A 60-year-old man comes to the office due to occasional episodes of dizziness, usually when he tries to get up quickly. He had sustained an anterior wall myocardial infarction 4 months ago, and had emergent percutaneous revascularization of his proximal left anterior descending artery with placement of a stent. He has no chest pain, shortness of breath, palpitations, or syncope. He has been able to resume walking about 3 miles every day.
His home medications include aspirin, clopidogrel, rosuvastatin, carvedilol, sacubitril-valsartan, and spironolactone. Echocardiography performed 1 week ago showed a large area of dyskinesia in the anterior and anterolateral myocardial segments, with an ejection fraction of 25%. There was also mild mitral and tricuspid regurgitation present. These findings are similar to the earlier echocardiogram performed at the time of myocardial infarction.
His blood pressure is 112/62 mm Hg and pulse is 68/min. A soft, 2/6 holosystolic murmur is heard at the cardiac apex in the left lateral position. Lungs are clear to auscultation.
His ECG in the office shows sinus rhythm and Q waves in precordial leads.
Which of the following is the most appropriate next step in management?

Question

A 60-year-old man comes to the office due to occasional episodes of dizziness, usually when he tries to get up quickly.  He had sustained an anterior wall myocardial infarction 4 months ago, and had emergent percutaneous revascularization of his proximal left anterior descending artery with placement of a stent.  He has no chest pain, shortness of breath, palpitations, or syncope.  He has been able to resume walking about 3 miles every day.
His home medications include aspirin, clopidogrel, rosuvastatin, carvedilol, sacubitril-valsartan, and spironolactone.  Echocardiography performed 1 week ago showed a large area of dyskinesia in the anterior and anterolateral myocardial segments, with an ejection fraction of 25%.  There was also mild mitral and tricuspid regurgitation present.  These findings are similar to the earlier echocardiogram performed at the time of myocardial infarction.
His blood pressure is 112/62 mm Hg and pulse is 68/min.  A soft, 2/6 holosystolic murmur is heard at the cardiac apex in the left lateral position.  Lungs are clear to auscultation.
His ECG in the office shows sinus rhythm and Q waves in precordial leads.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_9748_a2a5_853d_790a32ea7e44_MD0002_00 Current guidelines recommend implantable cardioverter-defibrillator (ICD) therapy for the primary prevention of sudden cardiac death (SCD) in patients with myocardial infarction (MI) with persistent left ventricular ejection fraction (LVEF) ≤30%, who are at least 40 days post-MI and 3 months post-revascularization (ie, coronary artery bypass grafting or percutaneous coronary intervention, if performed). It is also recommended in those with LVEF ≤35% and NYHA class II or III symptoms, regardless of prior MI. This patient's MI was treated with percutaneous revascularization 4 months ago, and he is on optimal medical therapy. He has persistent left ventricular dysfunction with an ejection fraction of 25%. The most appropriate next step is to counsel and offer him ICD placement for primary prevention of SCD (Choice D). (Choice A) Long-term ECG monitoring is indicated to evaluate for arrhythmias that may cause palpitations, syncope, or presyncope. However, this patient's dizziness with standing is likely due to orthostatic hypotension, which is common in heart failure patients due to the use of diuretics and multiple medications that cause vasodilation. Education about preventive measures (eg, arising slowly from sitting) is appropriate, but given low suspicion for paroxysmal arrhythmia as the cause of his dizziness, ECG monitoring is not indicated. (Choice B) Electrophysiological study (EPS) is helpful in patients with prior MI, LVEF 35%-40%, and documented nonsustained ventricular tachycardia on ECG monitoring (ie, borderline criteria for ICD placement). Those with inducible ventricular fibrillation or sustained ventricular tachycardia on EPS should undergo ICD placement for primary prevention of SCD. (Choice E) Submaximal exercise testing can help risk stratify patients with coronary artery disease, but it is unlikely to be helpful in this patient who is able to walk 3 miles every day without significant symptoms. Educational objective: Implantable cardioverter-defibrillator therapy is recommended for primary prevention of sudden cardiac death in patients with persistent LVEF ≤30% following myocardial infarction (MI) who are at least 40 days post-MI and 3 months post-revascularization (ie, coronary artery bypass grafting or percutaneous coronary intervention, if performed). It is also recommended in those with LVEF ≤35% and NYHA class II or III symptoms, regardless of prior MI. __________ References: Indications for ICD and cardiac resynchronization therapy for prevention of sudden cardiac death. (http://www.ncbi.nlm.nih.gov/pubmed/19210214) Primary prevention implantable cardioverter-defibrillators and survival in older women. (http://www.ncbi.nlm.nih.gov/pubmed/25543969)

A 60-Year-Old Man Comes to the Office Due to Occasional