michael s
(Michael S)
#1
value of cholesterol lowering even in patients with “average” total
LDL cholesterol levels of about 5mmol/l. It is arguable that any
patient who has had a myocardial infarct should be offered
treatment with a statin on the basis that their level of LDL cholesterol
is too high for them. However, this is not orthodox practice at
present. The previous practice of only measuring cholesterol levels
some months after an infarct should be abandoned and the levels
assayed on admissionat the same time as cardiac enzymes. This gives
a reliable figure for usual cholesterol levels: a delay of a couple of
days in sampling will not. Following the VA-HIT study treating
patients with HDL cholesterol levels 1 mmol/l with a fibrate
should be considered but again is not yet established practice.
ACE inhibitors
These drugs would of course be used in patients with
symptomatic heart failure but should also be used in asymptomatic
patients with ejection fractions <40%. This is associated with
significant decreases in mortality (20–30%) and in sudden death,
as well as in reinfarction. All ACE inhibitors so far tested share
these effects. Treatment should be started within 1–2 days of the
infarct and should be continued indefinitely. Whether all patients
should be given these drugs post-infarction, in the absence of
contraindications, is a more difficult issue. In unselected
populations the benefits of treatment are much less clear cut.
However, data from the recent HOPE trial^1 suggest substantial risk
reduction for higher risk vascular patients – which may include a
large proportion of patients who have suffered a myocardial
infarction. Other ongoing trials (such as EUROPA, using
Perindopril) may help clarify this issue.
Other action
In addition to these relatively specific measures, diabetes and
hypertension must of course be treated as required, and smoking
discouraged. Some have advocated the use of fish oils especially
in dyslipidaemic patients, either as supplements or as fish. The
use of warfarin has been controversial for many years. It is highly
effective in preventing cardiovascular events, particularly stroke,
but at the cost of more adverse effects than aspirin and the
inconvenience of monitoring. It is therefore not recommended for
first-line use by most cardiologists.
