New recommendations from the 1999 American College of Cardiology/American Heart Association acute myocardial infarction guidelines

• Published in: The Annals of pharmacotherapy 2001-05, Vol.35 (5), p.589-617
• Main Authors: Spinler, SA, Hilleman, DE, Cheng, JW, Howard, PA, Mauro, VF, Lopez, LM, Munger, MA, Gardner, SF, Nappi, JM
• Format: Article
• Language: English
• Subjects: Adrenergic beta-Antagonists - therapeutic use; Aged; American Heart Association; Angioplasty, Balloon, Coronary; Biological and medical sciences; Cardiology; Cardiovascular system; Contraindications; Female; Fibrinolytic Agents - therapeutic use; Heparin - therapeutic use; Humans; Male; Medical sciences; Miscellaneous; Myocardial Infarction - drug therapy; Myocardial Infarction - therapy; Pharmacology. Drug treatments; Platelet Aggregation Inhibitors - therapeutic use; Platelet Glycoprotein GPIIb-IIIa Complex - antagonists & inhibitors; Practice Guidelines as Topic; Societies, Medical; Stents; Thrombolytic Therapy - utilization; Ticlopidine - analogs & derivatives; Ticlopidine - therapeutic use; United States
• ISSN: 1060-0280; 1542-6270
• DOI: 10.1345/aph.10319

OBJECTIVE: To review literature relating to significant changes in drug therapy recommendations in the 1999 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for treating patients with acute myocardial infarction (AMI). DATA SOURCES: 1999 ACC/AHA AMI guidelines, English-language clinical trials, reviews, and editorials researching the role of drug therapy and primary angioplasty for AMI that were referenced in the guidelines were included. Additional data published in 2000 or unpublished were also included if relevant to interpretation of the guidelines. STUDY SELECTION: The articles selected influence AMI treatment recommendations. DATA SYNTHESIS: Many clinicians and health systems use the ACC/AHA AMI guidelines to develop treatment plans for AMI patients. This review highlights important changes in AMI drug therapy recommendations by reviewing the results of recent clinical trials. Insights into evolving drug therapy strategies that may impact future guideline development are also described. CONCLUSIONS: Several changes in drug therapy recommendations were included in the 1999 AMI ACC/AHA guidelines. There is emphasis on administering fibrin-specific thrombolytics secondary to enhanced efficacy. Selection between fibrin-specific agents is unclear at this time. Low response rates to thrombolytics have been noted in the elderly, women, patients with heart failure, and those showing left bundle-branch block on the electrocardiogram. These patient groups should be targeted for improved utilization programs. The use of glycoprotein (GP) IIb/IIIa receptor inhibitors in non-ST—segment elevation MI was emphasized. Small trials combining reduced doses of thrombolytics with GP IIb/IIIa receptor inhibitors have shown promise by increasing reperfusion rates without increasing bleeding risk, but firm conclusions cannot be made until the results of larger trials are known. Primary percutaneous coronary intervention (PCI) trials suggest lower mortality rates for primary PCI when compared with thrombolysis alone. However, primary PCI, including coronary angioplasty, is only available at approximately 13% of US hospitals, making thrombolysis the preferred strategy for most patients. Clopidogrel has supplanted ticlopidine as the recommended antiplatelet agent for patients with aspirin allergy or intolerance following reports of a better safety profile. The recommended dose of unfractionated heparin is lower than previously recommended, neces