balancing the medication portfolio 5 years after a heart attack copyright © 2014, all rights...

Balancing the Medication Portfolio 5 Years after a Heart Attack

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Dear Consult Guys:

Joe is 60 years old and recently relocated to our town. He saw me yesterday for a “new

patient visit” and I am not exactly sure how to proceed.

He has a history of having had a diaphragmatic wall myocardial infarction 5 years ago. The

records indicate that had presented several weeks after an episode of chest pain and was

found to have had an age indeterminant MI. A stress test revealed inferior scar with periscar

ischemia and then coronary angiography was done to define coronary artery anatomy The

records indicate that occlusion of a small right coronary artery was the cause of the MI. There

was no other coronary artery disease. PTCA was not done because it was felt that there was

no further viable myocardium at risk. His left ventricular ejection fraction was 48%.

He was treated with:

•Aspirin (325mg daily)

•Clopidogrel (75 mg daily)

•Metoprolol (50 mg twice daily)

•Enalapril (10 mg daily)

•Statin

He has been maintained on those medications.

Dear Consult Guys:

Joe is 60 years old and recently relocated to our town. He saw me yesterday for a “new

patient visit” and I am not exactly sure how to proceed.

He has a history of having had a diaphragmatic wall myocardial infarction 5 years ago. The

records indicate that had presented several weeks after an episode of chest pain and was

found to have had an age indeterminant MI. A stress test revealed inferior scar with periscar

ischemia and then coronary angiography was done to define coronary artery anatomy The

records indicate that occlusion of a small right coronary artery was the cause of the MI. There

was no other coronary artery disease. PTCA was not done because it was felt that there was

no further viable myocardium at risk. His left ventricular ejection fraction was 48%.

He was treated with:

•Aspirin (325mg daily)

•Clopidogrel (75 mg daily)

•Metoprolol (50 mg twice daily)

•Enalapril (10 mg daily)

•Statin

He has been maintained on those medications.

Copyright © 2014

He has no history of hypertension, diabetes, or hyperlipidemia. His father had a

myocardial infarction at age 50. Joe is a non-smoker.

He leads a very active life, exercises strenuously for 45 minutes a session 5 times per

week. His cardiovascular review of symptoms is negative. He is a financial analyst

specializing in portfolio management.

Exam:

BP 110/60, HR 55, R 16

JVP normal , carotid upstrokes normal without bruit

Lungs clear

S1, S2 normal. No murmur

Bowel sounds normal, abdomen non tender, no organomegaly

Distal pulses intact. No edema

Lipid panel:

Total Cholesterol 160

HDL 50

LDL 90

He has no history of hypertension, diabetes, or hyperlipidemia. His father had a

myocardial infarction at age 50. Joe is a non-smoker.

He leads a very active life, exercises strenuously for 45 minutes a session 5 times per

week. His cardiovascular review of symptoms is negative. He is a financial analyst

specializing in portfolio management.

Exam:

BP 110/60, HR 55, R 16

JVP normal , carotid upstrokes normal without bruit

Lungs clear

S1, S2 normal. No murmur

Bowel sounds normal, abdomen non tender, no organomegaly

Distal pulses intact. No edema

Lipid panel:

Total Cholesterol 160

HDL 50

LDL 90

Copyright © 2014

Joe’s question to me relates to his medications. He asks what medications should he be

taking to decrease the risk of having another myocardial infarction.

In much the way that he rebalances the financial assets of his clients he was me to asses

and rebalance his medical regimen.

There’s a lot at stake here. He has done well on his current regimen and my “gut feeling”

is that I should just continue it. On the other hand any evidence or consensus to direct

this “rebalancing” would be appreciated.

Signed,Concerned Doc

Joe’s question to me relates to his medications. He asks what medications should he be

taking to decrease the risk of having another myocardial infarction.

In much the way that he rebalances the financial assets of his clients he was me to asses

and rebalance his medical regimen.

There’s a lot at stake here. He has done well on his current regimen and my “gut feeling”

is that I should just continue it. On the other hand any evidence or consensus to direct

this “rebalancing” would be appreciated.

Signed,Concerned Doc

61 years oldDMI 5 years ago

Small RCA, no other CAD No revascularization LVEF 48% (reassessed 1 year ago)

Family history of CAD (father age 51)History hyperlipidemia treated

Joe

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Medications(initiated 5 years ago post MI evaluation)

Aspirin 325 mg dailyClopidogrel 75 mg dailyMetoprolol 50 mg twice dailyEnalapril 10 mg dailyStatin

Joe

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Recommendations

Recommendation 17: The organizations recommend that aspirin, 75 to 162 mg daily, should be continued indefinitely in the absence of contraindications in patients with stable IHD

*Grade: strong recommendation; high-quality evidence.

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Medications initiated 5 years ago at time of post MI eval:

Aspirin 325 mg daily 81-162 mg daily

Clopidogrel 75 mg daily

Metoprolol 50 mg twice daily

Enalapril 10 mg daily

Statin

Medications

Copyright © 2014

Freemantle N, Cleland J, Young P, Mason J, Harrison J. β Blockade after myocardial infarction: systematic review and meta regression analysis. BMJ : British Medical Journal

1999; 318:1730-1737.

• Mean follow up only 1.4 years• Median publication date of the 82

trials:1982• Most trials before modern reperfusion

therapy• Most trials before current medical

therapy

Recommendations

Recommendation 20:The organizations recommend that beta blocker therapy should be initiated and continued for 3 years in all patients with normal LV function following MI or acute coronary syndromes

*Grade: strong recommendation; moderate-quality evidence. Recommendation 21: The organizations recommend that

metoprolol succinate, carvedilol, or bisoprolol should be used for all patients with systolic LV dysfunction (ejection fraction <40%) with heart failure or prior MI, unless contraindicated


Copyright © 2014

Recommendations

Recommendation 22: The organizations recommend that ACE inhibitors should be prescribed in all patients with stable IHD who also have hypertension, diabetes, LV systolic dysfunction (ejection fraction <40%), and/or chronic kidney disease, unless contraindicated


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