Local guidelines for the management of myocardial infarction should be followed where they exist.

These notes give an overview of the initial and long-term management of myocardial infarction. The aims of management are to provide supportive care and pain relief, to promote revascularisation and to reduce mortality. Oxygen, diamorphine and nitrates provide initial support and pain relief; thrombolytics and aspirin promote revascularisation; long-term use of aspirin, beta-blockers, ACE inhibitors and statins help to reduce mortality further.

INITIAL MANAGEMENT. Oxygen  should be administered unless the patient has severe chronic obstructive airways disease.

The pain (and anxiety) of myocardial infarction is managed with slow intravenous injection of diamorphine ; an antiemetic such as metoclopramide (or, if left ventricular function is not compromised, cyclizine) by intravenous injection should also be given
Aspirin (chewed or dispersed in water) is given for its antiplatelet effect; a dose of 150–300 mg is suitable. If aspirin is given prior to arrival at hospital, a note saying that it has been given should be sent with the patient.
Thrombolytic drugs (alteplase, reteplase or streptokinase, are given to patients without contra-indications within 12 hours of a myocardial infarction, ideally within 1 hour; use after 12 hours requires specialist advice. Streptokinase remains the drug of choice although antibodies appear after 4 days and streptokinase should not therefore be used again after this time.
Nitrates  are used to relieve ischaemic pain. If sublingual glyceryl trinitrate is not effective, intravenous glyceryl trinitrate or isosorbide dinitrate is given.
Early intravenous administration of some beta-blockers  has been shown to be of benefit and patients without contra-indications should receive atenolol by intravenous injection at a dose of 5 mg over 5 minutes, and the dose repeated once after 10–15 minutes; metoprolol by intravenous injection is an alternative.
ACE inhibitors  are also of benefit to patients who have no contra-indications; in normotensive patients treatment with an ACE inhibitor can be started within 24 hours of the myocardial infarction and continued for at least 5–6 weeks (see below for long-term treatment).
All patients should be closely monitored for hyperglycaemia; those with diabetes or raised blood-glucose concentration should receive insulin.

LONG-TERM MANAGEMENT. Aspirin  should be given to all patients, unless contra-indicated, at a dose of 75–150 mg daily.

Beta-blockers  should be given to all patients in whom they are not contra-indicated and continued for at least 2–3 years. Acebutolol, metoprolol, propranolol and timolol are suitable.
Although other calcium-channel blockers  have no place in routine management, verapamil may be useful in patients in whom beta-blockers are inappropriate.
ACE inhibitors  are recommended for any patient with evidence of left ventricular dysfunction.
Nitrates  are used for patients with angina.
Statins are beneficial in preventing recurrent coronary events, particularly for patients at high risk because of other factors.