Post MI

Dosage
and Admin

Nstemi/ stemi/
pci with
stenting

Clopidogrel
75mg OD

Goals of tx
1. achieve
accumulative
RR of
secondary
MACE by 70%
2. bp control
<140/90 within
1-2 mos.
3. Achieve LDL-C
target ,
2mmol/L or
>50% reducn
in 2-3 mos.
4. 5-10% wt loss
in 3-5 mos,
normal BMI
18.5-24.9 in 1
year
5. complete
smoking
cessation in 612 mos.

ASA 325 mg
x 1 mo
Then, 81
mg
indifenitely

Non Pharm
1. RD
consultation
2. Smoking
cessation- inc
motivation,
social/family
support,
regular followup
3. Exercise 30-45
mins 3-

NTG 0.4mg
SL spray
For
symptoms
angina

DOT
Dual
Antiplatelet
Tx:
Clopidogrel/A
SA

DI

Metoprolol
100 mg bid
R/I: beta
block the pt.
as evid by
absence of
chest pain
along w/ HR
suppression

NSTEMI/STEMI- 1-12
mos
PCI w/ stentingatleast 12 mos.

Atorvastatin
(Lipitor)
80mg od po
qhs

(+) Endpt(s)

ASA +
Ibuprofen
(Ibuprofen
diminish
cardioprotecti
ve effects of
ASA, inc
toxicity/ risk
of bleeding)
MX: Tylenol
Extra
Strength 1
cap q4-6h prn
(max 8/day)
(-) ENdpt(s)

I- CV risk reduction
benefit > lipids
E- lipid lowering seen
in 4 weeks (>50%
reduction/ achieve
<2mmol/L LDL-C)
S- muscle side
effects
Myalgia or muscle painmild and tolerable
intially.
if it becomes intolerable
or dark
urine(Rhabdomyolysis)
is observed, call MD
C- Take with or without
food. Do not break
tablet, swallow whole.
Do not stop medication
without counseling your
doctor

Ramipril
(Altace)
5mg bid
R/I: lt cv
reduction, BP
independent
benefit

Non-stented: 1 yr
Bare metal stentatleast 1 mo.
Drug-eluting stent(xtolerate atleast 3
months), 1 yr

1. 70% RR of
secondary MACE
throughout tx.
2. <140/40 BP within
1-2 months
3. LDL-C <2mmol/L
w/in 2-3 months
4. 5-10% wt loss w/in
3-5 mos., then
normal BMI 18.5-24.9
in 6-12 months
5. complete smoking
cessation within 6-12
months.

Valsartan
(Diovan)
I.Dose: 20 mg BID
careful monitoring and
stable BP
UD: Within 7 days,
increase dose to 40 mg
BID, then gradually
increase dose to a
target of 160 mg BID as
tolerated

Minimize GI irritation
due to long term tx
w/
Aspirin/ Clopidogrel
Minimize risk
bleeding due to dual
anti-platelet therapy
Minimize weakness
slow heart rate due
to Metoprolol
Minimize ACE
induced cough and
serum potassium
increment
Minimize statin
induced myopathy,
GI problem, liver
injury (should not be
>3x UNL, no clinical
Sx, jaundice)

4.

4x/week
Weight normal
BMI/ wt loss

HF

BB + ACEI

Initiating
BBlocker
(When and
How)

R/I:

Fluid overload and

edema should be
corrected before
providing a B- Blocker,
why?
B-Blockers have 2
major effects on the
heart :
1- Decrease the heart
pumping power.
2- Decrease the heart
rate.
In fluid
overload/hypervolemic
state (i.e. 1+ pitting
edema, High
JVP, weight gain, &
crackles in the lungs).
There will be further
increase the
fluid overload and
edema. B-blockers
reduces heart power &
rate - slowing down
the circulation - less
blood reaching to the
kidneys for fluid
excretion - which will
finally results in more
fluid backing in the
periphery and chest
w/c could lead to heart
block.

Bisoprolol
1.25mg qd +
Ramipril 2.5mg
qd
Beta-blocker combined with
ACEI is considered to be first
line tx in HF patients with
LVEF <40%.

Bisoprolol
1.25mg qd
R/I: Also beta-blockers
improve symptoms and
reduce mortality and
morbidity. Initiating
bblocker at low dose with
slow titration in HF patient.
Bisoprolol is
cardioselective and no
intrinsic sympathomimetic
activity. Since patient has
COPD, using a cardioselective
bblocker is less likely to
trigger his respiratory
problem.

Ramipril
Naproxen
(Altace)
2.5mg bid po R/O- reduce
to target
hypotensive
5mg bid
effect of
after 2
Ramipril
weeks
(monitor BP),
fluid
*monitor SrCr and
retention,
potassium 1-2
renal failure
weeks after
initiation of tx/
dosage changes

R/O: Carvedilol- not

cardioselective,
sympathomimetic properties
will increase workload -> HF
worsening.

Advantages:
1. reduce mortality and
hospital readmission
2. reduce remission for HF
3. improve symptoms with
longterm use
4. improve ejection fraction,
decrease the rate of
reinfarction
*aim to target dose but
bradycardia is often the
limitation

Furosemide
40mg od, then 80
mg/ day until weight
loss of 0.5-1kg/ day
Once pt. is euvolemic,
reduce dose to

40mg

For pain (i.e.

sprained
ankle)
Acetaminoph

Non-pharm
- Limit fluid intake
to 1.5-2L/day
- Daily sodium <
2g(<5g in salt
form)
- Alcohol < 14
drinks a week, no
more than 3 drinks
a day
Exercise- start
when he recovers
from the injury

od
R: Increasing the dose of
furosemide to reduce
patients water retention. But
the dose of furosemide
should be reassessed
frequently as patients water
retention problem solved.

Stroke
Prevention in
Atrial
Fibrillation

Warfarin
2mg OD titrate
to 5mg in 5-7
days monitor,
desired INR of
2-3
OAC
> ASA
>ASA/Clopidog
rel
R/I: Warfarin
preferred OAC
in AFib w/ CAD

Positive Endpoints
1. Prevent and treat
Thromboembolic
complications
associated with a.fib;
2. Reduce risk of stroke

Negative Endpoints
1. No bleeding
complications throughout
therapy.
2. No dramatic rise in INR
value and maintain INR
within the target range for
the indication. (INR
monitoring daily until

en
(or Tylenol
No. 3 1 tab
q4-6h)

I- Warfarin is

R/O:
Rivaroxaban

E- warfarin reduces

-not
recommende
d in pt w/ CrCl
<30ml/min, is
renally
eliminated
and will
accumulate
and inc the
risk of
bleeding.

indicated for stroke

prevention in atrial
fibrillation
the risk of stroke by
70%

S- experience minor
bleeding(nose bleed or
during brushing teeth
or some bruises)
major bleeding :blood
in stool, blood in urine,
vomiting blood,
bleeding that does not
stop) patient should go
the E.R immediately.

C- INR test regularly

to keep it in the range
2-3
any new medication or
illness or trauma INR
values should be
monitored in the first 5
days.
patient can keep an
anitcoagulant calendar.
If dose missed, take
anytime that same day;
if forgotten til next day,
take both missed dose
plus same day dose(ie:
2 doses, there is NO
risk of bleeding).
If dose missed for 2 or
3 days in a row, DO
NOT take all of the
missed doses.

INR is within the

thrapeutic range for at
least 2 consecutive
days)