Dyslipidemia is related to the progression of atherosclerosis. Although treatment of dyslipidemia is beneficial in decreasing the number of coronary events its effect on infarct size and myocardial remodeling are still to be assessed. What is the best strategy in terms of preserve myocardial function after AMI?
This is standard and I refer you to the ACC/AHA guidelines on post myocardial infarction treatment. The mainstay as you state, are statins. With the addition of beta blockers, aspirin, ACE- inhibitors and/or ARB's and, if there is LV dysfunction, spironolactone.
Back in 2000, we began to prescribe statins to patients with AMI and saw a reduction in the incidence of complications, heart failure in the first place. After 5 years, survival was analyzed, and they saw that these patients survive better. And only then there were works that the appointment of statins to PTCA reduces the size of myocardial infarction.
Now we use 80 mg Atorva or 40 mg Rosuva in all AMI patients as early as possible and we do not consider level of Total Cl. In this case very important pleiotropic effect of statins.
Hi.. Paulo ..statin has great role after MI because of its pleotrophic effect ..Atotvastatin 80mg or rosuvastatin 40mg should be started as soon as myocardial infarction diagnosed.. It can prevent recurrent myocardial infarction and further myocardial damage.. Apart from statin ACE inhibitor, betablockers and spironolactone or eplerenone can improve myocardial remodeling after MI.. Thanks
Dear Biswajit Majumder,
you all right.
But I have only little question about using spironolactone or eplerenone in all patients with acute myocardial infarction. As per current guidelines those medications indicated in patients with complications like acute heart failure or reduсed ejection fraction. I hope my informations is helpful.
Hi Paulo and Sergey... Continuation with the discussion. Statin reduces infarction size and also myocardial remodeling not only by reducing reinfarction but also by improving microvascular dysfunction due improvement of Endothelial function via nitric oxide pathway. I agree that spironolactone and eplerenone should be used in patients of myocardial infarction with LV systolic dysfunction. Spironolactone and eplerenone should not be used immediately after MI like statin but it should be used 2to 3days after MI because early use after MI may be associated with increased risk of cardiac rapture... Thanks
Dear colleagues
Thanks for the informations
I agree with you and we have to use statins in high doses to improve microvascular function and reduce systolic dysfunctio.
Hallo Biswajit,
Thanks a lot for your opinion.
Early use of Spironolactone and Eplerenone after MI may be associated with increased risk of cardiac rapture? As for me it is new informations. What kind of mechanism? If you have any publications...
KR,
Sergey
Hi.. Sergey.. There is a concern that early use of mineralocorticoid antagonist early use after acute MI may increase the chance of cardiac rupture or aneurysm formation by Delyani et al because it interferes with collagen synthesis and infarction healing. That's why eplerenone was used in EPHESUS trial 3to 14days after MI.. But study subanalysis showed that early use of it may be much beneficial.. Further study needed to show wheather eplerenone used from 1day will be much beneficial.. Thanks
Hi Biswajit,
On day 3 and later, cardiac rupture can occur after thrombolysis. Especially if it is late, after 12-24 hours. Or inaccurately established the time of onset of a heart attack and had a late thrombolysis. It is dangerous to over-suppress inflammation, and thereby prevent the migration of neutrophils to the infarction zone, disrupting the processes of resorption. Just EPHESUS was conducted in the thrombolytic era. I participated in this study, and I must say that the patients died after discharge from the hospital. More often suddenly. Eplerenone does not particularly affect inflammation. And he can not quickly influence on fibrosis.
Cardiac rupture - it is often sudden cardiac death.
According to trial result (see tab.) no differences between groups.
Additional informations...
Current guidelines recommend the use of mineralocorticoid receptor antagonists (MRA) in patients presenting with heart failure post MI based on the results of the Eplerenone Post-AMI Heart Failure Efficacy and Survival Study (EPHESUS). The benefits observed were more pronounced in patients with early administration of eplerenone (within 3–7 days) when compared with a later administration (7–14 days).
Adamopoulos C, and all. Timing of eplerenone initiation and outcomes in patients with heart failure after acute myocardial infarction complicated by left ventricular systolic dysfunction: insights from the EPHESUS trial, Eur J Heart Fail, 2009, vol. 11(pg. 1099-1105).