“OPTIMAL MEDICAL TREATMENT OF ACUTE MYOCARDIAL INFARCTION “

“OPTIMAL MEDICAL TREATMENT OF ACUTE MYOCARDIAL INFARCTION “

Every first-contact doctor & all other doctors involved in treating acute myocardial infarction ( Heart attack) patients at various levels should have a clear endpoint in mind.

 That is the “GOAL OF TREATMENT IS REDUCTION OF INFARCT SIZE”.

This results in ;

1. Preserved left ventricular function.

2. Reduction of complications of myocardial infarction

3. Reduction of In-hospital mortality.

4. Preserved LV function offers a Good quality of life when discharged.

5 Improve longevity – live longer.

Reduction of infarct size is teamwork.

1. INITIAL SPEED & EFFICIENCY IN ACCESSING, JUDGMENT, DECISION MAKINGS & EXECUTION are the most important

2. APPROPRIATE EARLY in-hospital TREATMENT WITH OPTIMAL DOSES OF MEDICATIONS (EVIDENCE-BASED) also makes a significant contribution to this goal.

I assume you are all aware of

minutes equal muscles.

I will not discuss the immediate management but would like to point out that the following contribute to reducing infarct size.

1. The speed & efficiency in achieving the patency of infarct-related artery either by thrombolysis or primary PCI or rescue PCI in failed thrombolysis patients.

2. Ideally the door-to-needle time has to be < 20 minutes or Door balloon time < 90 minutes.

1. Loading doses of Aspirin 300mg, clopidogrel 600mg

( 600 mg is superior to 300mg & 180 mg of ticagrelor is superior to 600mg of clopidegrel)Atorvastatin 80 mg ( or rosuvastin 40mg)as soon as ST elevation is noted on the ECG contributes to infarct size reduction.

3. Enoxaparin following both thrombolysis and primary PCI for 48 – 72 hrs helps reduce infarct size.

4. Finally I want to emphasize that early use of beta blockers and ACEI in optimal also contributes to infarct size reduction.

It is the last two agents that I find, are not being given in appropriate doses and therefore I would like to reemphasize to achieve the optimal doses during the short hospital stay period of 3 to 5 days.

Optimal USE OF BETA-BLOCKERS IN POST-MI PATIENTS with preserved LV function.

Beta-blockers

Has to be started about 24 hrs after PCI or thrombolysis once the patient is hemodynamically stable.

The choice & starting dose would depend on LV function, pulse rate & blood pressure.

Bisoprolol is available in all government hospitals and is a choice for patients with LVEF > 45%

The discharging dose would be the maximum tolerated or maximum recommended dose.

 Bisoprolol has a long half-life and can be given once a day. There is no reason to split it into twice-daily doses. The peak plasma level is seen 4 hours after oral administration.

It is usually given in the morning as people are mentally and physically active during the daytime.

With preserved LV function, the target heart rate would be around 55 ( 50 to 60 ) bpm. This would suggest the patient is fully beta-blocked. In such a situation, maximum protection is given in terms of symptoms and survival.

When the patient is fully beta-blocked, the increase in heart rate, blood pressure, and the force of myocardial contraction during exercise and exertion is minimal, causing a remarkable increase in exercise tolerance.

This is the reason why the optimal dose of beta-blocking is considered the most effective anti-anginal medication.

Please note that the optimal dose is of considerable importance.

If not, patients are denied the optimum benefit of beta-blocking.

Major trials have shown that optimal beta blocking offers both symptomatic & survival benefits. About 15% reduction of fatal and non-fatal cardiac events is seen during an average of 3 years of follow-up.

The benefit of beta-blocking in patients who underwent primary PCI within the first few hours of the onset of pain with no wall motion abnormalities on echo study is clear.

 It is rather sad to see that many ( most) post-MI patients are discharged on bisoprolol 2.5 mg dose once daily, which would not offer the desired beneficial effects.

Therefore, I would earnestly request the doctors who are involved in managing immediate post-MI patients be responsible & not deny the benefits of optimum beta blocking.

 Make sure the dose is optimized during daily morning ward rounds as the optimum dose has to be achieved during the short hospital stay of 3 to 4 days.