A 68-year-old man is admitted with acute severe chest pain and ST-segment elevation in the inferior electrocardiogram leads. Coronary angiogram shows complete occlusion of the mid right coronary artery, which is successfully treated with a drug-eluting stent. It also shows 50% stenosis of the mid left anterior descending artery and 30% stenosis of the left circumflex artery. His other medical problems include hypertension and hyperlipidemia. Echocardiogram shows inferior wall hypokinesis with left ventricular ejection fraction of 50%. On the third day of hospitalization, the patient feels well and wants to go home. His blood pressure is 122/70 mm Hg and heart rate is 60/min. His current medications include atorvastatin, metoprolol, lisinopril, aspirin, and ticagrelor.
Which of the following is the best management for this patient?

Question

A 68-year-old man is admitted with acute severe chest pain and ST-segment elevation in the inferior electrocardiogram leads.  Coronary angiogram shows complete occlusion of the mid right coronary artery, which is successfully treated with a drug-eluting stent.  It also shows 50% stenosis of the mid left anterior descending artery and 30% stenosis of the left circumflex artery.  His other medical problems include hypertension and hyperlipidemia.  Echocardiogram shows inferior wall hypokinesis with left ventricular ejection fraction of 50%.  On the third day of hospitalization, the patient feels well and wants to go home.  His blood pressure is 122/70 mm Hg and heart rate is 60/min.  His current medications include atorvastatin, metoprolol, lisinopril, aspirin, and ticagrelor.
Which of the following is the best management for this patient?

Quizplus · Accepted Answer

This patient, who suffered a myocardial infarction (MI) and underwent a successful coronary intervention, is completely asymptomatic and is on appropriate medical therapy. Multiple randomized trials and subsequent meta-analyses have shown that exercise rehabilitation significantly improves outcomes after MI with an improvement in functional status and quality of life, and reduction in repeat hospitalization, recurrent MI, and all-cause mortality. All such patients with recent MI (and those with coronary artery bypass grafting, stable angina pectoris, or percutaneous coronary intervention) should be referred to a cardiac rehabilitation program after hospital discharge. (Choice B) This patient is on dual antiplatelet therapy with aspirin and ticagrelor (platelet P2Y12 receptor blocker) after his recent MI and coronary intervention. The addition of clopidogrel or prasugrel (or other platelet P2Y12 receptor blockers) to his current drug regimen is not recommended. (Choice C) Eplerenone is an aldosterone antagonist. It is recommended after ST elevation MI in patients who have a left ventricular ejection fraction <40%, are receiving an angiotensin-converting enzyme inhibitor and a beta blocker, and have either diabetes or symptomatic heart failure. There is no such indication in this patient. < (Choice D) Nitrates can be used for symptomatic relief in patients with persistent or recurrent angina pectoris after MI, especially in those with partial or incomplete revascularization. This patient has had successful intervention for a culprit lesion and is asymptomatic; additional nitrate therapy is not indicated. (Choice E) Routine stress testing of asymptomatic patients after successful percutaneous intervention is not recommended. This patient has no significant residual coronary artery disease, and stress testing prior to discharge is not indicated. Educational objective: Cardiac rehabilitation has been shown to significantly improve outcomes after myocardial infarction (MI), with an improvement in functional status and reduction in repeat hospitalization, recurrent MI, and all-cause mortality. It is recommended for all patients as a part of a secondary prevention program after recent MI. Routine pre-discharge stress testing of asymptomatic patients after successful revascularization is not recommended. __________ References: Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/15121495) Meta-analysis: secondary prevention programs for patients with coronary artery disease. (http://www.ncbi.nlm.nih.gov/pubmed/16263889)

A 68-Year-Old Man Is Admitted with Acute Severe Chest Pain