidogrel]] should continue for at least 14 days. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Use of [[warfarin]] in conjunction with [[aspirin]] and/or [[clopidogrel]] is associated with an increased risk of bleeding and should be monitored closely. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Long-term maintenance therapy (e.g., 1 year) with [[clopidogrel]] (75 mg per day orally) is reasonable in [[STEMI]] patients regardless of whether they undergo reperfusion with [[fibrinolytic therapy]] or do not receive [[reperfusion therapy]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) '' <nowiki>"</nowiki>
|}
 
==ACC / AHA Guidelines- Recommendations for Antiplatelet Agents/Anticoagulants: Warfarin (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Managing [[warfarin]] to an INR equal to 2.0 to 3.0 for paroxysmal or chronic [[atrial fibrillation]] or [[atrial flutter|flutter]] is recommended, and in post-[[MI]] patients when clinically indicated (e.g., [[atrial fibrillation]], [[left ventricular thrombus]]). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In patients requiring [[warfarin]], clopidogrel, and [[aspirin]] therapy, an INR of 2.0 to 2.5 is recommended with low dose [[aspirin]] (75 mg to 81 mg) and a 75 mg dose of clopidogrel. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Use of [[warfarin]] in conjunction with [[aspirin]] and/or [[clopidogrel]] is associated with an increased risk of bleeding and should be monitored closely. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In patients requiring [[warfarin]], [[clopidogrel]], and [[aspirin]] therapy, an INR of 2.0 to 2.5 is recommended with low dose [[aspirin]] (75 mg to 81 mg) and a 75 mg dose of [[clopidogrel]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
|}
|}


==ACC / AHA Guidelines- Recommendations for Renin-Angiotensin-Aldosterone System Blockers: ACE Inhibitors (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
===ACE Inhibitors (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>===


{|class="wikitable"
{|class="wikitable"
Line 208: Line 81:
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[ACE inhibitor]]s should be started and continued indefinitely in all patients recovering from [[STEMI]] with [[LVEF]] less than or equal to 40% and for those with [[hypertension]], [[diabetes]], or chronic [[kidney disease]], unless contraindicated. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[ACE inhibitor]]s should be started and continued indefinitely in all patients recovering from [[STEMI]] with [[LVEF]] less than or equal to 40% and for those with [[hypertension]], [[diabetes]], or chronic [[kidney disease]], unless contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[ACE inhibitor]]s should be started and continued indefinitely in patients recovering from [[STEMI]] who are not lower risk (lower risk defined as those with normal [[LVEF]] in whom cardiovascular risk factors are well controlled and [[revascularization]] has been performed), unless contraindicated. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[ACE inhibitor]]s should be started and continued indefinitely in patients recovering from [[STEMI]] who are not lower risk (lower risk defined as those with normal [[LVEF]] in whom cardiovascular risk factors are well controlled and [[revascularization]] has been performed), unless contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


Line 217: Line 90:
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Among lower risk patients recovering from [[STEMI]] (i.e., those with normal [[LVEF]] in whom cardiovascular risk factors are well controlled and [[revascularization]] has been performed) use of [[ACE inhibitor]]s is reasonable. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) '' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Among lower risk patients recovering from [[STEMI]] (i.e., those with normal [[LVEF]] in whom cardiovascular risk factors are well controlled and [[revascularization]] has been performed) use of [[ACE inhibitor]]s is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


==ACC / AHA Guidelines- Recommendations for Renin-Angiotensin-Aldosterone System Blockers: Angiotensin Receptor Blockers (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
===Angiotensin Receptor Blockers (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>===


{|class="wikitable"
{|class="wikitable"
Line 226: Line 99:
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Use of [[angiotensin receptor blocker]]s is recommended in patients who are intolerant of [[ACE inhibitor]]s and have [[HF]] or have had an [[MI]] with [[LVEF]] less than or equal to 40%. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Use of [[angiotensin receptor blocker]]s is recommended in patients who are intolerant of [[ACE inhibitor]]s and have [[HF]] or have had an [[MI]] with [[LVEF]] less than or equal to 40%. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' It is beneficial to use [[angiotensin receptor blocker therapy]] in other patients who are [[ACE-inhibitor]] intolerant and have [[hypertension]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' It is beneficial to use angiotensin receptor blocker therapy in other patients who are ACE-inhibitor intolerant and have [[hypertension]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


