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Acute coronary syndrome and myocardial infarction – Related resources

Cochrane reviews

Drug therapy

  • Nitrates administered within 24 hours of symptom onset in myocardial infarction appear to decrease day 2 all-cause mortality (4 to 8 deaths prevented per 1000). Continuation of nitrates beyond day 2 does not reduce mortality [Evidence Level: B].
  • Beta-blockers started within 24 hours of symptom onset appear not to reduce all-cause mortality after short-term use at 10 days in acute myocardial infarction [Evidence Level: B].
  • Calcium channel blockers started within 24 hours of symptom onset in acute myocardial infarction may not decrease mortality and a non-significant trend towards increased mortality is seen after short-term use of these drugs at 10 days. Calcium channel blockers administered after acute stroke seem not to affect mortality, although the evidence is insufficient [Evidence Level: C].
  • High dose (>=75 mmol) magnesium does not reduce mortality in patients receiving thrombolytic therapy for acute myocardial infarction. It may reduce the incidence of ventricular fibrillation, ventricular tachycardia and severe arrhythmia, but it may also increase the incidence of profound hypotension, bradycardia and flushing [Evidence Level: A].
  • Triflusal appears to have similar effect to aspirin in secondary prevention of serious vascular events in patients with stroke or TIA and AMI, with a lower risk of hemorrhagic complications [Evidence Level: B].
  • Fondaparinux is associated with reduced rates of major and minor bleeding compared to enoxaparin in acute coronary syndromes but it appears to be associated with an increased risk of catheter thrombosis in patients undergoing percutaneous coronary intervention[Evidence Level: A].
  • Compared to placebo, heparins for acute coronary syndromes in addition to standard therapy with aspirin prevent myocardial infarction, but not mortality [Evidence Level: A].
  • GP IIb/IIIa blockers reduce the risk of death at 30 days and the risk of death or MI at 30 days and 6 months in patients submitted to percutaneous coronary angioplasty, at a price of an increase in the risk of severe bleeding. For patients with unstable angina or non-ST-segment elevation infarction, there is only slight advantage in the reduction of death or MI, but no reduction in mortality [Evidence Level: A].

Surgery

  • Incentive spirometry may not be effective in reducing pulmonary complications and in decreasing the negative effects on pulmonary function in patients undergoing coronary artery bypass graft (CABG) [Evidence Level: C].
  • CABG may be superior to PTCA in terms of morbidity outcome and similar in terms of mortality. CABG patients may be less likely to need re-intervention than those treated using angioplasty with stents [Evidence Level: C].
  • Autologous stem/progenitor cells seem to lead to some improvements over standard treatment as measured by tests of heart function in the short and long term in patients with acute myocardial infarction, although the evidence is insufficient[Evidence Level: D].

Lifestyle and counselling

  • Patient education of coronary heart disease patients might possibly be beneficial compared to control but the evidence is insufficient [Evidence Level: D].
  • Psychological interventions may produce small to moderate reductions in depression and anxiety in coronary heart disease patients [Evidence Level: C].
  • Interventions using counselling and education aimed at behaviour change may not reduce total or coronary heart disease mortality or clinical events in general populations but may be effective in reducing mortality in high-risk hypertensive and diabetic populations[Evidence Level: C].
  • Dietary or supplemental omega 3 fats may not alter total mortality, combined cardiovascular events or cancers in people with, or at high risk of, cardiovascular disease or in the general population [Evidence Level: B].
  • Dietary advice from health personnel appears to be effective in reducing blood lipid levels, blood pressure and dietary fat intake, and increasing fruit and vegetable intake. [Evidence Level: B].
  • Low glycaemic index diets may slightly reduce total cholesterol and HbA1c, but evidence is insufficient to recommend such diets for the purpose of improving risk factors for CHD [Evidence Level: D].

Others

  • Routine oxygen therapy in patients with uncomplicated acute myocardial infarction (AMI) may not be beneficial and might possibly be harmful[Evidence Level: D].

Other evidence summaries

Drug therapy

  • Long-term use of aspirin dosages greater than 75 to 81 mg/d in the setting of cardiovascular disease prevention appear not to better prevent events but is associated with increased risks of gastrointestinal bleeding [Evidence Level: C].
  • Except for patients with a mechanical heart valve, the benefits of oral anticoagulant (OAC) therapy plus aspirin in reducing thromboembolic events appear to be unclear compared with OAC alone, and there may be increased risk of major bleeding [Evidence Level: B].
  • Aspirin and antilipemic agents appear to reduce reocclusion after coronary artery bypass surgery, and angiotensin-converting enzyme inhibitors may decrease ischaemic events [Evidence Level: B].
  • Compared with non aspirin-resistant patients, patients with cardiovascular disease who are aspirin resistant may have a four-fold increased risk of adverse cardiovascular outcomes while taking aspirin. This risk seems not to be reduced by currently used adjunctive antiplatelet agents [Evidence Level: C].
  • Intensive lipid lowering with high-dose statin therapy appears to provide a benefit over standard-dose therapy for preventing predominantly non-fatal cardiovascular events in patients with stable coronary heart disease or acute coronary syndrome [Evidence Level: B].
  • There is insufficient evidence on the effect of nitrates in the prevention of death or myocardial infarction in patients with unstable angina. However, nitrates are effective in pain relief and remain the first-line treatment together with heparin and aspirin in unstable angina [Evidence Level: D].
  • Beta-blockers and calcium antagonists appear to provide similar outcomes, but beta-blockers fewer adverse effects [Evidence Level: B].
  • Sotalol increases mortality in patients with myocardial infarction and left ventricular dysfunction [Evidence Level: A].
  • Verapamil use appears not to be associated with harm in patients with myocardial infarction [Evidence Level: B].
  • Nifedipine in sustained- and extended-release formulations appears to be safe when used in combination with other drugs (diuretics or beta-blockers) in patients with mild or moderate hypertension [Evidence Level: B].
  • In patients with coronary disease, the use of short-acting nifedipine in moderate to high doses may cause an increase in total mortality [Evidence Level: B].
  • Low-molecular weight heparin, administered in hospital subcutaneously, as an adjunct to thrombolysis in ST-elevation myocardial infarction, appears to be more effective than placebo and at least as effective and safe as intravenous unfractionated heparin for reducing cardiovascular events [Evidence Level: B].
  • Among patients with ST-elevation myocardial infarction (STEMI) treated with thrombolysis, low-molecular-weight heparins (LMWHs), compared to unfractionated heparin (UFH), appear to be associated with a reduction in reinfarction and a trend towards reduced mortality at 30-day follow-up, but with higher risk of major bleeding complications [Evidence Level: B].
  • Abciximab reduces death and reinfarction rates in patients undergoing primary stenting for acute ST-elevation myocardial infarction (STEMI) [Evidence Level: A].
  • Reteplase appears to be at least as effective as alteplase [Evidence Level: B].
  • Bolus pexelizumab plus infusion appears to be associated with a reduction in mortality up to 6 months in patients with acute myocardial infarction or undergoing coronary artery bypass surgery [Evidence Level: B].

