1 / 20

Risk stratification and secondary prevention following acute myocardial infarction

Risk stratification and secondary prevention following acute myocardial infarction. In-Ho Chae Department of Internal Medicine Seoul National University Hospital. CAD – risk stratification in general. Symptom Past medical history Physical finding Rest 12-lead ECG Echocardiography

justis
Download Presentation

Risk stratification and secondary prevention following acute myocardial infarction

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Risk stratification and secondary prevention following acute myocardial infarction In-Ho Chae Department of Internal Medicine Seoul National University Hospital

  2. CAD – risk stratification in general • Symptom • Past medical history • Physical finding • Rest 12-lead ECG • Echocardiography • Stress test • Exercise treadmill test • Dipyridamole Tl/MIBI-Tc myocardial SPECT • Dobutamine stress EchoCG • Myocardial enzyme

  3. Risk at initial presentation of AMI • Clinical parameters • Female • Old age ( >70 yrs) • DM • Prior angina pectoris or previous MI • EKG • Anterior wall MI • Inferior wall MI with RV infarction • ST change: multiple leads or high sum • High grade block: > type 2 Morbitz, IVCD

  4. Risk factors at initial presentation

  5. Risk during hospital course • Recurrent ischemia • Postinfarction angina • Reinfarction • Silent ischemia • ECK change • Holter monitoring • Non-Q-wave AMI • Initial manif.: non-ST or ST elevation ACS • Same as Q-wave AMI

  6. Risk at hospital discharge • Prognostic factors for short- & long-term survival • Resting LV function • Residual ischemic myocardium • Susceptibility to serious ventricular arrhythmia • Ventricular ectopic activity, electrical instability • Patency of infarct-related artery • Dx; EchoCG, stress test, EKG, CAG, etc

  7. High risk following AMI • Consider aggressive management • Recurrent ischemia at rest • CHF or LV EF < 40% • Sustained VT or VF >48 h post-MI • Not high risk • Stress test: exercise ECG, RI scan

  8. Echocardiography following AMI • Evaluating • Infarct size • Regional wall motion abnormality • Global LV function • Complication: MR, aneurysm, thrombi, pericardial effusion • Stress test • Dobutamine stress EchoCG: viability test

  9. Stress test following AMI • Predischarge test for uncomplicated AMI • Risk stratification of post-MI: prognosis • Functional capacity • Efficacy of current medication • Image: ECG, radionuclide scan, EchoCG • Stress: exercise, vasodilator, dobutamine

  10. Exercise ECG following AMI • Before discharge • Submaximal exercise (5 mets): 4-6 days • Symptom-limited exercise: 10-14 days • Early after discharge • 14-21 days • Late after discharge • 3-6 weeks after AMI • Low risk or inadequate test at discharge

  11. Myocardial SPECT following AMI • RI Scan > exercise ECG • Pre-excitation • Pacemaker rhythm • LBBB or LVH • >1mm ST change in resting ECG • RCA lesion

  12. Assessment for electrical instability • High risk of sudden cardiac death after AMI • QT dispersion: variability of QT interval • Holter: ventricular arrhythmia • EPS • Signal-averaged ECG: delayed fragmented conduction • Heart rate variability: beat-to-beat variability of RR interval • Baroreflex sensitivity

  13. Secondary prevention of AMI • Life style modification • Lipid modification • Antiplatelet agent • ACE inhibitor • Beta-adrenoreceptor blocker • Antiarrhythmic • Anticoagulant, nitrate, calcium antagonist • Hormone replacement therapy

  14. Life style and lipid modification • Stop smoking • Blood pressure control • Lipid risk • LDL > 100 mg/dl • HDL < 40 mg/dl • Statin: 30-40% reduction of cardiac mortality CARE, 4S • Niacin or gemfibrozil : TG & HDL !!

  15. Cardiovascular drugs -1 • Antiplatelet agents • 25% reduction of recurrent infarction, stroke, vascular death • Aspirin, clopidogrel >> ticlopidine • ACE inhibitor • Prevent ventricular remodeling • Decrease recurrent ischemia, arrhythmia, CHF • Ix; CHF, EF < 40%, RWMA

  16. Cardiovascular drugs -2 • Beta blocker • 20% reduction of long-term mortality • Early therapy < 6 hr of AMI • Calcium channel blocker • Not routine • Contraindication of beta blocker: asthma etc - diltiazem, verapamil • Nitrate • Not routine

  17. Cardiovascular drugs -3 • Anticoagulants • Not routine; even combination with aspirin • Ix: DVT, PTE, mural thrombi, large RWMA, Af, Hx of embolic CVA • Hormone replacement therapy • Not indicated in secondary prevention: HERS • Can be continue in case of primary prevention • Antioxidant • Not indicated

  18. Cardiovascular drugs –4 • Antiarrhythmic therapy • Class I: no role • Calss II: beta blocker – beneficial • Class III • D,I-sotalol: possible benefit • Dexsotalol: increase incidence of arrhythmia • Amiodarone: reduce mortality • Class IV • DHP - Nifedipine: maybe harmful ? • Non-DHP diltiazem: beneficial

  19. Drugs for secondary prevention of AMI • Aspirin • Statin • Beta blocker • ACE inhibitor • Proper antiarrhythmics as indicated • Life style modification

More Related