Long Term Management Of Acute Myocardial Infarction

Attention to all the modifiable risks factors and long-term administration of drugs have been extensively investigated. Avoidance of smoking is the single most useful measure to reduce the risk of recurrence. Hypercholesterolemia can be lowered by avoidance of saturated fats (butter, ghee, egg-yolk, animal fats etc), reduction in carbohydrate calories and regular exercise. Drugs which lower serum cholesterol are clofibrate (500 mg 3 or 4 times daily) and cholestyramine (8-12g twice daily with meals). These may be given in cases where dietary therapy alone is not fully effective. Though there is general agreement that lowering serum cholesterol is beneficial in arresting progress of atheroma, its effect cannot be confidently predicted in an individual case.

Several drugs have been tried on long-term basis with the hope of reducing platelet activity in initiating arterial thrombosis. Drugs in this class include sulphinpyrazone (200 mg four times a day), aspirin (150 mg daily) and dipyridamole (100 mg thrice a day). Reports of many studies are encouraging in that the incidence of reinfarction and sudden death are reduced.

During the past two decades, considerable progress has been made in the exact diagnosis and correction of coronary artery occlusion. Coronary arteriography enables visualization of the coronary arteries and their branches. The occlusion can be overcome by inserting bypass grafts from the aorta to the distal parts of the coronary arteries. Using the patient’s saphenous veins. This procedure has been fully standardized and all the occluded major coronary arteries can be grafted at the same session. The operative risk is well below 5%. Surgery definitely relieves angina and improves effort tolerance and the quality of life. It is probable that life is also prolonged. Though occlusion of the graft may develop in some cases, the place of coronary artery graft surgery has become established at present.

Indications for surgery are moderate to severe angina unresponsive to medical treatment and more than 50% occlusion of left main coronary artery (even if patient is asymptomatic).

Another ingenious method which is being developed at present is percutaneous transluminal coronary angioplasty (PCTA). In this; special ballon catheters are introduced into the coronary arteries and the stenosed segment is dilated under fluoroscopic vision. Fibrinolytic agents can also be directly indtroduced at the site of occlusion by this technique.

Since it has been realized that a major proportion of deaths occurs in the first two to six hours of onset of infarction, ambulances equipped with intensive care facilitates and resuscitation teams are provided to reach the patient’s home at the first call and transport him to hospital so that early deaths can be prevented to a considerable extent.