[Secondary prophylaxis after myocardial infarction, bypass surgery and percutaneous coronary intervention].

Patients who have sustained a myocardial infarction as well as patients treated with percutaneous coronary intervention or coronary bypass surgery have atherosclerotic coronary artery disease. They will need aggressive secondary prophylaxis, including modification of lifestyle risk factors. Most of these patients should be treated with statins. As clinical events often are manifestations of thrombotic complications, this patient group should be treated with platelet inhibition, anticoagulation, or both. After a myocardial infarction patients should be considered for anticoagulant treatment, for acetylsalicylic acid, or both. After coronary revascularisation acetylsalicylic acid should be considered primarily. If acetylsalicylic acid is contraindicated, clopidogrel is an alternative. After coronary stenting acetylsalicylic acid and clopidogrel should be prescribed combined, for up to one year afterwards. If indicated, anticoagulant treatment can be added to platelet inhibition. After bypass surgery, anticoagulation is equally effective as acetylsalicylic acid against graft occlusion and can be given alone if indicated. International Normalized Ratio can be aimed at 3.0 when anticoagulation is given alone, at 2.0-2.5 when combined with platelet inhibition. After a myocardial infarction patients should be given a beta-blocker if this is not strongly contraindicated and they also should be considered for ACE inhibitor treatment. These patients also seem to profit from a moderate supplement of n-3 polyunsaturated fatty acids.