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Q & A With the Expert on: Coronary Artery Disease Management of an Older Person With Unrecognized Q-Wave Myocardial Infarctio

ISSN: 1524-7929 VOLUME: 16 PUBLICATION DATE: Jun 01 2008

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Wilbert S. Aronow, MD

Q: A 73-year-old asymptomatic woman with no history of myocardial infarction (MI) is seen by her physician. She is a nonsmoker. Her blood pressure is 150/80 mm Hg. Her heart rhythm is regular with a ventricular rate of 82 beats per minute. Her body mass index is 25 kg/m². Her physical examination is normal except for her blood pressure.

A routine electrocardiogram shows evidence of an old anterior wall MI not present on a routine electrocardiogram obtained 1 year previously. A 2-dimensional echocardiogram shows a left ventricular ejection fraction (LVEF) of 39%. Her complete blood count, fasting blood sugar, and estimated glomerular filtration rate are normal. Her serum lipids show a total cholesterol of 194 mg/dL, a serum low-density lipoprotein (LDL) cholesterol of 120 mg/dL, a serum high-density lipoprotein (HDL) cholesterol of 50 mg/dL, and serum triglycerides of 120 mg/dL. She is not taking any medications.

How should this patient be treated?

A: The prevalence of an unrecognized Q-wave MI in older persons detected by a routine electrocardiogram in ten studies1 varied from 21%²to 68%³ of Q-wave MIs. In six studies, the incidence of new coronary events including recurrent MI, ventricular fibrillation, and sudden cardiac death in persons with unrecognized Q-wave MI was similar to (5 studies) or higher than (1 study) in persons with recognized Q-wave MI.^1,4,5

Therefore, postinfarction patients with unrecognized Q-wave MI should be treated similarly to postinfarction patients with recognized Q-wave MI.

Coronary risk factors must be treated intensively in older persons with prior MI.^6,7 The woman in the case above has isolated systolic hypertension, which should be treated with a low-salt diet and with a beta blocker plus an angiotensin-converting enzyme (ACE) inhibitor to reduce the systolic blood pressure to less than140 mm Hg.^6,8,9 If she had diabetes mellitus or chronic renal insufficiency, her systolic blood pressure should be reduced to less than 130 mm Hg.^6,8

This woman also has a high LDL cholesterol, which must be treated with a low-cholesterol, low-saturated-fat diet, and with a statin. Her serum LDL cholesterol must be reduced to less than 100 mg/dL, and optimally to less than 70 mm Hg.^6,7,10-12

Postinfarction patients should be treated with an antiplatelet drug, preferably low-dose aspirin.^6,7,13-15 I recommend using a 81-mg daily dose of aspirin since this dose has similar efficacy in reducing cardiovascular events and mortality to higher doses of aspirin with less bleeding.¹³

Postinfarction patients should be treated with a beta blocker (metoprolol, carvedilol, propranolol, or timolol) and an ACE inhibitor to reduce cardiovascular events and mortality, especially if the patient has a reduced left ventricular ejection fraction (LVEF), as this woman has.^6,7,9,16-23 This woman needs to be treated with a beta blocker plus an ACE inhibitor because she has a prior MI, a reduced LVEF, and isolated systolic hypertension.

Finally, this asymptomatic older woman should have a treadmill stress test, especially because of her reduced LVEF, since she is at increased risk for cardiovascular events and mortality.^1,7 If she has stress test–induced myocardial ischemia, further investigation is indicated.^1,7

The treadmill stress test should be performed before starting a physical exercise
program.^1,6,7,24 Influenza immunization with inactivated vaccine administered intramuscularly is recommended as part of secondary prevention in persons with coronary artery disease or other atherosclerotic vascular disease.^6,25

References:

