Management Of Post Myocardial Infarction Research Articles

The Impact of SGLT2 Inhibitors in Post-Myocardial Infarction Management: Insights from EMPACT-MI and DAPA-MI Trials.

The Impact of SGLT2 Inhibitors in Post-Myocardial Infarction Management: Insights from EMPACT-MI and DAPA-MI Trials.

Importance of reassessment to identify trajectories of chronic transition of clinical indicators in post-myocardial infarction management.

Despite advances in multidisciplinary acute care for myocardial infarction (MI), the clinical need to manage heart failure and elevated mortality risks in the remote phase of MI remains unmet. Various prognostic models have been established using clinical indicators obtained during the acute phase of MI; however, most of these indicators also show chronic changes in the post-MI phase. Although relevant guidelines recommend follow-up assessments of some clinical indicators in the chronic phase, systematic reassessment has not yet been fully established and implemented in a real-world clinical setting. Therefore, clinical evidence of the impact of such chronic transitions on the post-MI prognosis is lacking. We speculate that post-MI reassessment of key clinical indicators and the impact of their chronic transition patterns on long-term prognoses can improve the quality of post-MI risk stratification and help identify residual risk factors. Several recent studies have investigated the impact of the chronic transition of some clinical indicators, such as serum albumin level, mitral regurgitation, and left-ventricular dysfunction, on post-MI prognosis. Interestingly, even in MI survivors with these indicators within their respective normal ranges in the acute phase of MI, chronic transition to an abnormal range was associated with worsening cardiovascular outcomes. On the basis of these recent insights, we discuss the clinical significance of post-MI reassessment to identify the trajectories of several clinical indicators and elucidate the potential residual risk factors affecting adverse outcomes in MI survivors.

Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE): A randomized trial to improve post myocardial infarction management

ObjectiveWe evaluated the impact of a low intensity web-based and intensive nurse-administered intervention to reduce systolic blood pressure (SBP) among patients with prior MI. MethodsSecondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE) was a three-arm trial. Patients were randomized to 1) post-MI education-only; 2) nurse-administered telephone program; or 3) web-based interactive tool. The study was conducted 2009–2013. ResultsParticipants (n = 415) had a mean age of 61 years (standard deviation [SD], 11). Relative to the education-only group, the 12-month differential improvement in SBP was − 3.97 and − 3.27 mmHg for nurse-administered telephone and web-based groups, respectively. Neither were statistically significant. Post hoc exploratory subgroup analyses found participants who received a higher dose (>12 encounters) in the nurse-administered telephone intervention (n = 60; 46%) had an 8.8 mmHg (95% CI, 0.69, 16.89; p = 0.03) differential SBP improvement versus low dose (<11 encounters; n = 71; 54%). For the web-based intervention, those who had higher dose (n = 73; 53%; >1 web encounter) experienced a 2.3 mmHg (95% CI, −10.74, 6.14; p = 0.59) differential SBP improvement versus low dose (n = 65; 47%). ConclusionsThe main effects were not statistically significant. Practical ImplicationsCompleting the full dose of the intervention may be essential to experience the intervention effect. Clinical Trial RegistrationThe unique identifier is NCT00901277 (http://www.clinicaltrials.gov/ct2/show/NCT00901277?term=NCT00901277&rank=1).

Clinical impact of selective and nonselective beta-blockers on survival in patients with ovarian cancer.

Preclinical evidence has suggested that sustained adrenergic activation can promote ovarian cancer growth and metastasis. The authors examined the impact of beta-adrenergic blockade on the clinical outcome of women with epithelial ovarian, primary peritoneal, or fallopian tube cancers (collectively, epithelial ovarian cancer [EOC]). A multicenter review of 1425 women with histopathologically confirmed EOC was performed. Comparisons were made between patients with documented beta-blocker use during chemotherapy and those without beta-blocker use. The median age of patients in the current study was 63 years (range, 21-93 years). The sample included 269 patients who received beta-blockers. Of those, 193 (71.7%) were receiving beta-1-adrenergic receptor selective agents, and the remaining patients were receiving nonselective beta antagonists. The primary indication for beta-blocker use was hypertension but also included arrhythmia and postmyocardial infarction management. For patients receiving any beta-blocker, the median overall survival (OS) was 47.8 months versus 42 months for nonusers (P =.04). The median OS based on beta-blocker receptor selectivity was 94.9 months for those receiving nonselective beta-blockers versus 38 months for those receiving beta-1-adrenergic receptor selective agents (P<.001). Hypertension was associated with decreased OS compared with no hypertension across all groups. However, even among patients with hypertension, a longer median OS was observed among users of a nonselective beta-blocker compared with nonusers (38.2 months vs 90 months; P<.001). Use of nonselective beta-blockers in patients with EOC was associated with longer OS. These findings may have implications for new therapeutic approaches. Cancer 2015;121:3435-43. © 2015 American Cancer Society.

