Management of older persons after myocardial infarction

To review the management of the older person after myocardial infarction (MI).

A computer-assisted search of the English language literature (MEDLINE database) followed by a manual search of the bibliographies of pertinent articles.

Studies on the management of persons after MI were screened for review. Studies in persons older than 60 years and recent studies were emphasized.

Pertinent data were extracted from the reviewed articles. Emphasis was on studies involving older persons. Relevant articles were reviewed in depth.

Available data about therapy of persons after MI, including control of risk factors, use of aspirin and beta-blockers, and indications for use of angiotensin-converting enzyme inhibitors, long-term anticoagulant therapy, nitrates, calcium channel blockers, hormone replacement therapy, antiarrhythmic drugs, the automatic implantable cardioverter-defibrillator, and revascularization, with emphasis on studies involving older persons, were summarized.

Risk factors for coronary artery disease should be controlled after MI in older persons. A serum low-density lipoprotein (LDL) cholesterol >125 mg/dL after MI should be treated with lipid-lowering drug therapy to decrease the serum LDL cholesterol to <100 mg/dL. Aspirin in a dose of 160 mg to 325 mg daily should be given indefinitely. Indications for long-term anticoagulant therapy with warfarin after MI to maintain an international normalized ratio between 2.0 and 3.0 include secondary prevention of MI in persons unable to tolerate daily aspirin, persistent atrial fibrillation, and left ventricular thrombus. Beta-blockers should be given indefinitely. Angiotensin-converting enzyme inhibitors should be given to persons who have congestive heart failure, an anterior MI, or a left ventricular ejection fraction < or = 40%. Calcium channel blockers should not be used unless there is persistent angina pectoris despite beta-blockers and nitrates. Antiarrhythmic drugs other than beta-blockers should not be used. An automatic implantable cardioverter-defibrillator should be used in persons who have a history of ventricular fibrillation or serious sustained ventricular tachycardia or who are at very high risk for developing sudden cardiac death. Until data from the Heart Estrogen/ Progestin Replacement Study are available, use of an estrogen/progestin regimen is recommended in the treatment of postmenopausal women after MI unless they are at increased risk for developing breast cancer. The two indications for revascularization in older persons after MI are prolongation of life and relief of unacceptable symptoms despite optimal medical management.