After myocardial infarction, a stent or bypass surgery will be done once and for all and everything will be fine? Don't think so. After acute myocardial infarction, some drugs cannot be stopped for life, and once the drugs are stopped without authorization, it may cause catastrophe.
Author | Zhang Haicheng, Peking University People's Hospital
Mr. Xu is from Chengdu, Sichuan. He is 61 years old this year. He likes to smoke and play mahjong. More than two months ago, Mr. Xu had an anterior myocardial infarction and the doctor performed a stent operation for him.
After being discharged from the hospital, Mr. Xu accepted the lesson, quit smoking, and obediently took 5 drugs according to the doctor's order. But it didn't take long for Mr. Xu to feel good, so he stopped all the medicine and returned to the mahjong room to continue smoking and playing mahjong.
However, the tragedy was staged again, and Mr. Xu had a heart attack again! This is the 6th day after he stopped taking the medicine, less than 3 months after the last myocardial infarction. After the doctors actively rescued him, Mr. Xu was lucky enough to pass by the god of death. However, another myocardial infarction still affected his ventricular function.
Many people, like Mr. Xu, once successfully placed a stent or discharged from the hospital after recovery from coronary artery bypass grafting, they were completely relaxed, thinking that the blood vessels were dredged and the disease was eliminated. As a result, in addition to a slight improvement in lifestyle, no longer follow-up on time, and even self-reduction or withdrawal of medication, which eventually leads to catastrophe.
Therefore, I hereby remind patients after acute myocardial infarction, especially those who have received stents and bypasses, that they must not be taken lightly in their subsequent lives and must take medication and review them as directed by the doctor.
There are three main purposes of drug treatment after myocardial infarction:
1. Reduce or delay restenosis of coronary arteries;
2. Reduce symptoms and improve quality of life;
3. Reduce major cardiovascular and cerebrovascular events such as recurring myocardial infarction and stroke.
Even if stent or bypass surgery has been performed, these treatment measures are only in the category of "symptomatic" treatment, and do not fundamentally change the process of coronary atherosclerosis, but expand the coronary artery through stent expansion to increase the inner diameter of the narrowed artery lumen , Or increase the blood supply of the ischemic myocardium, and the stent operation itself will also cause damage to the intima of the local coronary artery, which can easily lead to restenosis of the local coronary artery. Therefore, the application of drugs to keep the stent or graft vessel open is very important.
In addition, the coronary arteries of the heart have multiple branches. The stent or bypass only selectively solves the problem of one or several arterial branches. Even if the stenosis of the arterial vessel or the bypass vessel is no longer narrowed, it cannot be guaranteed. There will be no atherosclerotic stenosis in the blood vessels implanted with stents or bypasses, and even atherosclerotic plaques in the blood vessels will rupture and block the blood vessels to form acute myocardial infarction. Therefore, after myocardial infarction, remember that the medicine cannot be stopped!
Anti-platelet aggregation drugs-the top priority
For patients with myocardial infarction, whether stents or bypasses are done, anti-platelet aggregation drug treatment is the top priority, and it is an important guarantee to prevent further acute and chronic thrombosis from blocking the coronary arteries. Unless there is a doctor's advice, the drug cannot be stopped for life. Commonly used clinical drugs include aspirin, clopidogrel, prasugrel, ticagrelor and other oral drugs.
Aspirin is an old drug for new use. The application is no longer high-dose, anti-rheumatic, antipyretic, but low-dose (usually about 100 mg) enteric-coated aspirin. As long as there is no contraindications such as peptic ulcers and acute bleeding diseases, it should As the drug of choice after acute myocardial infarction.
After drug-coated stent or bypass surgery, two anti-platelet aggregation drugs must be applied simultaneously within 1 to 2 years. Studies have shown that anti-platelet aggregation drug treatment reduces severe vascular events by 1/4, including non-fatal myocardial infarction by 1/3, non-fatal stroke by 1/4, and cardiovascular death by 1/6.
The best long-term dose of aspirin is 75-150 mg per day. The American College of Cardiology and American Heart Association guidelines recommend that, unless there are contraindications, patients with atherosclerosis should take aspirin for life, 75 to 162 mg per day.
These drugs can reduce the rate of restenosis and prevent cardiovascular and cerebrovascular diseases. However, taking these drugs requires regular review of blood routines in the hospital and observation of skin and mucous membranes for bleeding points.
In addition, these drugs (especially aspirin) often have gastrointestinal irritation, such as melena (watch out for gastrointestinal bleeding), blood in the stool (watch out for hemorrhoids), blurred vision (watch out for bleeding in the fundus), dizziness (watch out for bleeding) If you are suffering from stroke), you should seek medical attention in time and take medication under the guidance of a doctor.
In patients with acute myocardial infarction, regardless of whether stents or bypasses are performed, unless there are contraindications or otherwise prescribed by a doctor, statins cannot be stopped for life.
