Heart Attack

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Follow-up Treatment

Patients who suffer a heart attack are admitted to a cardiac care unit (CCU), usually for the first several days. In the CCU, the patient's heart rate, blood pressure, and heart rhythm are carefully monitored. Patients also are carefully monitored for recurring chest pain and shortness of breath.

Blood tests usually are performed every 8 hours for the first 24 hours to help assess the amount of heart damage. If intravenous unfractionated heparin is administered, regular blood tests are used to determine if the blood is "thinned" to the correct degree.

During the first several days, an echocardiogram (cardiac echo) may be used to assess the size and function of the heart and to determine if heart valves have become leaky or narrowed (stenotic).

For several days after a heart attack, most medications are administered intravenously. After a few days, most medications can be taken orally.

Studies have shown that acute and long-term aspirin therapy can decrease the chances of recurrent heart attack and death. Therefore, patients are often treated indefinitely with aspirin. In most cases, a 325 mg enteric-coated aspirin is prescribed. The enteric coating decreases the risk for stomach irritation.

According to the U.S. Food and Drug Administration (FDA), the pain reliever ibuprofen can interfere with the benefits of aspirin therapy. Patients who are on aspirin therapy should speak with a health care provider for information about taking ibuprofen.

Studies have shown that some patients are resistant to the effects of aspirin therapy. Regular blood tests may be performed to monitor the patient's response; the results of these tests can be used to adjust the aspirin dosage or change the medication.

A medication called clopedigrol (Plavix®) is an alternative to aspirin therapy. Clopedigrol decreases the "stickiness" of platelets to a greater degree than aspirin therapy.

In a study in which clopedigrol therapy was compared to aspirin therapy in patients with coronary heart disease, clopedigrol proved slightly more effective in decreasing future heart attacks and had a slightly lower incidence of stomach irritation and bleeding. These benefits are weighed against the higher cost of this medication. Current studies are assessing the potential benefits of therapy combining aspirin and clopedigrol.

The usual dose of clopedigrol is one 75 mg tablet daily. Side effects include abdominal pain, constipation, and nausea.

Angiotensin converting enzyme (ACE) inhibitors, which often are used to treat high blood pressure, may be administered for approximately 6 weeks following a heart attack. These medications may help the heart "heal," improving function (ejection fraction) and decreasing risk for heart failure, recurrent heart attack, and death. ACE inhibitors provide the greatest benefit in patients who have had a severe heart attack, those who experience heart failure, and those with long-term moderately or severely reduced heart function (i.e., those with ejection fractions less than about 40%).

ACE inhibitors include the following:

• Benazepril (Lotensin®)
  
• Captopril (Capoten®)
  
• Enalapril (Vasotec®)
  
• Fosinopril (Monopril®)
  
• Lisinopril (Prinivil®, Zestril®)
  
• Quinapril (Accupril®)
  
• Ramipril (Altace®)
  
• Trandolapril (Mavik®)
  

These medications are usually tolerated well, but there are potential side effects. Approximately 10% of patients develop a chronic nonproductive cough. Rarely, ACE inhibitors produce a sudden swelling of the lips, face, and cheek areas in an allergic reaction that can occur at any time during therapy. If an allergic reaction occurs, medical attention should be sought immediately. Because ACE inhibitors can affect kidney function and raise the potassium level, physicians monitor these during the first few weeks of treatment.

Angiotensin receptor blockers (ARBs) are similar to ACE inhibitors and also may be used to treat high blood pressure. These medications have been shown to help the heart to "heal" after a heart attack and may benefit patients with lower than normal heart function.

ARBs include candesartan (Atacand®), eprosartan (Tevetan®), and irbesartan (Avapro®). Side effects include cough, dizziness, low blood pressure, and headache.

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