Line 235: Line 108:
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Considering use in combination with [[ACE inhibitor]]s in [[systolic dysfunction]] [[HF]] may be reasonable. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) '' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Considering use in combination with [[ACE inhibitor]]s in [[systolic dysfunction]] [[HF]] may be reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


==ACC / AHA Guidelines- Recommendations for Renin-Angiotensin-Aldosterone System Blockers: Aldosterone Blockade (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
===Aldosterone Blockade (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>===


{|class="wikitable"
{|class="wikitable"
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Use of [[aldosterone]] blockade in post-[[MI]] patients without significant [[renal dysfunction]] or [[hyperkalemia]] is recommended in patients who are already receiving therapeutic doses of an [[ACE inhibitor]] and [[beta blocker]], have an [[LVEF]] of less than or equal to 40%, and have either [[diabetes]] or [[HF]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Use of [[aldosterone]] blockade in post-[[MI]] patients without significant [[renal dysfunction]] or [[hyperkalemia]] is recommended in patients who are already receiving therapeutic doses of an [[ACE inhibitor]] and [[beta blocker]], have an [[LVEF]] of less than or equal to 40%, and have either [[diabetes]] or [[HF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
|}


==ACC / AHA Guidelines- Recommendations for Beta Blockers (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
===Beta Blockers (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>===


{|class="wikitable"
{|class="wikitable"
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' It is beneficial to start and continue [[beta-blocker therapy]] indefinitely in all patients who have had [[MI]], [[acute coronary syndrome]], or [[LV dysfunction]] with or without [[HF]] symptoms, unless contraindicated. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' It is beneficial to start and continue [[beta-blocker therapy]] indefinitely in all patients who have had [[MI]], [[acute coronary syndrome]], or [[LV dysfunction]] with or without [[HF]] symptoms, unless contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
|}


==ACC / AHA Guidelines- Recommendations for Influenza Vaccination (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>==
===Influenza Vaccination (DO NOT EDIT)<ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>===


{|class="wikitable"
{|class="wikitable"
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Patients with [[cardiovascular disease]] should have an annual [[influenza vaccination]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Patients with [[cardiovascular disease]] should have an annual [[influenza vaccination]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
|}
==See also==
* [[The Living Guidelines: STEMI | The STEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
* [[acute coronary syndrome]]
* [[angina pectoris|angina]]
* [[Cardiac arrest]]
* [[coronary thrombosis]]
* [[Hibernating myocardium]]
* [[Stunned myocardium]]
* [[Ventricular remodeling]]


==Sources==
==Sources==
Line 282: Line 145:
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}


==External links==
[[Category:Disease]]
* [http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=pub Risk Assessment Tool for Estimating Your 10-year Risk of Having a Heart Attack] - based on information of the [[Framingham Heart Study]], from the United States [[National Heart, Lung and Blood Institute]]
* [http://www.nlm.nih.gov/medlineplus/heartattack.html Heart Attack] - overview of resources from [[MedlinePlus]].
* [http://ww2.heartandstroke.ca/Page.asp?PageID=1975&ArticleID=5288 Heart Attack Warning Signals] from the Heart and Stroke Foundation of Canada
* [http://www.regionalpci-stemi.org/index.html Regional PCI for STEMI Resource Center] - Evidence based online resource center for the development of regional PCI networks for acute STEMI
* [http://www.stemisystems.org/ STEMI Systems] - Articles, profiles, and reviews of the latest publications involved in STEMI care. Quarterly newsletter.
* [http://d2b.acc.org/ American College of Cardiology (ACC) Door to Balloon (D2B) Initiative.]
*[http://www.americanheart.org/heartattack American Heart Association's Heart Attack web site] - Information and resources for preventing, recognizing and treating heart attack.
 