A large number of epidemiological studies and evidence-based medicine in the past 20 years have shown that statins can significantly improve the incidence of coronary heart disease, mortality, revascularization rate, stroke incidence, and total incidence of patients with different cholesterol levels and cardiovascular risk. mortality rate.
First of all, statins can lower blood cholesterol levels, especially the worst low-density lipoprotein cholesterol that is easily deposited on the arterial wall, and hypercholesterolemia is an important cause of atherosclerosis.
Secondly, statins can also stabilize existing atherosclerotic plaques, reduce the probability of plaque rupture, thereby reducing cardiovascular and cerebrovascular disease events, and can reduce atrial fibrillation and sudden death.
Therefore, patients with coronary heart disease whose blood lipids are already normal still need to take these drugs for a long time, but the dosage should be adjusted under the guidance of a doctor.
These drugs have hepatotoxicity and muscle toxicity, and are positively correlated with the dose. The Chinese hepatitis virus carriers are much higher than those in the West. Therefore, when using statins, you should fully grasp the indications and closely observe changes in liver function, cholestasis and activity Patients with liver disease should not use statins.
In addition, statins can also cause myopathy and rhabdomyolysis. The common symptoms are non-specific muscle or joint pain. The elderly (especially over 80 years old), female, thin, weak, chronic renal insufficiency (especially diabetic nephropathy) and patients with perioperative myopathy are at higher risk of developing myopathy. Statins should be used with caution and the indications should be strictly controlled.
Therefore, taking these drugs should go to the hospital for regular review of liver function, muscle enzymes, etc., and observe for liver pain (watch out for liver damage), muscle pain (watch out for rhabdomyolysis) and other discomforts. If you have any problems, you should seek medical attention in time and take medication under the guidance of a doctor.
Beta blockers-the mainstay
A large number of clinical studies have shown that long-term use of β-blockers is beneficial to patients with coronary heart disease, especially acute myocardial infarction.
Beta-blockers reduce heart rate, weaken myocardial contraction, lower blood pressure, etc., on the one hand, reduce the myocardial demand for blood supply, on the other hand, reduce the load on the heart. It is one of the most important drugs for the treatment of exertional angina and myocardial infarction. First, it is contraindicated for variant angina pectoris, and it needs to be used under the guidance of a doctor. On the other hand, the application of β-blockers can reduce sudden cardiac death in patients with coronary heart disease and myocardial infarction by about 20%.
After acute myocardial infarction, regardless of whether a stent or bypass is done, unless there are contraindications, β-blockers should be taken for a long time. Special attention should be paid to the following situations: ① Chronic heart failure after myocardial infarction; ② Myocardium still remains after myocardial infarction Ischemia, such as angina pectoris, abnormal exercise load test, the coronary artery supplying viable myocardium is still stenosis; ③ patients with arrhythmia; ④ patients with hypertension.
These drugs can cause bradycardia, heart block, induce or aggravate heart failure, induce or aggravate asthma, and can also cause night chest pain.
Therefore, taking these drugs also needs to go to the hospital to review the electrocardiogram regularly, and observe whether there is fatigue, shortness of breath, wheezing, etc. If the patient has fatigue, chest tightness, palpitations (beware of bradycardia, heart block, and Holter if necessary), suffocation after activity (beware of heart failure, and echocardiography if necessary), wheezing (beware of asthma) , Perform bronchial provocation test if necessary), etc., seek medical attention in time, and take medication under the guidance of a doctor.
Other drugs-follow your doctor's advice! This is very important. Everyone is an independent individual. The medications have their own characteristics, and the complications and complications are also different. Therefore, the medications are also different. Many Chinese patent medicines also have many advantages in improving microcirculation. Long-term use can improve Prognosis!
Patients with hypertension and diabetes should use antihypertensive drugs and antidiabetic drugs for a long time to keep blood pressure and blood sugar within the normal range. Among antihypertensive drugs, calcium antagonists, ACEI, and ARB are the first choice. Calcium antagonists can expand coronary in addition to lowering blood pressure. Arteries, prevent coronary artery spasm, the latter two can improve myocardial remodeling in addition to lowering blood pressure and help heart function recovery.
If the coronary artery stenosis is not completely relieved, taking nitrate drugs is also beneficial, which can dilate the coronary arteries and increase the blood supply of the myocardium. The dosage and course of treatment should be determined according to whether the patient has angina and ischemia after the operation. It is generally used after the operation. Isosorbide mononitrate 20～60mg, once or twice a day, helps to control the symptoms of coronary heart disease and also helps prevent coronary artery spasm.
Patients after stent or bypass surgery should keep in mind that they must continue to take the medicine for a long time after the operation. Once the precordial pain or the above-mentioned discomforts occur, they must go to the hospital for examination in time.