From the Guidelines
The management of acute myocardial infarction (AMI) in a hospital setting requires immediate intervention with a coordinated approach focusing on reperfusion therapy, antiplatelet/anticoagulant medications, and supportive care, with the goal of reducing morbidity, mortality, and improving quality of life. For ST-elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) should be performed within 90 minutes of first medical contact if available, as recommended by the 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction 1. If PCI is not available within 120 minutes, fibrinolytic therapy should be administered within 30 minutes of hospital arrival.
Key Interventions
- Antiplatelet therapy includes aspirin (325mg loading dose, then 81mg daily indefinitely) and P2Y12 inhibitors like clopidogrel, ticagrelor, or prasugrel, as supported by the ACC/AHA guidelines for the management of patients with acute myocardial infarction 1.
- Anticoagulation with unfractionated heparin or enoxaparin should be initiated to prevent further clot formation.
- Additional medications include beta-blockers, ACE inhibitors/ARBs, and high-intensity statins to reduce myocardial oxygen demand and limit infarct size.
- Supplemental oxygen should be provided if oxygen saturation is below 90%, and pain management with morphine may be necessary, as outlined in the management of acute myocardial infarction in patients presenting with ST-segment elevation by the European Society of Cardiology 1.
Monitoring and Care
- Continuous cardiac monitoring, frequent vital signs, and serial ECGs and cardiac biomarkers are essential to promptly recognize and manage complications.
- The patient should be closely observed for signs of heart failure, cardiogenic shock, and arrhythmias, and treated accordingly, as emphasized in the 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction 1.
- Coronary angiography with subsequent revascularization therapy should be considered for patients with recurrent chest pain or evidence of myocardial ischemia, as recommended by the ACC/AHA guidelines for the management of patients with acute myocardial infarction 1.
From the FDA Drug Label
DOSAGE & ADMINISTRATION Myocardial Infarction Early Treatment During the early phase of definite or suspected acute myocardial infarction, initiate treatment with metoprolol tartrate as soon as possible after the patient’s arrival in the hospital. Such treatment should be initiated in a coronary care or similar unit immediately after the patient’s hemodynamic condition has stabilized Begin treatment in this early phase with the intravenous administration of three bolus injections of 5 mg of metoprolol tartrate injection each; give the injections at approximately 2-minute intervals. During the intravenous administration of metoprolol tartrate injection, monitor blood pressure, heart rate, and electrocardiogram In patients who tolerate the full intravenous dose (15 mg), initiate metoprolol tartrate tablets, 50 mg every 6 hours, 15 minutes after the last intravenous dose and continued for 48 hours.
The management of acute myocardial infarction (AMI) in a hospital setting involves:
- Initiating treatment with metoprolol tartrate as soon as possible after the patient's arrival in the hospital
- Starting treatment in a coronary care or similar unit after the patient's hemodynamic condition has stabilized
- Administering three bolus injections of 5 mg of metoprolol tartrate injection each, at approximately 2-minute intervals
- Monitoring blood pressure, heart rate, and electrocardiogram during intravenous administration
- Initiating metoprolol tartrate tablets 15 minutes after the last intravenous dose, in patients who tolerate the full intravenous dose 2
From the Research
Management of Acute Myocardial Infarction in a Hospital Setting
The management of acute myocardial infarction (AMI) in a hospital setting involves a combination of pharmacological and interventional therapies. The primary goals of treatment are to restore blood flow to the affected area of the heart, reduce the size of the infarct, and prevent further complications.
Pharmacological Therapies
- Aspirin is recommended for all patients with suspected AMI unless contraindicated 3
- Addition of a second antiplatelet agent (e.g. clopidogrel, ticagrelor, or prasugrel) is also recommended for most patients 3
- Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux is recommended 3
- Statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine are also used to manage AMI 3
- The use of clopidogrel in addition to aspirin has been shown to reduce mortality and major vascular events in patients with AMI 4
Interventional Therapies
- Percutaneous coronary intervention (PCI) with stent placement is recommended for patients with ST-segment elevation myocardial infarction (STEMI) as soon as possible 3
- Fibrinolytic therapy should be used first if PCI will be delayed for more than 120 minutes 3
- For patients with non-ST-segment elevation ACS, PCI is recommended, but fibrinolytic therapy is not typically recommended 3
- Coronary artery bypass grafting (CABG) may be necessary in some cases, ideally delayed 3 to 7 days after admission unless the patient has cardiogenic shock or other complications 3
Anticoagulation and Antiplatelet Therapy
- The use of anticoagulation and antiplatelet therapy in AMI is crucial to prevent further thrombus formation and reduce the risk of complications 5, 6, 7
- The choice of anticoagulant and antiplatelet agent depends on the individual patient's risk factors and clinical presentation 7
- New oral anticoagulants have been shown to be at least as effective as vitamin K antagonists in atrial fibrillation and may be used in certain cases of AMI 7