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PhD Candidate, Utrecht Institute for Pharmaceutical Sciences, Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht University, Utrecht, Netherlands
Director, SIR Institute for Pharmacy Practice Research, Leiden, Netherlands
Senior Researcher, SIR Institute for Pharmacy Practice Research; Utrecht Institute for Pharmaceutical Sciences, Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht University
Professor, Utrecht Institute for Pharmaceutical Sciences, Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht University
Reprints: Menno E van der Elst PharmD, Utrecht Institute for Pharmaceutical Sciences, Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht University, PO Box 80.082, 3508 TB, Utrecht, Netherlands, FAX 31 30 2539166, m.e.vanderelst{at}pharm.uu.nl
OBJECTIVE: To provide an evidence-based overview of drug treatment for long-term secondary prevention of myocardial infarction (MI).
DATA SOURCES: We conducted searches of MEDLINE (1966–August 2002), the Cochrane Controlled Trial Register, and the reference list of each identified study.
STUDY SELECTION/DATA EXTRACTION: Trials and meta-analyses were included using the following criteria: (1) randomized trials, (2) description of identification procedure, inclusion criteria, outcome measures, and statistical methods, (3) confirmed MIs, (4) treatment continued for at least 1 month, and (5) all-cause mortality as primary outcome; other events as secondary outcomes. All authors interpreted the results from trials that met the inclusion criteria.
DATA SYNTHESIS: In randomized clinical trials, low-dose aspirin, high-intensity oral anticoagulants, ß-blockers, angiotensin-converting enzyme (ACE) inhibitors, and statins decreased the risk of mortality and reinfarction after MI. Randomized clinical trials using calcium-channel blockers, antiarrhythmics, and hormone replacement therapy did not show benefits in patients with prior MI. Effects of the combined use of aspirin or oral anticoagulants with ß-blockers or ACE inhibitors plus statins must be derived from subgroup analysis of trials, but seem to be beneficial.
CONCLUSIONS: The use of at least aspirin or an oral anticoagulant, a ß-blocker or an ACE inhibitor, plus a statin should be incorporated in the treatment routine. Clopidogrel treatment might be an alternative to aspirin. Standard addition of a ß-blocker to ACE inhibitor–treated patients without reduced left-ventricular ejection fraction seems to be untimely.
Key Words: myocardial infarction, secondary prevention
Published Online, August 22, 2003. www.theannals.com, DOI 10.1345/aph.1C450
THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT
ACPE UNIVERSAL PROGRAM NUMBER: 407-000-03-030-H01
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