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A variety of complications can occur after myocardial infarction even when treatment is initiated promptly

Discharge on aspirin, since it is highly effective, inexpensive, and well tolerated, is a key quality indicator of myocardial infarction care In the WARIS-II trial, long-term anticoagulation with warfarin post-myocardial infarction was associated with a reduction in the composite of death, reinfarction, and stroke However, whether the results of this trial are transferable to the United States where anticoagulation services may be less organized and effective than in Norwegian hospitals is unknown In the CURE trial, clopidogrel for 3 12 months for non-ST elevation acute coronary syndromes resulted in a similar 20% relative risk reduction in cardiovascular death, myocardial infarction, and stroke

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Antman EM et al ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction) J Am Coll Cardiol 2004 Aug 4;44(3):E1 E211 [PMID: 15358047] Antman EM et al; ExTRACT-TIMI 25 Investigators Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction N Engl J Med 2006 Apr 6;354 (14):1477 88 [PMID: 16537665] Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial Lancet 2006 Feb 18;367(9510):569 78 [PMID: 16488800]

In clinical trials of thrombolysis, recurrent ischemia occurred in about one-third of patients, was more common following non ST elevation than ST elevation myocardial infarction, and had important short- and long-term prognostic implications Vigorous medical therapy should be instituted, including nitrates and -blockers as well as aspirin, anticoagulant therapy, and clopidogrel Most patients with postinfarction angina and all who are refractory to medical therapy should undergo early catheterization and revascularization by PCI or CABG

Abnormalities of rhythm and conduction are common 1 Sinus bradycardia This is most common in inferior infarctions or may be precipitated by medications Observation or withdrawal of the offending agent is usually sufficient If accompanied by signs of low cardiac output, atropine, 05 1 mg intravenously, is usually effective Temporary pacing is rarely required 2 Supraventricular tachyarrhythmias Sinus tachycardia is common and may reflect either increased adrenergic stimulation or hemodynamic compromise due to hypovolemia or pump failure In the latter, -blockade is contraindicated Supraventricular premature beats are common and may be premonitory for atrial fibrillation Electrolyte abnormalities and hypoxia should be corrected and caus-

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