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When should ACE inhibitors or warfarin be discontinued after myocardial infarction?
  1. SUSAN E WIEGERS,
  2. MARTIN ST JOHN SUTTON
  1. Hospital of the University of Pennsylvania
  2. 3400 Spruce Street, 9 E Gates Pavilion
  3. Philadelphia, PA 19104, US
  4. email: suttonm@mail.med.upenn.edu

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In the current climate of cost containment, discontinuation of medications shown to have efficacy has taken on an urgency that may not appear appropriate to the individual clinician when applied to the individual patient. However, it is often in the patient's best interest to decrease the number of medications prescribed. Following a myocardial infarction, patients are usually discharged on multiple medications including β adrenergic receptor blockers, angiotensin converting enzyme (ACE) inhibitors, aspirin, and lipid lowering agents. Polypharmacy is a national health issue that increases the risk of medication errors in formulation or dosage by the prescriber, the pharmacist or the patient, and increases the likelihood of drug interaction. Polypharmacy also decreases patient compliance with the medical regimen.1 ,2 Cost is a factor for many patients and one that may be underappreciated by physicians. In addition, no drug is without side effects. Discontinuation of a medication removes the possibility of untoward side effects, although at the same time eliminates the possibility of any further therapeutic benefit. It is this risk benefit analysis that must be applied to each patient's situation to determine appropriate pharmacotherapy. Hitherto, no studies have specifically addressed the appropriate timing for discontinuation of ACE inhibitors or warfarin after myocardial infarction, nor are any likely to be performed in the future. Thus these recommendations are necessarily speculative and rely on inferences drawn from the large clinical trials, as well as on of the natural history of ventricular remodelling and thrombus formation.

The case for ACE inhibitors

The case for ACE inhibition after myocardial infarction appears ironclad. A large meta-analysis established the efficacy of early administration with oral ACE inhibitors in the treatment of unselected patients with acute myocardial infarction.3 A 7% relative reduction in 30 day mortality was observed, with the higher risk …

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