A 56-year-old man comes to the physician for an initial evaluation. He reports tiredness and decreased exercise tolerance over the past few weeks. He feels "out of breath" when he goes ballroom dancing with his wife, which has been a regular activity for them. He has not had any cough, orthopnea, wheezing, and lower extremity edema. The patient's other medical problems include gastroesophageal reflux disease. Approximately a month ago he had a particularly severe episode of burning in the upper abdomen and chest, but he has not noted any dark stools or blood in the stool. He takes ranitidine intermittently and uses ibuprofen periodically for pain in his left knee but is not taking any regular medications. He has a 30-pack-year smoking history and drinks 1-2 beers per night. The patient's mother had diabetes mellitus and died of a stroke. His father died of colon cancer. His blood pressure is 144/89 mm Hg and pulse is 94/min and regular. BMI is 32 kg/m². Examination shows normal jugular venous pressure and clear lungs. First and second heart sounds are normal. Deep palpation in the epigastric region elicits mild tenderness. Laboratory results are as follows: ECG is shown in the exhibit. Which of the following is the most appropriate next step in pharmacotherapy?

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Explanation: 11ec2b69_be56_9b04_8f63_996a716e6368_MD0005_00 This patient's ECG showing Q waves and T wave inversions in contiguous inferior leads II, III, and aVF is consistent with prior myocardial infarction (MI). Depending on the size and location of the infarct, both ST elevation and non-ST elevation myocardial infarction can lead to Q waves on ECG. It is likely that his recent episode of burning chest pain represented an acute MI, and his new exercise intolerance and shortness of breath may be due to subsequent left ventricular systolic dysfunction. Patients with coronary artery disease (CAD) and prior MI should be started on appropriate therapy for secondary prevention of cardiovascular events, including beta blocker, high intensity statin, anti-platelet therapy, and ACE inhibitor or angiotensin-receptor blocker. In patients with a recent MI, beta blockers reduce short-term morbidity (recurrent symptoms, reinfarction, size of infarct) as well as short- and long-term mortality (if continued). They also improve survival in patients with CAD and left ventricular systolic dysfunction. Although there has been concern that beta blockers may mask hypoglycemic symptoms in patients with diabetes, their use after an MI is associated with improved survival rates; therefore, diabetes should not be viewed as a contraindication to their use. In addition to initiation of pharmacologic therapy, this patient should also undergo further evaluation and risk stratification (eg, transthoracic echocardiogram, myocardial perfusion stress test, possibly coronary angiography). (Choice A) Fibrate therapy (gemfibrozil or fenofibrate) is indicated to reduce triglyceride levels in patients with severe hypertriglyceridemia (>880 mg/dL). However, despite their favorable effects on lipids, these drugs have not demonstrated significant benefit on cardiovascular outcomes or mortality in patients with known CAD. (Choice B) This patient's laboratory data shows mild anemia that would be unlikely to cause his symptoms. In addition, iron deficiency should typically be confirmed with iron studies before iron supplementation is started. (Choice C) Ipratropium bromide is an anticholinergic agent that provides acute bronchodilation and long-term improvement in dyspnea and exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). Although this patient has a significant smoking history, he does not have cough or wheezing to suggest COPD. (Choice E) Sucralfate can provide symptomatic relief of gastroesophageal reflux disease symptoms (eg, heartburn); however, this patient's history and ECG findings are consistent with prior MI and he requires treatment and further evaluation for CAD. Educational objective: Beta blockers reduce short-term morbidity (recurrent symptoms or reinfarction) and improve long-term survival in patients with prior MI and/or left ventricular systolic dysfunction, and are an integral part of pharmacotherapy for secondary prevention of cardiovascular events following MI. References: Third universal definition of myocardial infarction. (http://www.ncbi.nlm.nih.gov/pubmed/22923432) AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. (http://www.ncbi.nlm.nih.gov/pubmed/22052934)

A 56-Year-Old Man Comes to the Physician for an Initial