What is the optimal management plan for a 62-year-old male with a history of MI, currently on Brilinta (ticagrelor), Lisinopril (lisinopril), and Atorvastatin (atorvastatin), with evidence of ischemia and infarction on cardiac imaging and mildly reduced left ventricle function?

Optimal Management for Post-MI Patient with Residual Ischemia and Reduced LVEF

This patient requires coronary angiography to evaluate for revascularization given the moderate-sized reversible ischemic defect on stress testing, and his medical therapy should be optimized with beta-blocker addition, ACE inhibitor dose escalation, and consideration of extended dual antiplatelet therapy given his high ischemic risk. 1

Immediate Priority: Coronary Angiography

Coronary angiography is reasonable in this patient with heart failure symptoms (LVEF 49%) and documented ischemia on stress testing to determine if revascularization is indicated. 1 The presence of a moderate-severity reversible defect in the apex, combined with mildly reduced left ventricular function, suggests viable myocardium at risk that could benefit from revascularization. 1

Medical Therapy Optimization

Beta-Blocker Therapy - Critical Gap

This patient is NOT currently on a beta-blocker, which represents a significant treatment gap. Beta-blockers are Class I recommendations (highest level) for patients with prior MI and reduced ejection fraction (<50%). 1

• Beta-blockers should be initiated immediately in this patient with LVEF 49% and prior MI to reduce morbidity and mortality. 1
• Evidence-based beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) are specifically recommended. 1
• Beta-blockers are particularly beneficial in patients with anterior MI or reduced LVEF, both present in this case (basal inferolateral infarction with LVEF 49%). 1

ACE Inhibitor Dose Escalation

The current lisinopril dose of 2.5 mg is subtherapeutic and should be uptitrated. 1, 2

• ACE inhibitors are Class I recommendations for all patients with LVEF <40%, and this patient's LVEF of 49% with regional wall motion abnormalities warrants aggressive ACE inhibition. 1
• The ATLAS trial demonstrated that higher doses of ACE inhibitors (lisinopril 32.5-35 mg daily) reduced mortality more than low doses (2.5-5 mg daily) in heart failure patients. 1
• Target lisinopril dose should be 20-40 mg daily unless limited by hypotension or renal dysfunction. 1, 2
• Monitor blood pressure carefully during uptitration, avoiding diastolic BP <60 mmHg. 1

Aldosterone Antagonist Consideration

An aldosterone antagonist (spironolactone or eplerenone) should be added given the LVEF of 49% and prior MI. 1

• Aldosterone blockade is recommended in post-MI patients with LVEF <40% who are receiving therapeutic doses of ACE inhibitor and beta-blocker. 1
• While this patient's LVEF is 49%, the presence of regional wall motion abnormalities and moderate hypokinesis suggests more significant dysfunction. 1
• Contraindications must be excluded: serum creatinine >2.5 mg/dL (men) or >2.0 mg/dL (women), and potassium >5.0 mEq/L. 1

Statin Therapy - Already Optimized

The current atorvastatin 40 mg is appropriate, though high-intensity statin therapy (atorvastatin 80 mg) has the strongest evidence for reducing death and ischemic events post-MI. 1, 3

• Consider increasing to atorvastatin 80 mg daily, the only high-dose statin proven to reduce death and ischemic events in ACS patients. 1
• Target LDL-C <70 mg/dL (1.8 mmol/L) or ≥50% reduction from baseline. 1, 3

Extended Dual Antiplatelet Therapy

This patient is a candidate for extended DAPT beyond the standard 12 months given his high ischemic risk profile. 1, 4

High Ischemic Risk Features Present:

• Prior MI (2019 - now >1 year post-event) 4
• Multivessel disease (apex ischemia + basal inferolateral infarction) 1, 5
• Reduced LVEF (49%) 4
• Evidence of ongoing ischemia on stress testing 1

Ticagrelor 60 mg Twice Daily Option

Ticagrelor 60 mg twice daily added to aspirin should be considered for extended secondary prevention in this high-risk patient. 1, 4

• The PEGASUS-TIMI 54 trial demonstrated that ticagrelor 60 mg twice daily (the dose he's currently NOT on - he's on 90 mg) reduced cardiovascular death, MI, or stroke by 16% at 3 years in patients with prior MI and high-risk features. 4, 5
• The 60 mg dose is preferred over 90 mg for long-term use due to better tolerability with similar efficacy. 1, 4
• The absolute risk reduction was 1.27% at 3 years (NNT=79), with TIMI major bleeding increased by 1.0% (NNH=100). 4
• Patients with multivessel CAD benefited more from ticagrelor in subgroup analyses. 1, 5

Bleeding Risk Assessment

Before continuing extended DAPT, assess bleeding risk predictors: 6

• History of spontaneous bleeding requiring hospitalization (absent per history) 6
• Presence of anemia (should be checked) 6
• Patients without these predictors had more favorable net benefit with ticagrelor 60 mg, including lower mortality (HR 0.79). 6

Alternative: Aspirin + Rivaroxaban 2.5 mg

Aspirin plus rivaroxaban 2.5 mg twice daily is an alternative intensified antithrombotic strategy if ticagrelor is not tolerated. 1

• The COMPASS trial showed this combination reduced ischemic events compared to aspirin alone in stable CAD patients. 1
• However, this combination is typically considered when P2Y12 inhibitor therapy is not suitable. 1

Revascularization Decision

The decision for revascularization depends on coronary anatomy and should be made after angiography. 1

• Myocardial revascularization is recommended when angina persists despite optimal medical therapy. 1
• This patient is currently asymptomatic, but the presence of moderate-severity reversible ischemia in viable myocardium may warrant revascularization even without symptoms. 1
• PCI or CABG choice depends on anatomy, SYNTAX score, and presence of diabetes. 1

Additional Considerations

Cardiac Rehabilitation

Cardiac rehabilitation should be recommended to improve functional capacity and reduce mortality. 1

ICD Evaluation

ICD consideration may be warranted if LVEF remains ≤35% at least 40 days post-MI and 3 months post-revascularization on optimal medical therapy. 1

• Current LVEF is 49%, so ICD is not indicated now. 1
• Reassess LVEF after medical therapy optimization and potential revascularization. 1

Blood Pressure Target

Target blood pressure <130/80 mmHg in this patient with CAD and prior MI. 1

• Avoid excessive diastolic BP lowering (<60 mmHg) which may worsen myocardial ischemia. 1

Common Pitfalls to Avoid

1. Do not continue current regimen without beta-blocker - this is a Class I indication that is currently missing. 1

2. Do not accept subtherapeutic ACE inhibitor dosing - lisinopril 2.5 mg is inadequate for this patient. 1, 2

3. Do not use immediate-release nifedipine or other short-acting dihydropyridine calcium channel blockers - these are contraindicated and increase mortality in CAD patients. 1

4. Do not delay angiography - the presence of reversible ischemia with reduced LVEF warrants anatomic evaluation. 1

5. Do not overlook aldosterone antagonist - this is often underutilized despite strong evidence in post-MI patients with reduced LVEF. 1