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Treatment of The Post- Myocardial Infarction Patient

The goal of primary prevention is to keep the patient from developing coronary artery disease or having a myocardial infarction. Once they’ve had a myocardial infarction, we want to prevent them from having a second myocardial infarction and prevent them from developing end stage heart disease, sudden death or ventricular dilatation and

You’ve heard a little bit about the intervention index in the previous talk and I’m going to spend some time talking about the intervention index as well, on secondary prevention. I think it’s very important to remember that there’s two areas that we can address. One is the basic cardiac risk factors, and I think they are also important in the patient who has already had an MI. I’m not going to talk about all of that, but there’s a fair amount of data with regards to some of the risk factors, such as smoking cessation. You’ve heard a lot about lipid management and I’ll briefly mention it again. Hypertension control. An area I’m not going to spend a lot of time on, but diabetes management becomes very important in these patients. The better control we can have our diabetics, the better we can impact upon their subsequent mortality. There’s been some very good data out there that better control decreases complication, including areas like re-infarction. We’ll talk a little bit about these other areas as well, and then spend most of my time really talking about the cardio-protection area because that’s where we have myocardial infarction, heart attack, heart atack, miocardial

Unfortunately I didn’t provide a handout either and the reason being that my secretary didn’t give it to me, but if you really want to make a note of important information, if you just copy down the cardio-protective areas that I talk about and the cardiac risk factor areas that are here, make yourself a check list. Every time you see a patient who has coronary disease or has an MI and you check off and make sure all these areas are addressed, you get the

Being a preventive and rehabilitative cardiologist, cardiac rehabilitation is an important aspect, I think, in the post MI patient’s care and it’s one that’s often forgotten. Cardiac rehabilitation is really a process where we try to take the patient and restore or maintain their optimal physiological, psychological, social, vocational and emotional status. We really try to get them back to being a whole person with a good quality of life. Most people though think that cardiac

Now, why do I even talk about cardiac rehabilitation? Well, there’s some very good data that was published in the late 80’s, early 90’s, in two meta-analyses. One was done in circulation and one was published in JAMA. One was

Morbidity and mortality data was all that was there and it was only primarily in MI patients. Great for today’s talk but might not be good if I were talking about a post-angina patient or a post-bypass patient. Most of it was done in the pre-thrombolytic era, and nowadays if we treat a MI patient who comes in the door with thrombolytic therapy, what we find is we can reduce their mortality at 30 days and one year somewhere around 6% or 7%, depending on

There’s overall substantial benefits, improvement in exercise tolerance, improvement in symptoms, improvement in blood lipid levels, reduction in cigarette smoking. I’m not going to spend a lot of time talking about cigarette smoking. Again, there’s great data out there that one of the biggest impacts we can have on decreasing one year

Other risk factors that may be important: blood pressure treatment is an important therapy that needs to be done. This is from the recent JNC VI. If you haven’t gotten recent update on the hypertension guidelines, they are very important to get because there have been some changes in how aggressive we need to be in the treatment of our patients, in a primary prevention perspective as well as a secondary prevention perspective. What I wanted to show here is that in fact the recommendations currently are that we use drug therapy in even patients who have high

I mentioned briefly, on that other slide, behavioral intervention and this is kind of a summary of a number of behavioral studies that have been done in post MI patients and you can see down here at the bottom, in a meta-analysis way that there’s a benefit in having some type of behavioral intervention in reducing no-fatal MI’s as well as cardiovascular mortality in our patients. One thing we really forget about our patients is that after a myocardial infarction, heart attack, heart atack, miocardial

Now I was going to spend a little bit of time talking about lipids but you guys have been overwhelmed and know that lipids are the only thing that’s important with regard to cardiovascular disease and primary prevention. That’s really not the case. I think that there’s a lot more that’s important in primary prevention than just lipid therapy. I think it’s one of the key factors, but I think that treating blood pressure, addressing other issues in primary prevention is important. I think that lipids are also an important factor in secondary prevention, as you’ve already heard. One of the largest trials done in secondary prevention was the 4S or the Scandinavian Simvastatin Survival Study, and as

What’s very interesting is that you often get the question, "Okay, lipids were great but what about some of the other therapies that we have for secondary prevention?" , as I’m going to talk about. I put this slide early on just to show you that in fact a lot of these benefits that we see, as least in cholesterol reduction, are there whether we have