[Diagnostic and therapeutic strategies in post-infarct]

It is of primary importance for the clinical cardiologist to keep in mind the parameters allowing an adequate prognostic stratification in post-infarct patients in view of making the best diagnostic and therapeutic choices. A diagnostic strategy, based on a pathophysiologic approach, should evaluate four aspects: spontaneous and stress-induced ischemia, myocardial viability, and ventricular arrhythmias. Spontaneous ischemia has an undefined prognostic value, especially in the thrombolytic era; therefore it seems reasonable to perform invasive procedures in patients who are not stabilized by an adequate medical therapy or with large jeopardized areas. In asymptomatic patients, a provocative stress test allows a more articulated decisional iter. It is preferably to perform the test by the most physiological exercise EKG, together with the echocardiographic imaging, after the acute phase. It has a high negative predictive value, but a low positive predictive value. The detection of myocardial viability is frequently performed, mainly in patients with large post-ischemic myocardial dysfunction. Among all the proposed methods, the echo-dobutamine test mainly allows to estimate patients in whom revascularization may result in more benefit. The role of ventricular arrhythmias as an independent prognostic factor is debated and has to be always considered in relationship to other parameters, particularly left ventricular function. Regarding the therapeutic strategy, the indications from recent trials, related to antithrombotic drugs, beta-blockers, ACE-inhibitors, nitrates, Ca-blockers and antiarrhythmic drugs, are emphasized.