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Ischemic heart diseases]]
[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]
[[Category:Hospitalist]]
[[Category:Emergency medicine]]
[[Category:Primary care]]
[[Category:Mature chapter]]
 
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Latest revision as of 00:17, 30 July 2020

Acute Coronary Syndrome Main Page

ST Elevation Myocardial Infarction Microchapters

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Overview

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ST elevation myocardial infarction secondary prevention On the Web

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For the chapter on Secondary Prevention of Coronary Artery Disease in general, click here.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Identifying and, when present, treating category I risk factors can be an optimal secondary prevention strategy in patients with STEMI. You can read more about general coronary heart disease secondary prevention HERE

Long-term Medical Therapy and Secondary Prevention

Patients are usually treated with several long-term medications following a ST elevation myocardial infarction with the goal of preventing secondary cardiovascular events such as further myocardial infarctions, congestive heart failure or cerebrovascular accident (CVA). Unless contraindicated, such medications may include:[1]

  • ACE inhibitor therapy should be commenced 24-48 hours post-MI in hemodynamically-stable patients, particularly in patients with a history of MI, diabetes mellitus, hypertension, anterior location of infarct (as assessed by EKG), and/or evidence of left ventricular dysfunction. ACE inhibitors reduce mortality, the development of heart failure, and decrease ventricular remodelling post-MI.[5]
  • Statin therapy has been shown to reduce mortality and morbidity post-MI.[6][7] The effects of statins may be more than their LDL lowering effects. The general consensus is that statins have plaque stabilization and multiple other ("pleiotropic") effects that may prevent myocardial infarction in addition to their effects on blood lipids.[8] A study by AJC by Herbert D. Aranow, et al. indicates that, for patients who underwent lipid-lowering therapy prior to having an acute myocardial infarction (AMI), infarct size was significantly less than for patients who had not received this earlier treatment. Data from 10,548 patients were collected from both the Global Use of Streptokinase or t-PA for Occluded Coronary Arteries (GUSTO) IIb (n=6,414) and the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Supression Using Integrilin Therapy (PURSUIT) (n=4,134) studies, with infarct size measured by patients' peak creatine kinase (CK) -MB levels. Patients who had lipid-lowering therapy had a median peak CK-MB of 4.2 times the upper limit of normal (ULN) compared to 5.2 times the ULN for those who were not pre-treated (p<0.0001). These results suggest a potential benefit of lipid-lowering therapy for patients at risk for an AMI. Noted limitations of the study include: the observational study design (both the potential effects of confounding variables and the "healthy-user bias" ); the lack of documented information differentiating between statin and nonstatin therapies; and the exclusion from analysis of patients who died during the index hospitalization.
  • The aldosterone antagonist agent eplerenone has been shown to further reduce risk of cardiovascular death post-MI in patients with heart failure and left ventricular dysfunction, when used in conjunction with standard therapies above.[9]
  • Omega-3 fatty acids, commonly found in fish, have been shown to reduce mortality post-MI.[10] While the mechanism by which these fatty acids decrease mortality is unknown, it has been postulated that the survival benefit is due to electrical stabilization and the prevention of ventricular fibrillation.[11] However, further studies in a high-risk subset have not shown a clear-cut decrease in potentially fatal arrhythmias due to omega-3 fatty acids.[12][13]
  • Reducing excess weight and exercising regularly.
  • Keeping blood pressure and diabetes under check.
  • Following a diet low in cholesterol (<200 mg daily) and saturated fat.
  • Increasing HDL- Patients with low HDL [A lipoprotein that transports cholesterol in the blood; composed of a high proportion of protein and relatively little cholesterol] (<35 mg/dl) are encouraged to exercise regularly and to take medications to increase HDL levels.
  • "Among patients with a recent myocardial infarction, colchicine at a dose of 0.5 mg daily led to a significantly lower risk of ischemic cardiovascular events than placebo". [14] In a randomized controlled trial of patients after myocardial infarction, the relative risk ratio of colchicine 0.5 mg once daily, as compared to placebo, for ischemic cardiovascular events was 0.77 and the relative risk reduction was 22.5%. In populations similar to those in this study which had a rate of risk as measured by the ischemic cardiovascular events of 7.1% without treatment, the number needed to treat is 63. [14]

