Therapy for acute myocardial infarction

Acute myocardial infarction occurs with increasing frequency with advancing age, and older patients with acute MI are at increased risk of a variety of complications including congestive heart failure, arrhythmias and conduction disturbances, myocardial rupture, cardiogenic shock, and death. Older patients thus comprise a high-risk subgroup of the MI population who consequently may derive substantial benefit from appropriately selected therapeutic interventions. At the same time, many interventions are associated with increased risks in the elderly, so that individualization of treatment is essential in all patients. Optimal therapy is thus based on a careful risk-benefit assessment of the available treatment options in conjunction with information on patient preferences and other relevant factors. Though many therapeutic trials of patients with acute MI have either excluded elderly patients or enrolled too few older subjects to permit definitive conclusions, sufficient data are available to make specific recommendations in several areas. As shown in Table 6, therapies of proven value in the acute-phase treatment of elderly patients with MI include aspirin and thrombolysis. Intravenous beta blockers are likely to be of benefit as well, and long-term oral beta blockade after MI is clearly beneficial. ACE inhibitors are of proven value in the long-term management of patients with left ventricular dysfunction (ejection fraction less than 40%), but initiation of an ACE inhibitor should probably be delayed for 48 to 72 hours in most cases. The role of other agents including nitrates, magnesium, diltiazem, and verapamil requires further clarification, but anti-arrhythmic drugs and dihydropyridine calcium antagonists should generally be avoided in the absence of specific indications for their use. Finally, though the role of catheterization and revascularization in elderly patients with acute MI requires additional study, current data indicate that age alone should not be considered a contraindication to these procedures. As the age of the population continues to rise, the number of older patients at risk of acute MI also increases. Though progressively more sophisticated interventions may ultimately result in sizable reductions in post-MI morbidity and mortality, given the high risk of adverse outcomes in this population the best treatment is prevention. Thus, the greatest potential for the future, as well as the greatest challenge, is to develop more effective strategies for preventing atherosclerosis and for conquering the epidemic of coronary heart disease.