patients post-myocardial infarction with left ventricular dys-
function or heart failure.
Treatable complications
These may occur early in the course of myocardial infarction,
and are best recognized and managed with the patient in a
coronary-care unit. Transfer from the admission room should
therefore not be delayed by obtaining x-rays, as a portable film
can be obtained on the unit if necessary. Complications
include cardiogenic shock (Chapter 31) as well as acute tachy-
or brady-dysrhythmias (Chapter 32). Prophylactic treatment
with anti-dysrhythmic drugs (i.e. before significant dysrhyth-
mia is documented) has not been found to improve survival.
LONG-TERM MEASURES POST-ACUTE CORONARY
SYNDROME
Modifiable factors should be sought and attended to as for
patients with angina (see above). Drugs are used prophylacti-
cally following recovery from myocardial infarction to pre-
vent sudden death or recurrence of myocardial infarction.
Aspirin and β-adrenoceptor antagonists each reduce the risk
of recurrence or sudden death. Meta-analysis of the many clin-
ical trials of aspirin has demonstrated an overwhelmingly sig-
nificant effect of modest magnitude (an approximately 30%
reduction in the risk of reinfarction), and several individual
trials of β-adrenoceptor antagonists have also demonstrated
conclusive benefit. Statins should routinely be prescribed, as
discussed under Management of stable angina above, because
of their clear prognostic benefit in this situation. In addition,
numerous trials have now demonstrated that long-term use of
ACEI in patients post-myocardial infarction with either overt
heart failure or clinically silent left ventricular dysfunction
prevents cardiac remodelling and subsequent development/
worsening of heart failure; and recent trials suggest that the
same is likely to be true of the angiotensin receptor blockers.
Finally, recent evidence from the EPHESUS trial has shown
that early treatment of patients with left ventricular dysfunc-
tion post-myocardial infarction (within a few days) with the
aldosterone antagonist eplerenone, continued long term (at
least 18 months), prevents development/progression of heart
failure and improves mortality.
Consideration of surgery/angioplasty
Ideally all patients who are potentially operative candidates
would have angiography at some stage, even if they have not
undergone early angiography/angioplasty as an in-patient. In
practice, the same considerations apply as for patients with
angina (see above), and in the UK angiography is currently
usually undertaken on the basis of a clinical judgement based
on age, co-existing disease, presence or absence of post-infarc-
tion angina, and often on a stress test performed after recovery
from the acute event (patients with a negative stress test are
considered to be at low risk of subsequent cardiac events).
Psychological and social factors
After recovery from myocardial infarction, patients require an
explanation of what has happened, advice about activity in
the short and long term, and about work, driving and sexual
activity, as well as help in regaining self-esteem. Cardiac rehabil-
itation includes attention to secondary prevention, as well as to
psychological factors. A supervised graded exercise programme
is often valuable. Neglect of these unglamorous aspects of man-
agement may cause prolonged and unnecessary unhappiness.DRUGS USED IN ISCHAEMIC HEART
DISEASEDrugs that are used to influence atherosclerosis are described
in Chapter 27. In the present chapter, we briefly describe those
drugs that are used to treat ischaemic heart disease either
because of their haemodynamic properties or because they
inhibit thrombosis.DRUGS THAT INFLUENCE HAEMODYNAMICSORGANIC NITRATES
Use and administration
GTNis used to relieve anginal pain. It is generally best used
as ‘acute’ prophylaxis, i.e. immediately before undertaking
strenuous activity. It is usually given sublingually, thereby
ensuring rapid absorption and avoiding presystemic metab-
olism (Chapter 5), but in patients with unstable angina it may
be given as an intravenous infusion. The spray has a some-
what more rapid onset of action and a much longer shelf-life
than tablets, but is more expensive. GTNis absorbed trans-
dermally and is available in a patch preparation for longer
prophylaxis than the short-term benefit provided by a sublin-
gual dose. Alternatively, a longer-acting nitrate, such as
isosorbide mononitrate, may be used prophylactically to
reduce the frequency of attacks; it is less expensive than GTN
patches and is taken by mouth. In patients whose pattern of
pain is predominantly during the daytime, it is prescribed to
be taken in the morning and at lunch-time, thereby ‘covering’
the day, but avoiding development of tolerance by omitting an
evening dose. Longer-acting controlled-release preparations
are available for once daily use, and these usually provide
nitrate cover during most of the day, but leave a small ‘nitrate-
free’ window of a few hours, thereby again preventing the
development of nitrate tolerance. Long-acting nitrates are also
used in combination with hydralazinein patients with heart
failure who are unable to take ACE inhibitors and, especially, in
patients of African origin (Chapter 31).
GTNis volatile, so the tablets have a limited shelf-life
(around six weeks after the bottle is opened) and they need to
be stored in a cool place in a tightly capped dark container,
without cotton wool or other tablets. Adverse effects can be
minimized by swallowing the tablet after strenuous activity is
completed (a more genteel alternative to spitting it out!),
because of the lower systemic bioavailability from gut than
from buccal mucosa.200 ISCHAEMIC HEART DISEASE