What is the recommended treatment for a patient with evidence of ischemia and infarction on SPECT myocardial perfusion images, mildly reduced left ventricle function, and a post-stress ejection fraction of 49%?

Recommended Treatment for Ischemia and Infarction with Mildly Reduced LV Function

This patient requires coronary angiography immediately to define coronary anatomy and guide revascularization, combined with aggressive medical therapy including dual antiplatelet therapy, high-intensity statin, beta-blocker, and ACE inhibitor. 1

Immediate Diagnostic Intervention

Coronary angiography is indicated as the next step given the combination of reversible ischemia (small apical defect), prior infarction (fixed basal inferolateral defect), and mildly reduced ejection fraction of 49%. 1 The presence of both ischemia and infarction in different territories suggests multivessel disease requiring anatomic definition. 1

Medical Therapy - Antiplatelet Agents

Initiate dual antiplatelet therapy (DAPT) immediately:

• Aspirin 75-100 mg daily is mandatory for all patients with coronary artery disease. 2
• Add ticagrelor or prasugrel (or clopidogrel if the others are unavailable or contraindicated) for 12 months. 2
• Add a proton pump inhibitor given the need for DAPT, as this patient is at higher risk for gastrointestinal bleeding. 2

Medical Therapy - Beta-Blockers

Beta-blocker therapy is Class I indicated for this patient with ejection fraction of 49% (below 50%) and evidence of prior myocardial infarction. 2 Beta-blockers reduce myocardial oxygen demand and decrease risk of death and recurrent MI. 2 Use carvedilol, metoprolol succinate, or bisoprolol, as these specific agents have been shown to reduce mortality. 2

Medical Therapy - Statins

Start high-intensity statin therapy immediately regardless of baseline lipid levels. 2 The target is LDL-C <1.8 mmol/L (70 mg/dL) or at least 50% reduction if baseline LDL-C is 1.8-3.5 mmol/L. 2 Statins provide both lipid-lowering and pleiotropic anti-inflammatory effects that benefit coronary disease. 2

Medical Therapy - ACE Inhibitors

ACE inhibitors are Class I indicated for this patient with ejection fraction of 49% and evidence of prior infarction. 2 Start within the first 24 hours if hemodynamically stable. 2 ACE inhibitors reduce risk of hospitalization and death in patients with LVEF <50%. 2 If ACE inhibitors are not tolerated, use an ARB (preferably valsartan). 2

Medical Therapy - Mineralocorticoid Receptor Antagonists

Consider adding an MRA if the patient has heart failure symptoms or diabetes, provided there is no renal failure or hyperkalemia. 2 MRAs are recommended for patients with ejection fraction <40% who are already on ACE inhibitor and beta-blocker. 2 While this patient's EF is 49%, the presence of regional wall motion abnormality and prior infarction may warrant consideration.

Medical Therapy - Antianginal Medications

For symptom control of ischemia:

• Beta-blockers serve as first-line therapy for anginal symptoms. 2
• Add sublingual nitroglycerin or nitroglycerin spray for immediate relief of anginal symptoms. 2
• If beta-blockers are inadequate, add calcium channel blockers or long-acting nitrates. 2

Revascularization Strategy

After coronary angiography defines anatomy:

• Proceed with PCI or CABG if suitable anatomy is identified for the territory supplying the reversible ischemic defect at the apex. 1
• For the fixed basal inferolateral defect, consider additional viability testing (PET, dobutamine stress echo, or cardiac MRI) to determine if hibernating myocardium is present that would benefit from revascularization. 1, 2
• The presence of viable but ischemic myocardium in the apex makes this territory a priority for revascularization. 1

Follow-Up Assessment

Repeat echocardiography:

• Perform echocardiography after revascularization to reassess ejection fraction and regional wall motion. 1
• Reevaluate LVEF 40 or more days after discharge to determine ICD candidacy if EF remains ≤35%. 2
• Continue monitoring every 12 months to assess for changes in cardiac function. 3

Risk Factor Modification

Implement comprehensive secondary prevention:

• Tobacco cessation with repeated counseling, nicotine replacement, varenicline, or bupropion. 2
• Cardiac rehabilitation enrollment is Class I recommended. 2
• Measure lipid panel, fasting glucose, and renal function if not already done. 2, 1
• Optimize blood pressure control and diabetes management. 2

Patient Education

Provide specific instructions:

• If anginal discomfort lasts more than 2-3 minutes, stop activity and take one dose of sublingual nitroglycerin. 2
• If chest pain is unimproved or worsening 5 minutes after one nitroglycerin dose, call 9-1-1 immediately. 2
• Additional nitroglycerin may be taken at 5-minute intervals (up to 2 more doses) while waiting for EMS. 2
• Report any worsening pattern of angina (more frequent, severe, or occurring with less effort). 2

Common Pitfalls to Avoid

• Do not delay coronary angiography in patients with this combination of findings—the reversible ischemia indicates viable myocardium at risk. 1
• Do not use intravenous beta-blockers if the patient develops hypotension, acute heart failure, or significant bradycardia. 2
• Avoid NSAIDs and certain calcium channel blockers that can negatively affect left ventricular function. 3
• Do not assume the fixed defect is non-viable without formal viability testing, as hibernating myocardium may benefit from revascularization. 1, 2