[Risk stratification following myocardial infarct]

In recent decades, early mortality of acute myocardial infarction has decreased from above 30% to below 10%. Many survivors of acute myocardial infarction are at increased risk for cardiac death and/or nonfatal recurrent ischemic events. This has not changed with the introduction of thrombolysis. How can high risk patients be identified who would benefit from coronary revascularization and/or from antiarrhythmic treatment? Based on clinical findings such as a large infarction, infarction of the anterior wall, congestive heart failure, cardiogenic shock during the acute phase, post-infarct angina and a history of previous infarctions, high risk patients who should undergo coronary angiography and--if feasible--revascularization can be defined. Patients with symptomatic arrhythmias should receive medical or interventional antiarrhythmic treatment. All patients who are clinically considered not to be at high risk should undergo risk stratification with signal averaged ECG, non-invasive stress testing and non-invasive quantification of left ventricular function. In the presence of late potentials, ischemia during stress testing and impaired left ventricular function, further evaluation with Holter ECG or an electrophysiologic study and coronary angiography is indicated. In infarct survivors over 75 years old, the therapeutic goal is improvement of quality of life, i.e. relief of symptoms, rather than improvement of prognosis. Invasive procedures should therefore be considered only in individual patients. However, in all postinfarct survivors the assessment and treatment of cardiovascular risk factors and secondary medical prevention is mandatory.