2007 Update of 2004 ACC / AHA Guidelines for the management of ST Segment Elevation Myocardial Infarction - Recommendations for Secondary Prevention (DO NOT EDIT)[15]

Aspirin (DO NOT EDIT)[15]

Class I
"1. For all post-PCI STEMI stented patients without aspirin resistance, allergy, or increased risk of bleeding, aspirin 162 mg to 325 mg daily should be given for at least 1 month after BMS implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75 mg to 162 mg daily. (Level of Evidence: B)"
Class IIa
"1. In patients for whom the physician is concerned about risk of bleeding lower-dose 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation. (Level of Evidence: C)"

Clopidogrel (DO NOT EDIT)[15]

Class I
"1. For all post-PCI patients who receive a DES, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). (Level of Evidence: B)"
"2. For all STEMI patients not undergoing stenting (medical therapy alone or PTCA without stenting), treatment with clopidogrel should continue for at least 14 days. (Level of Evidence: B)"
Class IIa
"1. Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. (Level of Evidence: C)"

Warfarin (DO NOT EDIT)[15]

Class I
"1. Managing warfarin to an INR equal to 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter is recommended, and in post-MI patients when clinically indicated (e.g., atrial fibrillation, left ventricular thrombus). (Level of Evidence: A)"
"2. Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely. (Level of Evidence: B)"
"3. In patients requiring warfarin, clopidogrel, and aspirin therapy, an INR of 2.0 to 2.5 is recommended with low dose aspirin (75 mg to 81 mg) and a 75 mg dose of clopidogrel. (Level of Evidence: C)"

ACE Inhibitors (DO NOT EDIT)[15]

Class I
"1. ACE inhibitors should be started and continued indefinitely in all patients recovering from STEMI with LVEF less than or equal to 40% and for those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. (Level of Evidence: A)"
"2. ACE inhibitors should be started and continued indefinitely in patients recovering from STEMI who are not lower risk (lower risk defined as those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated. (Level of Evidence: B)"
Class IIa
"1. Among lower risk patients recovering from STEMI (i.e., those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed) use of ACE inhibitors is reasonable. (Level of Evidence: B)"

Angiotensin Receptor Blockers (DO NOT EDIT)[15]

Class I
"1. Use of angiotensin receptor blockers is recommended in patients who are intolerant of ACE inhibitors and have HF or have had an MI with LVEF less than or equal to 40%. (Level of Evidence: A)"
"2. It is beneficial to use angiotensin receptor blocker therapy in other patients who are ACE-inhibitor intolerant and have hypertension. (Level of Evidence: B)"
Class IIb
"1. Considering use in combination with ACE inhibitors in systolic dysfunction HF may be reasonable. (Level of Evidence: B)"

Aldosterone Blockade (DO NOT EDIT)[15]

Class I
"1. Use of aldosterone blockade in post-MI patients without significant renal dysfunction or hyperkalemia is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF of less than or equal to 40%, and have either diabetes or HF. (Level of Evidence: A)"

Beta Blockers (DO NOT EDIT)[15]

Class I
"1. It is beneficial to start and continue beta-blocker therapy indefinitely in all patients who have had MI, acute coronary syndrome, or LV dysfunction with or without HF symptoms, unless contraindicated. (Level of Evidence: A)"

Influenza Vaccination (DO NOT EDIT)[15]

Class I
"1. Patients with cardiovascular disease should have an annual influenza vaccination. (Level of Evidence: A)"

Sources

  • The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [16]
  • The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [15]

