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Clinical Review

Fortnightly review: Secondary prevention in acute myocardial infarction

BMJ 1998; 316 doi: (Published 14 March 1998) Cite this as: BMJ 1998;316:838
  1. Rajendra H Mehta, cardiology fellow,
  2. Kim A Eagle, chief of clinical cardiology
  1. University of Michigan Hospital, Division of Cardiology, Taubman Center 3910, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0366, USA
  1. Correspondence to: Dr Eagle

    Acute myocardial infarction affects hundreds of thousands of people each year. Around a quarter die, half of them before reaching a hospital. Survivors are at increased risk of recurrent myocardial infarctions or cardiac death, with a 10% death rate in the first year after discharge and a subsequent annual death rate of 5%—six times that in people of the same age who do not have coronary artery disease. Whereas aggressive management of the acute infarction has been enthusiastically adopted, far less attention has been given to preventive strategies. Though most doctors agree with the importance of secondary prevention, the results of studies suggest that many patients are currently not being given optimal preventive care. Since most patients after acute myocardial infarction are routinely followed up in primary care, general practitioners must be fully informed and participate in treatment strategies designed for the secondary prevention of coronary artery disease.


    We conducted a Medline search for all articles on acute myocardial infarction dating from January 1980 to August 1997, with particular emphasis on secondary prevention in acute myocardial infarction. We scanned all of these reports, which numbered more than 3000. In this review we have also incorporated current standard practice at the University of Michigan, Ann Arbor, for managing myocardial infarction.

    β Blockers

    Several controlled trials in more than 35 000 survivors of myocardial infarction have shown the benefit of long term treatment with β blockers in reducing the incidence of recurrent myocardial infarction, sudden death, and all cause mortality (table 1).1-8 β Blockers reduce myocardial workload and oxygen consumption by reducing the heart rate, blood pressure, and contractility, and they increase the threshold for ventricular fibrillation. A meta-analysis of such treatment in patients who have had myocardial infarctions shows a 20% reduction in long term mortality and a 34% reduction in …

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