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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 theyíve 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.

Youíve heard a little bit about the intervention index in the previous talk and Iím going to spend some time talking about the intervention index as well, on secondary prevention. I think itís very important to remember that thereís 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. Iím not going to talk about all of that, but thereís a fair amount of data with regards to some of the risk factors, such as smoking cessation. Youíve heard a lot about lipid management and Iíll briefly mention it again. Hypertension control. An area Iím 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. Thereís been some very good data out there that better control decreases complication, including areas like re-infarction. Weíll 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 thatís where we have myocardial infarction.

Unfortunately I didnít provide a handout either and the reason being that my secretary didnít 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.

Being a preventive and rehabilitative cardiologist, cardiac rehabilitation is an important aspect, I think, in the post MI patientís care and itís one thatís 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.

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

Morbidity and mortality data was all that was there and it was only primarily in MI patients. Great for todayís 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%.

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

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 havenít 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.

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 thereís a benefit in having some type of behavioral intervention in reducing no-fatal MIís as well as cardiovascular mortality in our patients. One thing we really forget about our patients is that after a myocardial infarction.

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 thatís important with regard to cardiovascular disease and primary prevention. Thatís really not the case. I think that thereís a lot more thatís important in primary prevention than just lipid therapy. I think itís 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 youíve already heard. One of the largest trials done in secondary prevention was the 4S or the Scandinavian Simvastatin Survival Study.