Surgery

  • In single- or double-vessel disease, off-pump coronary artery bypass (OPCAB) reduces the need for re-intervention for ischaemia, the recurrence of angina and major coronary adverse events at 1 to 5 years compared with percutaneous coronary intervention (PCI) but is associated with an increased length of hospital stay. There appears not to be differences between OPCAB and PCI in death, myocardial infarction, and stroke [Evidence Level: A].
  • Facilitated percutaneous coronary intervention, particularly by thrombolytic therapy, increases mortality, reinfarction, urgent revascularisation and bleeding [Evidence Level: A].

Physiotherapy and rehabilitation

  • The addition of psychosocial treatments to standard cardiac rehabilitation reduces mortality and morbidity, psychological distress and some biological risk factors [Evidence Level: A].

Lifestyle and counselling

  • Fish consumption may decrease the risk of coronary death in high-risk populations, but probably not in low-risk populations [Evidence Level: C].
  • Omega-3 fatty acids appear to reduce total mortality and the risk of death due to myocardial infarction in CHD patients, but there is no evidence of the benefit in patients taking statins [Evidence Level: B].
  • Vitamin E and vitamin C are of unknown effectiveness, and beta carotene may be harmful [Evidence Level: C].
  • Current evidence does not seem to support the use of ginseng to treat cardiovascular risk factors, although the evidence is insufficient [Evidence Level: D].

Prevention and screening

  • Waist-to-hip ratio appears to have a graded and highly significant association with myocardial infarction risk in most ethnic groups worldwide. The use of waist-to-hip ratio instead of BMI appears to improve the risk estimate of myocardial infarction [Evidence Level: B].
  • Low cardiorespiratory fitness may be a strong and independent predictor of CVD and all-cause mortality and comparable in importance with that of diabetes mellitus and other CVD risk factors [Evidence Level: C].
  • Self-reported dyspnea at cardiac stress testing appears to be an independent predictor of the risk of death from cardiac or any causes [Evidence Level: B].
  • Exertion-related MIs may occur in habitually inactive people with multiple cardiac risk factors [Evidence Level: C].

Others

  • Troponin T and troponin I predict adverse cardiac events in patients with unstable angina pectoris [Evidence Level: A].
  • The ACI diagnostic instrument appears to be effective in the diagnosis of cardiac ischaemia. Other technologies that appear effective include the ACI-TIPI, the pre-hospital ECG, the Goldman chest pain protocol, and the ECG exercise test [Evidence Level: B].
  • Prehospital ECG with advanced notification of emergency department (ED) may reduce time to treatment from arrival in the ED [Evidence Level: C].

Clinical guidelines

  • Thygesen K, Alpert JS, Jaffe AS et al. Third universal definition of myocardial infarction. Eur Heart J 2012;33(20):2551-67.  [PMID:22922414]
  • Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33(20):2569-619.  [PMID:22922416]
  • Authors/Task Force Members, Hamm CW, Bassand JP et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; First published online: August 26, 2011  [PMID:21873419]
  • European Association for Percutaneous Cardiovascular Interventions, Wijns W, Kolh P et al. Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2010;31(20):2501-55.  [PMID:20802248]
  • ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): Circulation 2007;116:803–877.
  • Antman EM, Anbe DT, Armstrong PW, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004 Aug 3;110(5):588-636.  [PMID:15289388]
  • Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation 2008 Jan 15;117(2):296-329.  [PMID:18071078]
  • Heidbuchel H, Verhamme P, Alings M et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17(10):1467-507.  [PMID:26324838]
  • Heidbuchel H, Verhamme P, Alings M et al. EHRA Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013:Apr 26. [Epub ahead of print]  [PMID:23625209]
  • Heidbuchel H, Verhamme P, Alings M et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15(5):625-51.  [PMID:23625942]
  • Lip GY, Huber K, Andreotti F et al. Antithrombotic management of atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing coronary stenting: executive summary--a Consensus Document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the European Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2010;31(11):1311-8.  [PMID:20447945]

Literature

  • White HD, Chew DP. Acute myocardial infarction. Lancet 2008;372(9638):570-84.  [PMID:18707987]


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