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- Page navigation anchor for Secondary prevention following myocardial infarction: time to consider the immune system?Secondary prevention following myocardial infarction: time to consider the immune system?Isted et al have discussed updated guidelines for the secondary prevention of myocardial infarction (MI), in particular regarding two anti-platelet dugs, the P2Y12 receptor inhibitors ticagrelor and clopidogrel.Recent scientific progress allows a better understanding of the molecular pathophysiology of MI, and the immune system is now understood to play a vital role in the post-infarct tissue repair process. However, excessive inflammation may exacerbate adverse remodelling1,2 and a range of drugs modulating the immune response has been tested for addition to post-MI pharmacotherapy. Several studies, including the CANTOS trial targeting the inflammatory cytokine IL-1, have shown promising effects, especially on the secondary prevention of MI.3Importantly, current standard post-MI pharmacotherapies including P2Y12 receptor inhibitors already affect the immune system. P2Y12 receptors are expressed not only on platelets, but also on leukocytes4 and P2Y12 receptor inhibitors suppress neutrophil degranulation, platelet-leukocyte aggregate formation and pro-inflammatory cytokine expression.5 They thus have an overall immunosuppressive effect that may need to be considered in selected patient groups. Future trials and practice guidelines should therefore take into account the pleiotropic effects of current post-MI medication on the immune system.6...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Response from authors to 'IHD with AF anticoagulation' queryResponse from authors to 'IHD with AF anticoagulation' queryWith regard to Dr Sharvill’s query about co-management of atrial fibrillation, the authors wish to reiterate the importance of an individualised cardiologist-led approach in patients requiring long-term anticoagulation following a myocardial infarction. These patients represent a challenging sub-group in whom the relative risks of potentially catastrophic thromboembolic events must be weighed against a significantly increased bleeding risk. An illustrative ‘triple therapy’ regimen was quoted in our article (aspirin, clopidogrel and warfarin) given that this remains a commonly used combination. Exploring the expanding range of triple therapy regimens was felt to be beyond the scope of this paper given its complexity. Please refer to these excellent resources for more information.1-3 A commonly discussed theme in these reviews is the paucity of high quality evidence to support one regimen over another, particularly with the expanding range of DOACs in use.In response to the second query, NICE guidance states "do not offer people without left ventricular systolic dysfunction or heart failure, who have had an MI more than 12 months ago, treatment with a beta-blocker unless there is an additional clinical indication for a beta-blocker".2 This assessment of systolic function should be based on the echocardiogram performed during the index admission for the myocardial infarction, unless a subseque...Show MoreCompeting Interests: None declared.
- Page navigation anchor for IHD with AF anticoagulationIHD with AF anticoagulation
I am confused. A recent BMJ article on the same subject (atrial fibrillation post ischemic hear disease) advised that after 1 year of dual therapy with anticoagulant and anti-platelets the anti-platelet should be stopped.1 European cardiovascular society also advises DOAC over warfarin for af so this article advising clopidogrel and warfarin for life confuses me. Less importantly perhaps the recommendation on the use of B Blockers perhaps could be expanded. Annual review is recommended in the BMJ article but sadly this may less common in the UK health system where secondary care has discharged the patient and primary care seems not always to be organised or perhaps funded to take this on. Should all patients have an echo at 1 year and if normal systolic function then stop beta-blockers?
Reference1. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2016;134:e123-55. doi:10.1161/CIR.0000000000000404.Competing Interests: None declared.