References

  1. ↑ Smith A, Aylward P, Campbell T, et al. Therapeutic Guidelines: Cardiovascular, 4th edition. North Melbourne: Therapeutic Guidelines; 2003. ISSN 1327-9513
  2. ↑ Peters RJ, Mehta SR, Fox KA; et al. (2003). "Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study". Circulation. 108 (14): 1682–7. doi:10.1161/01.CIR.0000091201.39590.CB. PMID 14504182. Unknown parameter |month= ignored (help)
  3. ↑ Yusuf S, Peto R, Lewis J, Collins R, Sleight P (1985). "Beta blockade during and after myocardial infarction: an overview of the randomized trials". Prog Cardiovasc Dis. 27 (5): 335–71. PMID 2858114.
  4. ↑ Dargie HJ (2001). "Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial". Lancet. 357 (9266): 1385–90. PMID 11356434. Unknown parameter |month= ignored (help)
  5. ↑ Pfeffer MA, Braunwald E, Moyé LA; et al. (1992). "Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators". N. Engl. J. Med. 327 (10): 669–77. PMID 1386652. Unknown parameter |month= ignored (help)
  6. ↑ Sacks FM, Pfeffer MA, Moye LA; et al. (1996). "The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators". N. Engl. J. Med. 335 (14): 1001–9. PMID 8801446. Unknown parameter |month= ignored (help)
  7. ↑ Sacks FM, Moyé LA, Davis BR; et al. (1998). "Relationship between plasma LDL concentrations during treatment with pravastatin and recurrent coronary events in the Cholesterol and Recurrent Events trial". Circulation. 97 (15): 1446–52. PMID 9576424. Unknown parameter |month= ignored (help)
  8. ↑ Ray KK, Cannon CP (2005). "The potential relevance of the multiple lipid-independent (pleiotropic) effects of statins in the management of acute coronary syndromes". J. Am. Coll. Cardiol. 46 (8): 1425–33. doi:10.1016/j.jacc.2005.05.086. PMID 16226165. Unknown parameter |month= ignored (help)
  9. ↑ Keating GM, Plosker GL (2004). "Eplerenone : a review of its use in left ventricular systolic dysfunction and heart failure after acute myocardial infarction". Drugs. 64 (23): 2689–707. PMID 15537370.
  10. ↑ "Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico". Lancet. 354 (9177): 447–55. 1999. PMID 10465168. Unknown parameter |month= ignored (help)
  11. ↑ Leaf A, Albert CM, Josephson M; et al. (2005). "Prevention of fatal arrhythmias in high-risk subjects by fish oil n-3 fatty acid intake". Circulation. 112 (18): 2762–8. doi:10.1161/CIRCULATIONAHA.105.549527. PMID 16267249. Unknown parameter |month= ignored (help)
  12. ↑ Brouwer IA, Zock PL, Camm AJ; et al. (2006). "Effect of fish oil on ventricular tachyarrhythmia and death in patients with implantable cardioverter defibrillators: the Study on Omega-3 Fatty Acids and Ventricular Arrhythmia (SOFA) randomized trial". JAMA. 295 (22): 2613–9. doi:10.1001/jama.295.22.2613. PMID 16772624. Unknown parameter |month= ignored (help)
  13. ↑ Raitt MH, Connor WE, Morris C; et al. (2005). "Fish oil supplementation and risk of ventricular tachycardia and ventricular fibrillation in patients with implantable defibrillators: a randomized controlled trial". JAMA. 293 (23): 2884–91. doi:10.1001/jama.293.23.2884. PMID 15956633. Unknown parameter |month= ignored (help)
  14. ↑ 14.0 14.1 Tardif JC, Kouz S, Waters DD, Bertrand OF, Diaz R, Maggioni AP; et al. (2019). "Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction". N Engl J Med. doi:10.1056/NEJMoa1912388. PMID 31733140.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 15.6 15.7 15.8 15.9 Antman EM, Hand M, Armstrong PW; et al. (2008). "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: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter |month= ignored (help)
  16. ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA 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 (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter |month= ignored (help)

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