Beurrier D, Danchin N
Service de Cardiologie A, Hôpitaux de Brabois, CHU de Nancy, Vandoeuvre.
Presse Med. 1994 Feb 26;23(8):380-4.
Advances in the treatment of the acute phase of myocardial infarction have lead to the need for adequate secondary treatment. beta-blockers have been largely demonstrated to be effective antianginal agents, acting on three determining factors: heart rate, systemic blood pressure and myocardial contractility. Used in secondary prevent treatment, beta-blockers lead to significant improvement in global post-myocardial infarction mortality, reduced from 9.4 to 7.6% and in reinfarction rates, reduced from 7.5 to 5.6%. Prescription of beta-blockers beyond the acute phase is an essential part of secondary prevention. For calcium antagonists however, there is no evidence of improved prognosis after myocardial infarction. There is no improvement in mortality or reinfarction rates. Class I antiarrhythmic drugs are not indicated as systematic treatment after myocardial infarction. Angiotensin converting enzyme inhibitors can reduce long-term mortality and late occurrence of congestive heart failure, particularly in patients with moderate to severe left ventricular dysfunction. Among the anti-thrombotic drugs, oral anticoagulants seem to offer no clear advantage over aspirin. Large trials of anti-arrhythmic agents have failed to demonstrate any clinical benefit in asymptomatic patients with ventricular ectopic beats, and the results of secondary prevention trials using amiodarone are still awaited. Myocardial revascularization using coronary bypass surgery or percutaneous transluminal coronary angioplasty should be proposed mainly in symptomatic patients or in subsets of patients with multi-vessel disease and altered left ventricular function. Finally, rehabilitation measures should be aimed at correcting cardiovascular risk factors and improving physical fitness.
心肌梗死急性期治疗的进展引发了对充分二级治疗的需求。β受体阻滞剂已被充分证明是有效的抗心绞痛药物，作用于三个决定性因素：心率、体循环血压和心肌收缩力。在二级预防治疗中使用β受体阻滞剂可使心肌梗死后总体死亡率显著改善，从9.4%降至7.6%，再梗死率也从7.5%降至5.6%。在急性期过后开具β受体阻滞剂处方是二级预防的重要组成部分。然而，对于钙拮抗剂，没有证据表明其能改善心肌梗死后的预后。死亡率和再梗死率并无改善。I类抗心律失常药物不适合作为心肌梗死后的常规治疗。血管紧张素转换酶抑制剂可降低长期死亡率和充血性心力衰竭的晚期发生率，尤其是在中重度左心室功能不全的患者中。在抗血栓药物中，口服抗凝剂似乎并不比阿司匹林有明显优势。大型抗心律失常药物试验未能证明对无症状室性早搏患者有任何临床益处，使用胺碘酮的二级预防试验结果仍有待观察。主要应对有症状的患者或患有多支血管病变且左心室功能改变的患者亚组采用冠状动脉搭桥手术或经皮腔内冠状动脉成形术进行心肌血运重建。最后，康复措施应旨在纠正心血管危险因素并改善身体素质。
