Cardiovascular disease remains the leading cause of mortality in the U.S. It causes leading to of every six deaths. On hospital discharge many patients are dismayed at the number of pills they are asked to take every day. Often they had felt perfectly healthy prior to the sudden cardiac event, and may have taken pride in not using medications. I often hear something like, “I’m just not much on taking medications.” This is one of the situations where the evidence supporting the use of several medications is really overwhelmingly strong, and I feel compelled to strongly encourage even reluctant patients to use the drugs. Forgetting to take these drugs or choosing not to take them can significantly increase a patient’s odds of dying. Some non-pharmaceutical measures also make a big difference.
From time to time I read an article that prompts me to relay the information translated more towards a lay audience. That was the case today when I read the Nov 2013 article titled, Myocardial Infarction: Management of the Subacute Period. This title may seem medical jargon, but the article talks about how to manage the details of care in the days to months after a heart attack to improve a patient’s chance of survival. Here is a review of the interventions we recommend to save lives in people who have had a heart attack:
- Quit smoking: This is probably the number one behavior change in terms of reducing mortality. Use of nicotine replacement products is considered safe and can improve quit rates in the post-MI patient.
- Exercise: Studies have shown a 26% reduction in cardiovascular mortality when patients undergo an exercise based cardiac rehabilitation program when compared to post-MI patients who do not participate in this type of program. Goals post the program are 150 minutes weekly of an exercise like brisk walking.
- Dietary counseling can reduce mortality rates, with the Mediterranean Diet having the best data for improved survival rates.
- Learn to recognize the symptoms of recurrent coronary disease. This can help you seek early care if you do have symptoms of coronary disease.
Medications to Reduce Post-MI Mortality:
- Aspirin: Aspirin use significantly reduces the chance or a recurrent cardiovascular event like MI, stroke or death. The number needed to treat (NNT) is only 22, meaning by treating 22 patients with aspirin post MI one of these events can be prevented.
- Other Anti-platelet Drugs: In patients who have an angioplasty or stent, an additional anti-platelet drug should usually be used to prevent clotting in the repaired coronary artery. These drugs fall in a class called P2Y12 Inhibitors, and include Plavix (clopidogrel), Effient (prasugrel) and Brillinta (tricagrelor). When drug-eluting stents are used one of these drugs is recommended for at least a year, but otherwise the best duration of use is unknown. Your cardiologist will give you a recommendation for how long to use these meds.
- Beta-blockers: These drugs are usually started immediately when an acute coronary syndrome is detected, and especially when the pump-function of the heart is reduced are important. How long and what dose to use depends on the specifics of an individual’s situation, but most post-MI patients should take a beta-blocker for some period of time. The three drugs with the best data supporting their use are carvedilol, metoprolol and bisoprolol.
- ACE inhibitor or ARB Drugs: These medications which work on the angiotensin/renin system, antiotensin converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARB) medications when started early after an MI have been shown to reduce mortality as early as one-month post MI, with greater effect over time. When started early one cardiovascular event is avoided for every 27 patients treated (NNT=27).
- Statin therapy: The statin medications have also been shown to reduce mortality post MI. The effect is not simply due to reduction in LDL cholesterol. By starting a statin the day prior to placing a stent the absolute risk of a post-stent MI is reduced by 6%. Another way to look at this is by treating 17 patients with a statin prior to placing a stent one MI can be prevented.
This is a lot of stuff to do and a lot of drugs to take. It can be discouraging for many patients who prior to their MI may not have been on any medications to now be told they need to take up to 5 or 6 different medications, in addition to quitting smoking and going to cardiac rehab. Still the evidence is very strong that if patients comply with advice to take these drugs and make the lifestyle changes recommended, they can greatly improve their chances of avoiding a second heart attack or other cardiovascular event like stroke.