for the long haul: improving longevity after mi copyright © 2015, all rights reserved from the...
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For the Long Haul:
Improving Longevity After MI
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Stumper
A 65 year old man Anterior wall MI two weeks ago History of diabetesCatheterization revealed occluded LAD40% stenosis of the right coronary Normal coronary arteriesLeft ventricle in the territory of the occluded LAD is
akineticLVEF is 35%He has dyspnea on mild exertion NYHA Class IICopyright © 2015
Patient
In addition to titration of his medical therapy, what other approach should be planned to decrease his long term mortality? DiabeticAnterior MI two weeks ago
LAD occluded, anterior scar, RCA 40% stenosis LV Ejection fraction 35%
NYHA Class IIDoing well
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Which guideline directed medical therapy decreases mortality?
Beta blocker 25% mortality reduction first year
ACE-Inhibitor -benefit especially with LVEF < 40%
Aspirin 75-162 mg indefinitely
P2Y12 platelet receptor antagonist: clopidogrel, prasugrel, ticagrelor
Cholesterol lowering - statinAldosterone antagonist
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Aldosterone antagonists (often forgotten)
They decrease mortality in the following: NYHA class III, IV heart failure and LVEF < 35% NYHA class II HF and LVEF < 30 % Post STEMI, already receiving ACEI, LVEF < 40, and either
symptomatic heart failure or diabetes Start before discharge, mortality benefit if first 30 days Monitor for hyperkalemia
Our patient is diabetic and should receive aldosterone antagonists Needs Influenza vaccination
Guideline Directed Medical Therapy
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What additional therapy can reduce mortality?
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A. CABG or PTCA
B. AICD
C. AICD only if EPS testing inducible ventricular tachycardia.
D. AICD only if repeat echo 40 days post MI reveals LVEF has not improved.
E. Amiodarone
*Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;51(21):e1-e62. doi:10.1016/j.jacc.2008.02.032.
Answer
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D. AICD only if: LVEF has not improved 40 days post MI
ICD implanted per guidelines has been shown to decrease mortality.
LVEF < 35%Defib implanted 6-40 days post MINO difference in overall death
Hohnloser SH et al. Prophylactic Use of an Implantable Cardioverter–Defibrillatorafter Acute MyocardialInfarction N Engl J Med 2004; 351:2481-2488.
Pouleur AC et al. Pathogenesis of Sudden Unexpected Death in a Clinical Trial of Patients With Myocardial Infarction and Left Ventricular Dysfunction,Heart Failure, or Both. Circulation. 2010;122:597-602
Major Cause of Death Early Post MI Recurrent MI or cardiac rupture
Major Cause of Death 3 month Post MI Arrhythmia
Primary Prevention: ICD Implant Errors
< 40 days post MIClass IV CHFLife expectancy less than one yearInadequate medical CHF regimen
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Clinical Pearls
ICDs decrease mortality in patients with ischemic and non-ischemic cardiomyopathy.
Ventricular function may improve following myocardial infarction, ICD implantation should be considered in the patient with cardiomyopathy if : LVEF is < 35% despite maximal medical therapy at least
40 days following myocardial infarction. Recurrent MI and cardiac rupture are common causes of
death during 40 days post MI and not be prevented by ICD. Arrhythmia common cause of death more than 40 days
post MI and that can be reversed by an ICD.
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