title: Improving the management of patients after myocardial infarction, from admission to discharge.
abstract: BACKGROUND
  Recent developments in pharmacologic and device therapy, as well as initiatives to increase the use of standard orders and promote in-hospital communication, have improved the care of patients with myocardial infarction (MI). The increased presence of hospitalists, physicians who provide in-hospital care as a specialty, promises to provide further improvements.
  
  
  OBJECTIVE
  This article reviews current information on evidence-based care of the hospitalized MI patient, with a particular emphasis on identifying left ventricular dysfunction (LVD) and appropriate treatments.
  
  
  METHODS
  MEDLINE was searched for all large-scale clinical trials providing information on the care of post-MI patients with or without LVD and/or heart failure (HF), with no limit on time period. The search terms were post-myocardial infarction, large-scale, randomized, clinical trial, left ventricular dysfunction, and/or heart failure. All trials investigating therapies currently recommended in the American College of Cardiology/American Heart Association ST-elevation MI (ACC/AHA STEMI) guidelines and including post-MI patients with or without LVD and/or HF, as indicated by signs and symptoms of HF or Killip class, were included.
  
  
  RESULTS
  In the acute setting, the ACC/AHA STEMI guidelines recommend the use of aspirin, clopidogrel, beta-blockers, angiotensin-converting enzyme inhibitors, heparin (low molecular weight or unfractionated), and glycoprotein IIb/IIIa inhibitors (if the patient is undergoing a percutaneous coronary intervention). The guidelines recommend use of aldosterone antagonists and statins at discharge, in addition to continuation of all acute therapies. The ACC/AHA guidelines apply to all patients after MI and do not specify whether the recommended therapies are effective in post-MI patients with LVD or HE Reviewing the trials that included post-MI patients with LVD and/or HF, it appears that in some cases, only certain agents within a class have been evaluated (eg, post-MI beta-blocker trials often excluded patients with LVD, and the efficacy of atenolol has not been evaluated in post-MI patients with LVD or HF), and some agents have not shown as much efficacy as others in this high-risk patient population (eg, metoprolol appeared to be associated with poorer outcomes in this population than carvedilol). Rather than recommending an entire class, hospital care maps and critical-care pathway tools should incorporate the use of evidence-based agents.
  
  
  CONCLUSIONS
  The use of evidence-based care in the hospital has the potential to substantially reduce morbidity and mortality in post-MI patients with LVD and/or HE The hospitalist can facilitate the best practices and best care of the post-MI patient through the use of in-hospital critical-care pathway tools.
authors.affiliation: Department of Medicine, Univeristy of California Irvine Medical Center, USA. anamin@uci.edu
authors.forename: Alpesh
authors.initials: A
authors.lastname: Amin
mesh_terms: D003266:Continuity of Patient Care; D006801:Humans; D009203:Myocardial Infarction / Q000628:therapy*; D010343:Patient Admission; D010351:Patient Discharge; D011787:Quality of Health Care