From the Guidelines
Management of angina and myocardial infarction (MI) requires a step-by-step approach, prioritizing lifestyle modifications, medical therapy, and revascularization as needed, with a focus on reducing morbidity, mortality, and improving quality of life.
Initial Management
For stable angina, initial management includes:
- Lifestyle modifications (smoking cessation, exercise, diet)
- Medical therapy with aspirin 75-100mg daily, a statin like atorvastatin 40-80mg daily, and anti-anginal medications such as beta-blockers (metoprolol 25-100mg twice daily) or calcium channel blockers (amlodipine 5-10mg daily) 1
- Sublingual nitroglycerin 0.4mg can be used as needed for acute symptoms
Revascularization
For persistent symptoms despite optimal medical therapy, coronary angiography with possible revascularization (PCI or CABG) should be considered, taking into account the patient's risk factors, anatomy, and functional evaluation 1
Acute MI Management
For acute MI management, the first step is immediate recognition of symptoms and activation of emergency services. Upon arrival to a medical facility, patients should receive:
- Aspirin 325mg
- Supplemental oxygen if saturation is below 90%
- Pain control with IV morphine 2-4mg as needed For STEMI, urgent reperfusion therapy is critical, with primary PCI preferred if available within 90 minutes of first medical contact, or fibrinolytic therapy (such as alteplase 15mg IV bolus followed by 0.75mg/kg over 30 minutes) if PCI is not available within 120 minutes 1
Post-MI Care
Post-MI care includes:
- Cardiac rehabilitation
- Continued medical therapy with dual antiplatelet therapy, beta-blockers, ACE inhibitors, and high-intensity statins
- Close follow-up to monitor for complications and optimize secondary prevention strategies, including lifestyle modifications and risk factor management 1 The selection of a medical regimen should be tailored to the individual patient's needs and circumstances, with a focus on reducing morbidity, mortality, and improving quality of life. Some key points to consider in the management of angina and MI include:
- The use of anti-ischaemic treatment, such as beta-blockers and calcium channel blockers, to reduce symptoms and improve quality of life
- The importance of risk factor management, including lifestyle modifications and medical therapy, to reduce the risk of future cardiovascular events
- The need for close follow-up and monitoring to optimize secondary prevention strategies and improve outcomes 1
From the FDA Drug Label
In patients who need an antiplatelet effect within hours, initiate clopidogrel tablets with a single 300 mg oral loading dose and then continue at 75 mg once daily. Clopidogrel tablets are indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non–ST-segment elevation ACS (unstable angina [UA]/non–ST-elevation myocardial infarction [NSTEMI]), including patients who are to be managed medically and those who are to be managed with coronary revascularization By blocking catecholamine-induced increases in heart rate, in velocity and extent of myocardial contraction, and in blood pressure, metoprolol reduces the oxygen requirements of the heart at any given level of effort, thus making it useful in the long-term management of angina pectoris Metoprolol has no intrinsic sympathomimetic activity, and membrane-stabilizing activity is detectable only at doses much greater than required for beta-blockade.
The step by step management of angina and MI involves:
- Initiating clopidogrel with a single 300 mg oral loading dose and then continuing at 75 mg once daily for patients who need an antiplatelet effect within hours 2
- Using metoprolol to reduce the oxygen requirements of the heart, thus making it useful in the long-term management of angina pectoris 3
- Managing ACS patients with clopidogrel to reduce the rate of myocardial infarction and stroke 2 Key considerations include:
- Antiplatelet therapy with clopidogrel for patients with ACS or MI 2
- Beta-blockade with metoprolol for long-term management of angina pectoris 3
From the Research
Step-by-Step Management of Angina and MI
The management of angina and myocardial infarction (MI) involves a combination of pharmacological and non-pharmacological interventions. The following steps outline the management approach:
- Prehospital Administration of Aspirin: Aspirin administration in the prehospital setting may be beneficial in patients with unstable angina and acute MI, as it reduces mortality and reinfarction rates 4.
- Pharmacologic Therapy: The primary drugs used in the treatment of angina pectoris include organic nitrates, beta-adrenoceptor antagonists, Ca2+ antagonists, and antithrombotic agents such as aspirin and heparin 5.
- Management of Unstable Angina: Aspirin and heparin reduce the risk of MI, and aspirin increases survival in patients with unstable angina. Heparin and nitrates alleviate angina pain, and beta-blockers and Ca2+ antagonists may have a role in pain relief 5.
- Management of Acute MI: The approach to managing MI in the intensive care unit setting includes diagnosis, classification, and treatment of unstable angina, non-ST elevation MI, and ST-segment elevation MI, as well as management of acute complications 6.
- Post-MI Angina Management: Angina management after acute MI treated with percutaneous coronary intervention (PCI) is crucial, as angina is present in one-third of PCI-treated MI patients as early as 6 weeks after discharge. Non-β-blocker antianginal medications are infrequently used in these patients, even among those with persistent angina and those undergoing revascularization 7.
- Contemporary Management Strategies: A multipronged treatment approach, including goal-directed revascularization, adjunctive pharmacological therapy, and aggressive secondary prevention measures, is essential in the management of MI. Emphasis is placed on the choice of primary reperfusion therapy for ST-elevation MI, risk-stratification of patients with non-ST elevation MI, and selection of anti-ischaemic and antithrombotic therapy 8.