Further in-hospital management

The patient is examined daily.

Blood should be taken for cardiac enzyme determination for 2-3 days.

For patients with myocardial infarction (MI) who do not have heart failure all patients should be treated with (unless contra-indicated) (1):

Early pharmacological intervention

• antiplatelet therapy
  • following an acute coronary syndrome all patients should be maintained on long term aspirin therapy. A dose of 75-150 mg aspirin per day is recommended in patients with acute coronary syndrome (1)
  • NICE (2) state that:
    • clopidogrel, in combination with low-dose aspirin, should be continued for 12 months after the most recent acute episode of non-ST-segment-elevation acute coronary syndrome. Thereafter, standard care, including treatment with low-dose aspirin alone, is recommended unless there are other indications to continue dual antiplatelet therapy
    • after an ST-segment-elevation MI, patients treated with a combination of aspirin and clopidogrel during the first 24 hours after the MI should continue this treatment for at least 4 weeks. Thereafter, standard treatment including low-dose aspirin should be given, unless there are other indications to continue dual antiplatelet therapy
      
      
• statin therapy
  • patients with an acute coronary syndrome should be commenced on long term statin therapy prior to hospital discharge
    
    
• beta blocker and antianginal therapy
  • patients with unstable angina or evidence of myocyte necrosis should be maintained on long term beta blocker therapy
  • patients with clinical myocardial infarction should be maintained on long term beta blocker therapy
  • nitrates
    • should be used in acute coronary syndromes to relieve cardiac pain due to continuing myocardial ischaemia or to treat acute heart failure
      
      
• Ace inhibitors
  • patients with unstable angina or myocyte necrosis should be commenced on long term angiotensin converting enzyme inhibitor therapy. A Patients with clinical myocardial infarction should be commenced on long term angiotensin converting enzyme inhibitor therapy within the first 36 hours
    
    
• Angiotensin receptor blockers
  • patients with clinical myocardial infarction complicated by left ventricular dysfunction or heart failure should be commenced on long term angiotensin receptor blocker therapy if they are intolerant of angiotensin converting enzyme inhibitor therapy
    
    
• aldosterone receptor antagonists
  • patients with clinical myocardial infarction complicated by left ventricular dysfunction (ejection fraction <0.40) in the presence of either clinical signs of heart failure or diabetes mellitus should be commenced on long term eplerenone therapy

Prophylactic heparin should be given if the patient according to the perceived risk of venous thromboembolism.

Bed rest is recommended for 24-48 hours followed by gradual mobilisation. Discharge is planned for day 7-10. The patient should be followed in the clinic after about six weeks.

Clopidogrel may be indicated (see linked item).

Reference:

1. SIGN (2012). Heart Disease
2. NICE (May 2007). Secondary prevention in primary and secondary care for patients following a myocardial infarction
3. Sabatine MS et al. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Eng J Med 2005; 352:1179-89