1. Risk stratification and secondary prevention following acute myocardial infarction In-Ho Chae Department of Internal Medicine Seoul National University Hospital

2. CAD – risk stratification in general Symptom Past medical history Physical finding Rest 12-lead ECG Echocardiography Stress test Exercise treadmill test Dipyridamole Tl/MIBI-Tc myocardial SPECT Dobutamine stress EchoCG Myocardial enzyme

3. Seoul National University Hospital Risk at initial presentation of AMI Clinical parameters Female Old age ( >70 yrs) DM Prior angina pectoris or previous MI EKG Anterior wall MI Inferior wall MI with RV infarction ST change: multiple leads or high sum High grade block: > type 2 Morbitz, IVCD

4. Seoul National University Hospital Risk factors at initial presentation

5. Seoul National University Hospital Risk during hospital course Recurrent ischemia Postinfarction angina Reinfarction Silent ischemia ECK change Holter monitoring Non-Q-wave AMI Initial manif.: non-ST or ST elevation ACS Same as Q-wave AMI

6. Seoul National University Hospital Risk at hospital discharge Prognostic factors for short- & long-term survival Resting LV function Residual ischemic myocardium Susceptibility to serious ventricular arrhythmia Ventricular ectopic activity, electrical instability Patency of infarct-related artery Dx; EchoCG, stress test, EKG, CAG, etc

7. Seoul National University Hospital High risk following AMI Consider aggressive management Recurrent ischemia at rest CHF or LV EF < 40% Sustained VT or VF >48 h post-MI Not high risk Stress test: exercise ECG, RI scan

8. Seoul National University Hospital Echocardiography following AMI Evaluating Infarct size Regional wall motion abnormality Global LV function Complication: MR, aneurysm, thrombi, pericardial effusion Stress test Dobutamine stress EchoCG: viability test

9. Seoul National University Hospital Stress test following AMI Predischarge test for uncomplicated AMI Risk stratification of post-MI: prognosis Functional capacity Efficacy of current medication Image: ECG, radionuclide scan, EchoCG Stress: exercise, vasodilator, dobutamine

10. Seoul National University Hospital Exercise ECG following AMI Before discharge Submaximal exercise (5 mets): 4-6 days Symptom-limited exercise: 10-14 days Early after discharge 14-21 days Late after discharge 3-6 weeks after AMI Low risk or inadequate test at discharge

11. Seoul National University Hospital Myocardial SPECT following AMI RI Scan > exercise ECG Pre-excitation Pacemaker rhythm LBBB or LVH >1mm ST change in resting ECG RCA lesion

12. Seoul National University Hospital Assessment for electrical instability High risk of sudden cardiac death after AMI QT dispersion: variability of QT interval Holter: ventricular arrhythmia EPS Signal-averaged ECG: delayed fragmented conduction Heart rate variability: beat-to-beat variability of RR interval Baroreflex sensitivity

13. Seoul National University Hospital

14. Secondary prevention of AMI Life style modification Lipid modification Antiplatelet agent ACE inhibitor Beta-adrenoreceptor blocker Antiarrhythmic Anticoagulant, nitrate, calcium antagonist Hormone replacement therapy

15. Seoul National University Hospital Life style and lipid modification Stop smoking Blood pressure control Lipid risk LDL > 100 mg/dl HDL < 40 mg/dl Statin: 30-40% reduction of cardiac mortality CARE, 4S Niacin or gemfibrozil : TG & HDL !!

16. Seoul National University Hospital Cardiovascular drugs -1 Antiplatelet agents 25% reduction of recurrent infarction, stroke, vascular death Aspirin, clopidogrel >> ticlopidine ACE inhibitor Prevent ventricular remodeling Decrease recurrent ischemia, arrhythmia, CHF Ix; CHF, EF < 40%, RWMA

17. Seoul National University Hospital Cardiovascular drugs -2 Beta blocker 20% reduction of long-term mortality Early therapy < 6 hr of AMI Calcium channel blocker Not routine Contraindication of beta blocker: asthma etc - diltiazem, verapamil Nitrate Not routine

18. Seoul National University Hospital Cardiovascular drugs -3 Anticoagulants Not routine; even combination with aspirin Ix: DVT, PTE, mural thrombi, large RWMA, Af, Hx of embolic CVA Hormone replacement therapy Not indicated in secondary prevention: HERS Can be continue in case of primary prevention Antioxidant Not indicated

19. Seoul National University Hospital Cardiovascular drugs –4 Antiarrhythmic therapy Class I: no role Calss II: beta blocker – beneficial Class III D,I-sotalol: possible benefit Dexsotalol: increase incidence of arrhythmia Amiodarone: reduce mortality Class IV DHP - Nifedipine: maybe harmful ? Non-DHP diltiazem: beneficial

20. Seoul National University Hospital Drugs for secondary prevention of AMI Aspirin Statin Beta blocker ACE inhibitor Proper antiarrhythmics as indicated Life style modification