The Log book for the secondary prevention of coronary artery disease: A pilot study

IntroductionIn secondary prevention (SP) of coronary artery disease (CAD), in particular after an acute myocardial infarction (MI), a better knowledge and self-management by the patient may have various supports. The Log book (LB) for CAD patients in Côte d’Or, was created in 2010 by a multidisciplinary team of healthcare professionals of Côte d’Or, from a regional care network. This pilot study evaluated LB as novel support for SP after acute MI. MethodsA prospective study on 183 patients hospitalised for an acute MI in the region of Côte d’Or from 1st May to 30th October 2010. Patients were randomized in 91 patients who received an LB at the time of their hospitalisation (LB+ group), and 92 patients who were not given an LB (LB– group). The follow up (FU) was performed at 4 months and 1 year. ResultsBaseline characteristics were similar in the 2 groups, except for smoking, which was more frequent in the LB-group than in the LB+ group. At FU, LB was usually well accepted by both patients and their general practitioners (GP). At 4 months FU, the patients LB+ were more prone to see their general practitioners than patients LB– (100% vs 85% in the LB– group, P=0.007). Moreover, in LB+ group, there was a trend towards a more frequent physical activity, including exercise bike (P=0.009) and an increase in HDL-cholesterol (HDL-c) (P=0.165). At 1 year FU, body mass index from LB+ was more reduced than in patients LB– (P=0.029). Finally, there was a trend towards lower morbi-mortality (hospitalisation for cardiovascular cause or death) in the LB+ group than in the LB– group (11 vs 22%, P=0.083). ConclusionThis pilot study showed the feasibility of LB as a support for SP and its interest in post MI management in a local care network setting. In addition, our study provides encouraging data on the potential benefits of this pioneer tool for SP.

Patient-provider communication, self-reported medication adherence, and race in a postmyocardial infarction population.

ObjectivesOur objectives were to: 1) describe patient-reported communication with their provider and explore differences in perceptions of racially diverse adherent versus nonadherent patients; and 2) examine whether the association between unanswered questions and patient-reported medication nonadherence varied as a function of patients’ race.MethodsWe conducted a cross-sectional analysis of baseline in-person survey data from a trial designed to improve postmyocardial infarction management of cardiovascular disease risk factors.ResultsOverall, 298 patients (74%) reported never leaving their doctor’s office with unanswered questions. Among those who were adherent and nonadherent with their medications, 183 (79%) and 115 (67%) patients, respectively, never left their doctor’s office with unanswered questions. In multivariable logistic regression, although the simple effects of the interaction term were different for patients of nonminority race (odds ratio [OR]: 2.16; 95% confidence interval [CI]: 1.19–3.92) and those of minority race (OR: 1.19; 95% CI: 0.54–2.66), the overall interaction effect was not statistically significant (P=0.24).ConclusionThe quality of patient–provider communication is critical for cardiovascular disease medication adherence. In this study, however, having unanswered questions did not impact medication adherence differently as a function of patients’ race. Nevertheless, there were racial differences in medication adherence that may need to be addressed to ensure optimal adherence and health outcomes. Effort should be made to provide training opportunities for both patients and their providers to ensure strong communication skills and to address potential differences in medication adherence in patients of diverse backgrounds.

Practical algorithms for pharmacologic management of the post myocardial infarction patient.

