Balancing the Medication Portfolio 5 Years after a Heart Attack
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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.
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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
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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
61 years oldDMI 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
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Medications(initiated 5 years ago post MI evaluation)
Aspirin 325 mg dailyClopidogrel 75 mg dailyMetoprolol 50 mg twice dailyEnalapril 10 mg dailyStatin
Joe
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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.
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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
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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
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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
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
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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.
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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
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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