1. Balancing the Medication Portfolio 5 Years after a Heart Attack COPYRIGHT © 2014, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2014 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.

4. 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

5. 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

6. 61 years old DMI 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 Copyright © 2014

7. Medications (initiated 5 years ago post MI evaluation) Aspirin 325 mg daily Clopidogrel 75 mg daily Metoprolol 50 mg twice daily Enalapril 10 mg daily Statin Joe Copyright © 2014

9. 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. Copyright © 2014

10. 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

11. 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

12. 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

13. 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

14. 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 *Grade: strong recommendation; high-quality evidence. Copyright © 2014

15. 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 *Grade: strong recommendation; high-quality evidence. Copyright © 2014

16. 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

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