References 1. Aronow WS, Fleg JL. Diagnosis of coronary heart disease in the elderly. In: Aronow WS, Fleg JL, Rich MW, eds. Cardiovascular Disease in the Elderly. 4th ed. New York, NY: Informa Healthcare; 2008:243-267. 2. Aronow WS. Prevalence of presenting symptoms of recognized acute myocardial infarction and of unrecognized healed myocardial infarction in elderly patients. Am J Cardiol 1987;60:1182. 3. Aronow WS, Starling L, Etienne F, et al. Unrecognized Q-wave myocardial infarction in patients older than 64 years in a long-term healthcare facility. Am J Cardiol 1985;56:483. 4. Aronow WS. New coronary events at four-year follow-up in elderly patients with recognized or unrecognized myocardial infarction. Am J Cardiol 1989;63:621-622. 5. Nadelmann J, Frishman WH, Ooi WL, et al. Prevalence, incidence, and prognosis of recognized and unrecognized myocardial infarction in persons aged 75 years or older: The Bronx Aging Study. Am J Cardiol 1990;66:533-537. 6. Smith SC Jr, Allen J, Blair SN, et al; ACC/AHA; National Heart, Lung, and Blood Institute. ACC/AHA guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: Endorsed by the National Heart, Lung, and Blood Institute [published correction appears in Circulation 2006;113(22):e847]. Circulation 2006;113(19):2363-2372. 7. Aronow WS. Management of the older patient after myocardial infarction. In: Aronow WS, Fleg J, Rich MW, eds. Cardiovascular Disease in the Elderly. 4th ed. New York, NY: Informa Healthcare; 2008:327-349. 8. Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report [published correction appears in JAMA 2003;290(2):197]. JAMA 2003;289(19):2560-2572. Published Online: May 14, 2003. 9. Aronow WS, Ahn C. Incidence of new coronary events in older persons with prior myocardial infarction and systemic hypertension treated with beta blockers, angiotensin-converting enzyme inhibitors, diuretics, calcium antagonists, and alpha blockers. Am J Cardiol 2002;89:1207-1209. 10. Grundy SM, Cleeman JI, Merz CN, et al; National Heart, Lung, and Blood Institute; American College of Cardiology Foundation; American Heart Association. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines [published correction appears in Circulation 2004;110(6):763]. Circulation 2004;110(2):227-239. 11. Aronow WS, Ahn C. Incidence of new coronary events in older persons with prior myocardial infarction and serum low-density lipoprotein cholesterol ≥125 mg/dL treated with statins versus no lipid-lowering drug [published correction appears in Am J Cardiol 2002;89(12):1452]. Am J Cardiol 2002;89(1):67-69. 12. Deedwania P, Stone PH, Bairey Merz CN, et al. Effects of intensive versus moderate lipid-lowering therapy on myocardial ischemia in older patients with coronary heart disease. Results of the Study Assessing Goals in the Elderly (SAGE). Circulation 2007;115:700-707. Published Online: February 5, 2007. 13. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients[published correction appears in BMJ 2002;324(7330):14]. BMJ 2002;324(7329):71-86. 14. Krumholz HM, Radford MJ, Ellerbeck EJ, et al. Aspirin for secondary prevention after acute myocardial infarction in the elderly: Prescribed use and outcome. Ann Intern Med 1996;124:292-298. 15. Aronow WS, Ahn C. Reduction of coronary events with aspirin in older patients with prior myocardial infarction treated with and without statins. Heart Dis 2002;4:159-161. 16. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. Heart Outcomes Prevention Evaluation Study Investigators [published corrections appear in N Engl J Med 2000;342(18):1376; N Engl J Med 2000;342(10):748]. N Engl J Med 2000;342:145-153. 17. Fox KM; EURropean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: Randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 2003;362:782-788. 18. Gundersen T, Abrahamsen AM, Kjekshus J, Ronnevik PK. Timolol-related reduction in mortality and reinfarction in patients ages 65-75 years surviving acute myocardial infarction. Prepared for the Norwegian Multicentre Study Group. Circulation 1982;66:1179-1184. 19. Beta-Blocker Heart Attack Trial Research Group. A randomized trial of propranolol in patients with acute myocardial infarction. JAMA 1982;247:1707-1714. 20.Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: The CAPRICORN randomised trial. Lancet 2001;357:1385-1390. 21. Aronow WS, Ahn C, Kronzon I. Effect of beta blockers alone, of angiotensin-converting enzyme inhibitors alone, and of beta blockers plus angiotensin-converting enzyme inhibitors on new coronary events and on congestive heart failure in older persons with healed myocardial infarcts and asymptomatic left ventricular systolic dysfunction. Am J Cardiol 2001;88:1298-1300. 22. Aronow WS, Ahn C. Effect of beta blockers on incidence of new coronary events in older persons with prior myocardial infarction and diabetes mellitus. Am J Cardiol 2001;87:780-781, A8. 23. Aronow WS, Ahn C. Effect of beta blockers on incidence of new coronary events in older persons with prior myocardial infarction and symptomatic peripheral arterial disease. Am J Cardiol 2001;87:1284-1286. 24. Aronow WS. Exercise therapy for older persons with cardiovascular disease. Am J Geriatr Cardiol 2001;10:245-252. 25. Davis MM, Taubert K, Benin AL, et al;American Heart Association; American College of Cardiology; American Association of Cardiovascular and Pulmonary Rehabilitation; American Association of Critical Care Nurses; American Association of Heart Failure Nurses; American Diabetes Association; Association of Black Cardiologists, Inc; Heart Failure Society of America; Preventive Cardiovascular Nurses Association; American Academy of Nurse Practitioners; Centers for Disease Control and Prevention and the Advisory Committee on Immunization. Influenza vaccination as secondary prevention for cardiovascular disease: A science advisory from the American Heart Association/American College of Cardiology [published correction appears in J Am Coll Cardiol 2006;48(12):2610. J Am Coll Cardiol 2006;48(7):1498-1502. Published Online September 15, 2006.

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