The pharmacologic management of the patient post myocardial infarction (MI) aims to achieve several goals. Chief among these is to prevent subsequent events, which include death, reinfarction, and rehospitalization. Secondary goals include preventing arrhythmias, minimizing left ventricular (LV) remodeling, and preventing progression to heart failure. This review describes practical algorithms for use in the pharmacologic management of the patient post MI based on American Heart Association/American College of Cardiology guidelines. The intensity of drug treatment is determined guided by the degree of LV dysfunction and the presence or absence of ischemia and arrhythmic risk markers. All patients post MI require an angiotensin-converting enzyme (ACE) inhibitor and antiplatelet therapy, usually with aspirin. In individuals who cannot tolerate an ACE inhibitor, an angiotensin receptor blocker (ARB) is an adequate substitute. Numerous studies document the efficacy of ACE inhibitors, which decrease mortality and the risk of heart failure and stroke. Aldosterone blockade is recommended long-term for patients post MI with an LV ejection fraction < or = 40% and either symptomatic heart failure or diabetes. Use of a beta blocker is an important addition to most post-MI drug regimens. Beta blockers decrease mortality and are especially effective in patients with impaired LV function. Among the beta blockers, carvedilol, which also has alpha-adrenergic receptor blocking activity, was found to decrease mortality significantly in patients with low ejection fractions and heart failure. Another drug therapy of value in post-MI treatment is use of calcium-channel blockers. These are restricted to patients with conserved LV function in whom congestion is absent and in whom beta blockers are contraindicated. Current guidelines also recommend that patients post MI with elevated cholesterol levels should be prescribed lipid therapy with a statin at hospital discharge.

Real-world algorithms for the optimal use of drugs and devices in the patient post myocardial infarction and the future of post myocardial infarction management.

Patients with left ventricular dysfunction (LVD) are at increased risk for dying suddenly of cardiac causes. The most common causes of LVD are coronary artery disease (CAD) and myocardial infarction (MI). Aggressive intervention following MI is essential for minimizing the myocardial damage that leads to LVD and the subsequent risk for heart failure and sudden cardiac death. This article describes practical algorithms for managing the patient post MI to minimize such risks. The degree of LVD is a key factor for determining clinical management strategies in the patient post MI. Risk factor reduction and selective neurohormonal blockade, especially with angiotensin-converting enzyme inhibitors, are usually recommended in the presence or absence of LVD, along with early use of a beta blocker. In patients with LVD, more aggressive intervention includes extended use of a beta blocker. In cases of LVD progressed to heart failure, the mixed beta and alpha blocker carvedilol has improved outcomes significantly. In clinical trials, carvedilol has been demonstrated to have antiarrhythmic activity, a property that offers protection against sudden arrhythmic death in high-risk patients with LVD. Addition of an aldosterone antagonist is also advised in patients with heart failure. In selected patients with reduced ejection fractions, use of surgical/catheter treatment and device therapy offers further benefits.

Prescribing of β-blockers after myocardial infarction: A preliminary study of physician motivations and barriers

Background: Clinical practice guidelines (CPGs) recommend β-blocker medications in the management of post-myocardial infarction (MI) patients to prevent subsequent MI; evidence suggests that this therapy continues to be underutilized. The decision-making process that physicians use for treating post-MI patients should be explored; behavior-change interventions have been proposed among researchers in this field. Objective: The aim of this pilot study was to develop measures for examining this issue using the transtheoretical model (TTM) of change, including physician stage of readiness for change and physician salience (ie, decisional balance) for the pros (ie, facilitators) and cons (ie, barriers) of prescribing β-blockers to post-MI patients. Methods: In this cross-sectional study, a TTM-based questionnaire was developed from the literature and from interviews with a convenience sample of physicians practicing in cardiology; the questionnaire was subjected to expert panels for revision and was pretested. It was then mailed to all physicians practicing family medicine, internal medicine, or cardiology during the autumn of 2003 in northern West Virginia, a state with a high prevalence of cardiovascular disease and MI-related mortality. Results: Among the 309 physicians who received the questionnaire, 103 responded; 55 responses were complete and eligible for inclusion in the analysis. Most (92.7%) responded to the TTM measures in the action and maintenance stages of change for prescribing β-blockers for post-MI patients. Results also suggested they had significant salience ( P < 0.05) for the cons of prescribing β-blocker therapy to patients with relative contraindications that were indicated in the earlier versions of the CPGs, but not in the latest version. Other specific barriers to prescribing were also identified. Conclusions: Results of this preliminary study suggest that it would be relevant to increase physician knowledge of the updated CPGs regarding use of β-blockers in the presence of conditions previously deemed relative contraindications.

