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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 diabetes
 Catheterization revealed occluded LAD
 40% stenosis of the right coronary
 Normal coronary arteries
 Left ventricle in the territory of the occluded LAD is
akinetic
 LVEF is 35%
 He has dyspnea on mild exertion
 NYHA Class II
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Patient
In addition to titration of his medical therapy, what other
approach should be planned to decrease his long term
mortality?
 Diabetic
 Anterior MI two weeks ago
 LAD occluded, anterior scar,
 RCA 40% stenosis
 LV Ejection fraction 35%
 NYHA Class II
 Doing 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 - statin
 Aldosterone antagonist
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Guideline Directed Medical Therapy
 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
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What additional therapy can reduce mortality?
A.
B.
C.
D.
E.
CABG or PTCA
AICD
AICD only if EPS testing inducible ventricular tachycardia.
AICD only if repeat echo 40 days post MI reveals LVEF
has not improved.
Amiodarone
Copyright © 2015
*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
D. AICD only if:
 LVEF has not improved
 40 days post MI
ICD implanted per guidelines has been shown to
decrease mortality.
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LVEF < 35%
Defib implanted 6-40 days post MI
NO difference in overall death
Hohnloser SH et al. Prophylactic Use of an Implantable Cardioverter–Defibrillatorafter Acute Myocardial
Infarction N Engl J Med 2004; 351:2481-2488.
 Major Cause of Death Early Post MI
 Recurrent MI or cardiac rupture
 Major Cause of Death 3 month Post MI
 Arrhythmia
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
Primary Prevention: ICD Implant Errors
 < 40 days post MI
 Class IV CHF
 Life expectancy less than one
year
 Inadequate 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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