From the Guidelines
The patient's management could be optimized by obtaining a current echocardiogram to assess cardiac function and guide therapy, as well as considering an increase in the metoprolol dose to better control PVCs and heart rate, given the current dose of 12.5mg twice daily is relatively low, as recommended by the 2018 European Society of Cardiology guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1. The patient's current medication regimen includes metoprolol tartrate 12.5 mg/bid, which may not be sufficient to control the frequent monomorphic PVCs, and an increase in dose may be necessary. The spironolactone dose could be uptitrated to 25mg daily if potassium and renal function allow, as mineralocorticoid receptor antagonists are recommended in patients with an LVEF < 40% and heart failure or diabetes, who are already receiving an ACE inhibitor and a beta-blocker, provided there is no renal failure or hyperkalemia, as stated in the 2018 European Society of Cardiology guidelines 1. Adding an ACE inhibitor or ARB would be beneficial for this patient with prior MI and heart failure, as ACE inhibitors are recommended, starting within the first 24 h of STEMI in patients with evidence of heart failure, LV systolic dysfunction, diabetes, or an anterior infarct, according to the 2018 European Society of Cardiology guidelines 1. Consider transitioning from IV to oral furosemide once the patient stabilizes, and evaluation for ischemia with stress testing or coronary angiography should be considered given the prior MI without revascularization. The patient would benefit from close monitoring of electrolytes, particularly with diuretic therapy, and addressing the frequent PVCs may require antiarrhythmic therapy or electrophysiology consultation if they persist despite beta-blocker optimization. Lastly, ensure the patient has appropriate follow-up arranged after discharge to monitor response to therapy and adjust medications as needed. It is also important to note that the patient's lipid management should be optimized, with a goal of LDL-C < 70 mg/dL, as recommended by the 2018 European Society of Cardiology guidelines 1. The patient's current statin dose of atorvastatin 80 mg/d is appropriate, but further therapy to reduce LDL-C should be considered if the patient remains at high risk, as stated in the 2018 European Society of Cardiology guidelines 1.
From the Research
Current Treatment and Management
- The patient is currently being treated with IV lasix, which has improved their shortness of breath (SOB) symptoms 2.
- The patient's medication regimen includes ASA 81 mg/d, Atorvastatin 80 mg/d, Dapagliflozin 10 mg/d, Metoprolol Tartrate 12.5 mg/bid, and Spironolactone 12.5 mg/d.
- The use of sacubitril/valsartan in combination with dapagliflozin has been shown to improve cardiac function in patients with heart failure with reduced ejection fraction (HFrEF) 3.
Optimization of Treatment
- The patient's treatment plan may be optimized by considering the use of antiplatelet therapy, such as clopidogrel, in addition to ASA, to reduce the risk of recurrent myocardial infarction and restenosis after primary percutaneous coronary intervention 4.
- The patient's dosing regimen may need to be adjusted based on their individual characteristics, such as age, weight, and renal function, to ensure optimal treatment outcomes 5.
- The use of angiotensin-receptor blockade and neprilysin inhibition with sacubitril/valsartan may be considered as an alternative to ramipril to reduce cardiovascular events in patients with STEMI 6.
Monitoring and Follow-up
- The patient's cardiac function, including left ventricular ejection fraction (LVEF) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, should be closely monitored to assess the effectiveness of treatment 3.
- The patient's renal function, including creatinine levels, should be monitored to adjust the dosing regimen as needed 5.
- The patient's blood pressure and heart rate should be closely monitored to adjust the treatment plan as needed 3.