Management of Acute Myocardial InfarctionAspirinChewed in ED (325mg)GPIIb/IIIa Tirofiban 0.4 ug/kg/min over 30 min, then infuse 0.1 ug/kg/min for non-ST elevated MI patients at high-risk (elevated serum markers, refractory ischemia)Reperf for ST or new LBBB 12 hrs of symptom onsetFront loaded Rx treatment fibrinolytics* (dosing on back of card) or Primary PTCA Heparin (unfractionated UFH)IV in alteplase, reteplase, PTCA treated patients and non-ST elevation MI; large or ant. MI, AF, prior embolus, LV thrombus 60 U/kg bolus, infusion 12 U/kg/hr (max 4000 U bolus/ 1000 U/hr infusion for pts 70kg) to maintain aPTT 50-70 secondsBeta-Blockers*IV Metoprolol (up to 15mg in 3 divided doses) or IV Atenolol (10mg in 2 divided doses)StatinsACE InhibitorsInitial dose 6.25 mg captopril followed by 12.5 mg 2 hrs later, 25 mg 10-12 hrs later, then 50 mg b.i.d. or lisinopril 5 mg initially, 5 mg after 24 hrs, 10 mg after 48 hrs, then 10 mg daily180-325mg qd81 mg qd indefinitelyReperfusion: alteplase/reteplase can be repeated for recurrent occlusionOral Metoprolol 50-100mg daily or Atenolol 50-100mg qd or other beta-blockersOral daily indefinitelyDaily for up to 6 wksLonger if Sx CHF or LVEF 40%Education on low-fat dietRecommend low-fat dietIndefinitely if LDL-C 100mg/dl48 hrs in alteplase, reteplase treated patients: SubQ heparin for all until ambulatoryCoumadin for 3-6 months if LV thrombus seen or thromboembolism; chronically for AFAfter First 24 HoursDischargeMedicationFirst 24 HoursAfter First 24 HoursDischargeTherapyFirst 24 HoursLow Molecular Weight Heparin (LMWH) Subcutaneously (SC) 1mg/kg b.i.d. for patients with non-ST elevation MI if no contraindications; all patients not treated with fibrinolytics, if no contraindications (alternative to UFH)Pharmacological TherapyNon-Pharmacological TherapyNitroglycerinIV for 24-48 hrs if no contraindicationsOnly for ongoing ischemia or uncontrolled hypertensionOral for residual ischemiaDietary AdviceReinforce cessationReferral to smoking cessation classes if desiredSmokingReinforce cessationHallway ambulationRecommend regular aerobic exerciseExerciseEducationPerform pre-discharge ETTCath patients with significant ischemiaPre-discharge ETTFor uncomplicated patient plan on 4-5 daysECHO or MUGA prior to d/c if no LV gramACE inhibitors if LVEF 40% or in-hospital CHFMeasure LVEFStart exerciseRefer to rehab program near their homeCardiac RehabilitationAfter 1st 24 hrsshould not be given de novo to postmenopausal women after acute MI. Women already taking HRT plus progestin at time of AMI can continue. Counsel all postmenopausal women about potential benefits of HRT.Offer options of HRTHormone Replacement Therapy (HRT)Date of last revision: September, 1999; AMI*Cautions/Relative Contraindications: Heart rate 0.24 seconds; severe PVD; SAP 180/110 mm Hg)IHistory of prior cerebrovascular accident or known intracerebral pathology not covered in contraindicationsICurrent use of anticoagulants in therapeutic doses (INR 2-3); known bleeding diathesisIRecent trauma (within 2-4 wks), including head traumaINoncompressible vascular puncturesIRecent (within 2-4 wks) internal bleedingIFor streptokinase/anistreplase: prior exposure (especially within 5d-2y) or prior allergic reactionIPregnancyIActive peptic ulcerIHistory of chronic hypertensionCould be an absolute contraindication in low-risk patients with myocardial infarction.* 2000 American College of Cardiology and American Heart Association, Inc.The following material was adapted from the ACC/AHA Guidelines for The Management of Patients with Acute Myocardial Infarction: 1999 Update. For a copy of the full report or Executive Summary as published inJACC and Circulation, visit our Web sites at http:/www.acc.org or http:/www.americanheart.org or call the ACC Resource Center at 1-800-253-4636, ext.694.