Practical guidelines for treatment with beta-blockers and nitrates in patients with acute myocardial infarction

Treatment of a patient with myocardial infarction might include opiates and sedatives to reduce pain and anxiety, heparin, antiarrhythmic drugs, diuretics which aim at improvement of myocardial function and drugs which might reduce the ischemic area at risk and thus mortality such as beta-blockers, vasodilators and possibly calcium antagonists. Obviously a selection of these and other therapeutic agents should be made for each individual patient. Guidelines for such a selection are presented in this paper. These are based on assessment of the hemodynamic state in a given patient: heart rate, blood pressure and presence or absence of heart failure as determined by non-invasive examination or by hemodynamic monitoring with a pulmonary artery catheter. An attempt should be made to reach an optimal hemodynamic state quickly, preferably within one hour of admission to the coronary care unit: a heart rate between 60 and 80 b.p.m., a systolic blood pressure between 100 and 140 mmHg and absence of signs of heart failure. For this purpose fast-acting intravenous drugs should be employed. Possibly myocardial preservation could also be achieved by prompt recanalization of an occluded coronary artery. At present, however, this is still an experimental procedure which should be further investigated.