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Guideline Appraisal: Management of Myocardial Infarction with Aspirin and Clopidogrel.

Management of Myocardial Infarction with Aspirin and Clopidogrel
 
A clinical guideline is a well laid down framework guiding clinical practice in a specific clinical situation (DiCenso, Guyatt, & Ciliska, 2005; Sackett et al, 2000). Usually guidelines are developed for the management of specific health problems. For instance, the American Heart Association/American College of Cardiology often develops guidelines for the management of cardiovascular disorders. The purpose of this paper is to appraise the clinical guidelines for the management of myocardial infarction provided by the American college of cardiology/American heart association.
Objectives or purpose of the clinical guidelines
The name of the guideline is: ACC/AHA guidelines for the management of ST- elevation myocardial infarction. The present guideline is an update of a previous guideline done by the same authors and published by the same organization in 2004. The purpose of the present manual guideline is to pay special attention to the successful progressions that have been made since on the advances that have made since 1999 “regarding diagnosis and management of patients with ST- elevation myocardial infarction” (DiCenso, Guyatt, & Ciliska, 2005; Sackett et al, 2000).
The 2004 guideline objectives were;

To help physicians and other healthcare providers in clinical decision making by describing desirable steps to follow in terms of diagnosis, management, and prevention of ST-elevation myocardial infarction (STEMI).
To lay emphasis on the advances that have made since 1999 regarding diagnosis and management of patients with ST- elevation myocardial infarction.

The guidelines are meant for the management of adults with ST-elevation myocardial infarction (STEMI), and adults at risk of ST-elevation myocardial infarction (STEMI).
Task force that put forward the guidelines
These guidelines were put forward by the ACC/AHA task force on practice guidelines and jointly published by the AHA and ACC.
Peer review
The current guidelines have been subjected to rigorous vetting by both internal and external peer reviewers. In addition the acc and aha do not accept funding from any external sources. This enhances the credibility of the findings and recommendations (Trochim, 2001). All the guideline developers were required to declare their relationship with industry. This ensures that participants are not overly biased when formulating the recommendations.
The reviews were done as follows;

Three outside reviewers nominated by the AHA
Three outside reviewers nominated by the ACC
One reviewer representing the American academy of family physicians
One reviewer from the Canadian cardiovascular society
58 content reviewers

Practical clinical recommendations provided on management of myocardial infarction with
aspirin and clopidogrel.
For pre-hospital management of STEMI using aspirin the following recommendations were made;

Administer 162 to 325 mg of aspirin (chewed) to patients who present with chest pain and are suspected to have STEMI paying attention to its contraindications.
While awaiting pre-hospital emergency service providers to arrive, community level health care providers should advice the patient suspected to have STEMI to chew 162 to 325 mg of aspirin
Pre-hospital EMS providers should administer 162 to 325 mg of aspirin (chewed) to chest pain patients suspected

Recommendations for treatment with clopidogrel

Start clopidogrel and continue for at least one month in patients undergoing diagnostic cardiac catheterization
Clopidogrel (75 mg per day) should be combined with aspirin once a diagnosis of STEMI has been made (therapy should last for at least 14 days) regardless of whether reperfusion therapy will be instituted or not.
If CABG is planned, withhold clopidogrel unless the benefit of revascularization is deemed greater than the risk of bleeding.
Clopidogrel may be administered to patients undergoing fibrinolytic therapy and are allergic to aspirin
Administer a loading dose of 300mg to patients who are over 75years who are receiving fibrinolytic therapy.

Benefits versus risks
The benefits obtained from aspirin and clopidogrel therapy may be greater than the risk of excessive bleeding in some situations. However, in some situations the evidence put forward is based on expert opinion only. In the absence of data from multiple randomized clinical trials, some guidelines should be applied cautiously to individual clinical situations (Grace, 2006; Hayward, Wilson, Tunis, Bass, Guyatt, 2006).

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