Improving the management of patients after myocardial infarction, from admission to discharge

Abstract

Background: Recent developments in pharmacologic and device therapy, as well as initiatives to increase the use of standard orders and promote inhospital communication, have improved the care of patients with myocardial infarction (MI). The increased presence of hospitalists, physicians who provide in-hospital care as a specialty, promises to provide further improvements. Objective: This article reviews current information on evidence-based care of the hospitalized MI patient, with a particular emphasis on identifying left ventricular dysfunction (LVD) and appropriate treatments. Methods: MEDLINE was searched for all largescale clinical trials providing information on the care of post-MI patients with or without LVD and/or heart failure (HF), with no limit on time period. The search terms were post-myocardial infarction, large-scale, randomized, clinical trial, left ventricular dysfunction, and/or heart failure. All trials investigating therapies currently recommended in the American College of Cardiology/American Heart Association ST elevation MI (ACC/AHA STEMI) guidelines and including post-MI patients with or without LVD and/or HF, as indicated by signs and symptoms of HF or Killip class, were included. Results: In the acute setting, the ACC/AHA STEMI guidelines recommend the use of aspirin, clopidogrel, β-blockers, angiotensin-converting enzyme inhibitors, heparin (low molecular weight or unfractionated), and glycoprotein IIb1IIIa inhibitors (if the patient is undergoing a percutaneous coronary intervention). The guidelines recommend use of aldosterone antagonists and statins at discharge, in addition to continuation of all acute therapies. The ACC/AHA guidelines apply to all patients after MI and do not specify whether the recommended therapies are effective in post-MI patients with LVD or HE Reviewing the trials that included post-MI patients with LVD and/or HF, it appears that in some cases, only certain agents within a class have been evaluated (eg, post-MI β-blocker trials often excluded patients with LVD, and the efficacy of atenolol has not been evaluated in post-MI patients with LVD or HF), and some agents have not shown as much efficacy as others in this high-risk patient population (eg, metoprolol appeared to be associated with poorer outcomes in this population than carvedilol). Rather than recommending an entire class, hospital care maps and critical-care pathway tools should incorporate the use of evidence-based agents. Conclusions: The use of evidence-based care in the hospital has the potential to substantially reduce morbidity and mortality in post-MI patients with LVD and/or HE The hospitalist can facilitate the best practices and best care of the post-MI patient through the use of in-hospital critical-care pathway tools.