Quelle est la place des inhibiteurs calciques lorsque les bêta-bloquants sont contre-indiqués dans le traitement du post-infarctus du myocarde ?

The purpose of this paper is to examine the eventual benefits of treatment with calcium channel blockers in post-myocardial infarction, through an overview of main placebo-controlled trials that have been conducted to test this therapeutic in acute coronary syndromes. It appears obvious that the vast majority of these trials was conducted in the pre-reperfusion era and failed to demonstrate a reduction in mortality. To conclude, the superiority of a therapy with calcium antagonists over a placebo in the management of post-myocardial infarction remains unknown. In contrast, adverse effects associated with the prescription of calcium antagonists are well known.

Angiotensin II Receptor Antagonists Alone and Combined with Hydrochlorothiazide

Angiotensin II receptor antagonists (angiotensin receptor blockers; ARBs) and thiazide diuretics have an accepted place in the management of hypertension. Most patients require combination therapy with two or more drugs to adequately control blood pressure to targets recommended by European and international guidelines. ARBs and the thiazide diuretic hydrochlorothiazide have complementary modes of action. Fixed-dose combinations of an ARB and low-dose hydrochlorothiazide provide a convenient and effective treatment option for patients who do not achieve blood pressure targets on monotherapy, without compromising the placebo-like tolerability of ARBs. In Europe, fixed-dose combinations with hydrochlorothiazide currently are available for the ARBs candesartan, eprosartan, irbesartan, losartan, telmisartan, and valsartan. Recently, a number of studies have focused on the use of ARBs in monotherapy and in combination therapy, in conditions including congestive heart failure, post-myocardial infarction management, hypertension with cardiovascular risk factors, and diabetic and non-diabetic nephropathy. Evidence from these studies suggests a beneficial role beyond the antihypertensive effect of these therapies in providing protection against cardiovascular, renovascular, and cerebrovascular events.

Is there a clinically significant gender bias in post-myocardial infarction pharmacological management in the older (>60) population of a primary care practice?

BackgroundDifferences in the management of coronary artery disease between men and women have been reported in the literature. There are few studies of potential inequalities of treatment that arise from a primary care context. This study investigated the existence of such inequalities in the medical management of post myocardial infarction in older patients.MethodsA comprehensive chart audit was conducted of 142 men and 81 women in an academic primary care practice. Variables were extracted on demographic variables, cardiovascular risk factors, medical and non-medical management of myocardial infarction.ResultsWomen were older than men. The groups were comparable in terms of cardiac risk factors. A statistically significant difference (14.6%: 95% CI 0.048–28.7 p = 0.047) was found between men and women for the prescription of lipid lowering medications. 25.3% (p = 0.0005, CI 11.45, 39.65) more men than women had undergone angiography, and 14.4 % (p = 0.029, CI 2.2, 26.6) more men than women had undergone coronary artery bypass graft surgery.ConclusionWomen are less likely than men to receive lipid-lowering medication which may indicate less aggressive secondary prevention in the primary care setting.

Can we justify HEROICS in the management of post myocardial infarction cardiogenic shock?

Can we justify HEROICS in the management of post myocardial infarction cardiogenic shock?

Management of Postmyocardial Infarction in the Elderly Patient

Elderly patients have a significantly higher mortality and morbidity compared with younger patients in the postmyocardial infarction period and thus, with the appropriate management have a greater potential for benefit compared with younger patients. It has been shown in the large randomized trials that elderly patients with acute myocardial infarction benefit significantly from administration of beta-blocking agents and angiotensin-converting enzyme inhibitors. Aspirin and warfarin sodium (Coumadin) have been shown to benefit patients of all age groups. Secondary prevention with cessation of smoking, use of lipid-lowering agents, treatment of hypertension, and estrogen therapy in the postmenopausal woman have been shown to be effective. Elderly patients, therefore, who are free of general noncardiac disability and who can be expected to live meaningful lives should be offered a comprehensive program to reduce their cardiac morbidity and mortality after discharge following acute myocardial infarction.

