Treatment

• Oxygen, if there are problems in oxygenation (pulmonary oedema)
• For treating pain
  • Glyceryl nitrate: mouth spray or sublingual tablet
  • Morphine 4 to 6 mg intravenously (i.v.), additionally 4 mg 1 to 3 times at 5-minute intervals, if necessary. Oxycodone 3 to 5 mg i.v. is an alternative.
  • A beta-blocker (metoprolol, atenolol, practolol) 2 to 5 mg i.v. may sometimes ease the pain.
• Aspirin 250 mg, chewable tablet or dissolved in water, unless there are contraindications (active ulcer, hypersensitivity to aspirin, anticoagulation) ("Collaborative overview of randomised trials of antiplatelet therapy" 1994; DARE-948032, 1999) [A].
• A beta-blocker (Danchin, DeBenedetti, & Urban, 2002) [A] is always instituted, unless there are contraindications (asthma, hypotension, heart insufficiency, conduction disturbance, bradycardia). The first dose can be given intravenously if the patient is in pain, or orally if the patient is pain-free and time has passed since the infarction. Beta-blockers are useful especially in patients who are tachycardic and hypertensive but do not have heart failure.
  • i.v. dose: metoprolol or atenolol 5 mg
  • Orally: metoprolol or atenolol 25 to 50 mg x 2
• Thrombolytic therapy, unless there are contraindications ("Indications for fibrinolytic therapy," 1994; DARE-948029, 1999) [A].
• Immediate percutaneous transluminal angioplasty (PTCA) (Grines et al., 2003; DARE-20030287, 2004; Keeley, Boura, & Grines, 2003; DARE-20038039, 2004) [A] if available. May be performed when thrombolytic therapy is contraindicated. The effect is better than that of thrombolysis in the acute phase and also in long-term follow-up. Stenting probably improves the outcome (Meads, et al, 2000; DARE-20018012, 2002) [A] (Grines et al., 1999). Further treatment with clopidogrel for 3 months.
• An ACE inhibitor to all patients with signs or symptoms of heart failure or ejection fraction (EF) <40, anterior wall infarction, or reinfarction (Domanski et al., 1999; DARE-990660, 2000; Danchin, De Benedetti, & Urban, 2002) [A]. Therapy is not usually started on the first day.
  • For example: captopril. Start with 6.25 mg and increase the dose rapidly.
• Continuous nitrate therapy (Mehta & Yusuf, 2000) [A]
  • Administered as an infusion, if the patient has ischaemic pain and pain medication has no effect. Nitrate infusion (see the Finnish Medical Society Duodecim guideline "Nitrate Infusion in Angina Pectoris and Myocardial Infarction").
  • Orally (e.g., isosorbide dinitrate 10 to 20 mg x 2 to 3)
• Heparinization is often indicated, if the patient
  • Needs prolonged bed rest and is clearly obese (thrombosis prophylaxis)
  • Has atrial fibrillation (also permanent warfarin therapy)
  • Has ventricular aneurysm (also permanent warfarin therapy)
  • Has unstable angina pectoris
  • Has embolic complications
• Anticoagulation with warfarin is often started in massive anterior infarction and when transient ischemic attack (TIA) or stroke (mural thrombosis) occurs with MI.