Lipid lowering

ST elevation myocardial infarction

Other ACS

• Fasting lipid profile within first 24 hours.
• Low (less than 7% of calories) saturated fat and low (less than 200 mg) cholesterol diet.
• Target LDL-C substantially less than 100 mg/dL AND (Class II-a) non-HDL-C levels substantially less than 130 mg/dL.
  • Prescribe statins on discharge to virtually all patients (see full guidelines).
  • Add niacin or fibrate for patients with HDL-C less than 40 mg/dL if target LDL-C not met and if diet and exercise fail to elevate HDL-C.
  • Add niacin or fibrate if triglycerides are greater than 500 mg/dL.
  • Dietary supplement niacin is not a substitute for prescription niacin.
  • Over-the-counter niacin use requires physician approval.

• Statin treatment for
  • LDL cholesterol > 125 mg/dL before or > 100 mg/dL after dietary intervention OR
  • Begin statin treatment within 24 to 96 hours for LDL cholesterol > 100 mg/dL (IIa)
• Add fibrate or niacin for HDL cholesterol < 40 mg/dL regardless of LDL value

Circulation.1999;100:1016
Circulation.2004;110:588

Circulation.2000;102:1193 Circulation.2002;106:1893

Long-term management

ST elevation myocardial infarction

Other ACS

• ASA indefinitely/ Clopidogrel or warfarn if unable to take ASA
• Beta blockers for all (IIa) or all non-low risk (I) without contraindications
• ACE inhibitors for all patients (Class II-a) or patients with LV dysfunction or heart failure.
• Lipid management with goal of LDL-C substantially less than 100 and triglyceride less than 200.
• Blood pressure goal less than 140/90 or 130/80 for renal disease or diabetes
• Aldosterone blockade if LVEF is less than 0.40 and patient has CHF or diabetes.
• Target waist circumference less than 40 inches im men and 35 inches in wome.
• Target Body mass index to 18.5 to 24.9 kb/m2.
• Stop smoking
• Physical activity 30 minutes 3 to 4 times each week.
• Diabetic HbA1 less than 7%

• ASA indefinitely
• Beta blockers, absent contraindications
• ACE inhibitors for LVEF less than 40%, diabetics, or hyperytensives
• Clopidogrel
  • Indefinitely for aspirin allergy or severe intolerance
  • At least 9 months for non-interventional patients
  • At least 1 to 3 months for interventional patients
• Nitrates as needed for residual ischemic symptoms

Circulation.1999;100:1016
Circulation.2004;110:588

Circulation.2000;102:1193 Circulation.2002;106:1893

Estrogen replacement therapy

ST elevation myocardial infarction

Other ACS

• Post-menopausal woman taking HRT can continue

• Hormone therapy with estrogen plus progesteron should not be started for secondary prevention of CHD.
• Women taking hormone therapy when admitted should stop.
• Women who have been taking hormone therapy for two or more years should stop while at bed rest then discuss risks and benefits before restarting.

• HRT should not be started after myocardial infarction for purposes of secondary prevention.

Circulation.1999;100:1016
Circulation.2004;110:588

Circulation.2000;102:1193 Circulation.2002;106:1893

Oral anticoagulation

ST elevation myocardial infarction

Other ACS

•  Warfarin for aspirin-allergic patients
  • Without stent implantation: INR 2.5 to 3.5.
  • With stent implantation: INR 2.0 to 3.0 and clopidogrel 75 mg/d
• Other indications
  • Atrial fibrillation - INR 2.0 to 3.0
  • LV thrombus - three months for all without contraindications and indefinitely for all without increased risk of bleeding.
  • Extensive LV dysfunction and extensive wall motion abnormality (e.g. anterior MI) Class II-a.

• Severe global post-infarction LV systolic dysfunction

Circulation.1999;100:1016
Circulation.2004;110:588

Circulation.2000;102:1193 Circulation.2002;106:1893