1) Management of acute myocardial infarction involves aspirin, P2Y12 inhibitors like prasugrel or ticagrelor, and revascularization with either primary PCI or fibrinolytic therapy. 2) Antiplatelet therapy with dual antiplatelet therapy (DAPT) for 1 year is indicated for all patients after drug-eluting or bare-metal stents. 3) Early use of beta blockers, ACE inhibitors, and statins provides long-term benefits in reducing mortality for patients with acute MI.

1. Management of acute MI
Dr. Lailmaah Habibi 3rd year trainee of KABUL RBH ( afg), 2017

2.  Aspirin :all pts definite or suspected MI
 𝑝2 𝑦12 inhibitors: in combine with aspirin, ‘v shown ↑ important benefits in
acute STEMI
 Preferred 𝑝2 𝑦12I : prasugrel & ticagrelor

3. 1) Primary PCI
2) Fibrinolytic thX
Drug eluting
stents

4. a)_PCI stenting is standard for AMI
I. DES
II. BMS
b)_ antiplatelet therapy after drug-eluting / bare metal stents
 DAPT is indicated for 1yr in all pts (medical thX & pts undergoing
revascularization irrespective of stent type

5.  Alteplase (rt_PA)
 Reteplase (r_PA)
 Tenecteplase (TNK_PA)
 Streptokinase (SK)

6.  Selection of a fibrinolytic agent :
 differences in efficacy between them are small
 principal objective is to administer a thrombolytic agent within
30 min of presentation or even during transport.

7.  aspirin
 Anticoagulation: continued until revascularization / duration of hospital stay or
(up to 8 days) .
 LMWH (enoxaparin or fondaparinux) is prefered to UFH
 (A) LMWH
 (B) UFH
 (c) Prophylactic Therapy Against Gastrointestinal Bleeding

8.  Initial attempt should be made to relieve pain vs sublingual NTG
 IV opioids provide most rapid & effective analgesia also ↓pulmonary
congestion.
 Morphine sulfate4-8 mg / meperidine 50-75 mg .

9.  The benefits in STEMI pts divided into: those occur immediately when the drug
is given acutely /over the long term after infarction.
 metoprolol 25-50 mg orally BID
 Carvedilol 6.25 mg BID , titrated to 25 mg BID

10.  NTG is the agent of choice for continued or recurrent ischemic pain
↓Bp & ↓ pulmonary congestion
 routine nitrate administration not recommended

11.  short- and long-term survival improvement vs ACE inhibitor therapy.
 Because substantial amounts of the survival benefit occur on the 1ST day, ACE
inhibitor Tx should commenced early in pts without hypotension, especially
with large / Ant _MI

12.  patients with ACE inhibitor intolerance
 valsartan 160 mg orally BID is equivalent to captopril in ↓ mortality
& ↑ expensive alternative to captopril.

13.  ↓ Mortality rate of pts with advanced HF
 Spironolactone 25mg/d
 Eplerenone 25 mg /d

14.  All pts in the abcense of CI should receive statins
 Goal LDL < 70mg/dl or 70% ↓ in LDL level

15.  No studies to support the routine use of CCBs
 Long- acting CCBs should generally be reserved for management of HTN
& ischemia as 2nd & 3rd line medications after beta-blockers and
nitrates.

16.  Smoking Cessation and lifestyle modifications.
 Aspirin, Beta Blockers and Clopidogrel will be indefinite.
 Lipid lowering medication along with diet modifications

17.  Source:
 CMDT 2017
 HARRISSON TEXTBOOK EDITION 19TH
 WASHINGTON MANUAL 35TH EDITION