Recent Advances: Clinical pharmacology and therapeutics

Therapeutic practice rarely changes greatly as a result of a single investigation or trial. Traditionally, experiments carried out in the laboratory lead to small scale studies in humans, some of which may be translated into larger controlled clinical trials, which, if successful, may begin to influence patient management. The time scale of this process varies greatly. At one end of the spectrum a new biotechnology product may be developed with great rapidity, tested in a small cohort of patients, and be used by specialists within seven to eight years of its initial design. On the other hand valuable information on drugs of proved therapeutic value may languish in the literature for some 10 to 15 years before being widely accepted into clinical practice (for example, thrombolytic drugs after myocardial infarction). Dissemination of the results of research is as important as the original research itself, and implementation may represent an even bigger hurdle. It is not an easy task to describe the advances in clinical pharmacology and therapeutics over the past year. I will start with the general issue of cost effective prescribing, which has moved up the political agenda in Britain after the publication of two influential reports. I will then cover four specialist therapeutic areas (AIDS, post myocardial infarction management, neurodegenerative disease, and diabetes), where treatment has become clearer because of positive or negative trial results. Finally, I will discuss the clinical exploitation of experimental findings on nitric oxide, which will have important roles in many diseases. The issue of therapeutic cost effectiveness is not new, but several events have occurred recently to give the topic special prominence. Firstly, the latest reforms in the NHS have left all health care professionals questioning how burgeoning drug costs, which now account for pounds sterling3.3bn out of a total NHS budget of …

The Council for Myocardial Ischemia and Infarction: Advisory group reports on silent myocardial ischemia, heart rate control, and post-myocardial infarction management

This yearly report from the advisory groups of the Council for Myocardial Ischemia and Infarction reflects the Council’s continued interest in silent ischemia, acute intervention, and postmyocardial infarction management. The Council reviews ongoing research in an effort to translate recent results into current, practical approaches to treatment. Some of its current consensual statements resemble those of the 1991 report. Research on silent myocardial ischemia, for example, continues to question whether treatment can modify its negative prognosis. Stratification of the postmyocardial infarction patient according to the use of thrombolytic therapy and then by type of infarction is still considered a reasonable approach. Certain guidelines, however, have been reinforced by new data and experience. For example, the pharmacologic options available for heart rate control have recently increased, engendering a reexamination of therapy with digoxin, traditionally the optimum treatment for atria1 fibrillation.

The effects of a transtelephonic surveillance and prehospital emergency intervention system on the 1-year course following acute myocardial infarction

We evaluated the effect on morbidity and mortality of a post-myocardial infarction management and intervention system. One thousand four patients were prospectively randomized to an intervention group that included routine and emergency transtelephonic follow-up and ECG monitoring or to control; all subjects were followed for 1 year. For symptoms suggestive of myocardial ischemia, intervention patients telephoned the project emergency office, were instructed by a project nurse to selfadminister intramuscular lidocaine with an autoinjector, and were then transported to the nearest emergency facility. Cardiac death or arrest was decreased 29% in intervention patients ( p = 0.066), while all-cause mortality was decreased by 24% ( p < 0.11). Routine transtelephonic ECG monitoring detected ventricular ectopy in 48% of intervention patients, with almost 50% of these findings classified as complex forms. Ventricular ectopy detected during routine calls within 60 days of the acute myocardial infarction conferred a threefold increase in mortality ( p = 0.001). In addition, control patients were 2.4 times more likely to be clinically depressed ( p < 0.03) and returned to work less quickly ( p < 0.03) when compared to intervention patients. Lidocaine injections were associated with an absence of ventricular ectopy on arrival at the Emergency Room in 64% and with a low incidence of lidocaine-associated side effects. There was only one case of unauthorized use of the self-injector. These findings demonstrate that an outpatient postmyocardial infarction transtelephonic surveillance program can be safely and effectively conducted, can detect complex ventricular arrhythmias of prognostic significance, can improve the quality of life, and may reduce 1-year cardiac mortality.

The Management of Post-myocardial Infarction

The Management of Post-myocardial Infarction

Book ReviewThe First Year after a Myocardial Infarction Postmyocardial Infarction Management and Rehabilitation

Book ReviewThe First Year after a Myocardial Infarction Postmyocardial Infarction Management and Rehabilitation