Reducing the risks of sudden death and heart failure post myocardial infarction: utility of optimized pharmacotherapy

Current guidelines define the standard of care for patients after myocardial infarction (MI), with particular focus on patients with significant ventricular dysfunction. Inherent in these recommendations are assumptions about the relative risks and benefits, as well as the costs, of the available options. This review will consider strategies to prevent sudden death and heart failure post-MI by utilization of pharmacologic therapies--angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), aldosterone antagonists, statins, and beta-blockers--in parallel with the approaches reviewed elsewhere in this supplement. A patient-centric approach necessitates that drugs in each class be compared for efficacy within this patient population. Clinical trials have demonstrated the efficacy of several drugs, such as ACE inhibitors, beta-blockers, and aldosterone antagonists, in patients post-MI, yet these benefits do not seem to be reflected in the epidemiologic data. This may reflect underutilization of these therapies or, alternatively, support the notion that efficacy in clinical trials does not assure effectiveness in clinical practice. The latter point is a subject of ongoing investigation, while the former is being addressed through quality-of-care initiatives. In clinical practice, aggressiveness is key, starting with patient education. If patients understand their risks better, compliance and adoption of a more ideal lifestyle seem more likely. However, even with educational programs, human nature teaches us that marked change in behavior is difficult and therefore, to minimize risks, particularly of sudden death and heart failure post infarction, an optimized pharmacologic regimen serves as a powerful tool.