From the Guidelines
The patient with a prior infarct in the inferolateral wall and peri-infarct ischemia should undergo revascularization, as it has been shown to improve prognosis in patients with moderate or severe ischemia, as demonstrated by observational studies and noninvasive imaging techniques 1.
Key Considerations
- The extent of ischemia is strongly related to the risk of subsequent death and/or myocardial infarction (MI), with a possible benefit from revascularization 1.
- Revascularization has been associated with improved late survival, even in patients ≥75 years of age, and in those with ≥10% inducible ischemia by SPECT 1.
- The patient's treatment plan should include:
- Dual antiplatelet therapy with aspirin and clopidogrel
- High-intensity statin therapy, such as atorvastatin
- A beta-blocker, such as metoprolol
- An ACE inhibitor, like lisinopril, especially if there's reduced heart function
Next Steps
- Prompt cardiology referral for further evaluation and management
- Coronary angiography to determine the need for revascularization (stenting or bypass surgery)
- Lifestyle modifications, including smoking cessation, heart-healthy diet, regular exercise, and tight control of diabetes and hypertension if present
Rationale
The presence of peri-infarct ischemia indicates viable heart muscle at risk for future damage, and the previous infarct puts the patient at higher risk for heart failure and future cardiac events if not properly managed. Revascularization, in addition to optimal medical therapy, has been shown to improve prognosis in patients with moderate or severe ischemia, making it a crucial component of the patient's treatment plan 1.
From the Research
Myocardial Perfusion Imaging Study Findings
- The study shows prior infarct in the inferolateral wall with some peri-infarct ischemia, which is a common finding in patients with coronary artery disease 2.
- Mild ischemia in the inferolateral wall on myocardial perfusion imaging is seen frequently in practice and may indicate significant stenosis in the left circumflex (LCX) territory 2.
- The presence of abnormal myocardial perfusion imaging, even with normal coronary angiography, may predict a higher prevalence of coronary and peripheral vascular events 3.
Management and Treatment
- A combination therapy with aspirin, an ACE inhibitor, and a statin reduces 1-year mortality in patients after acute myocardial infarction 4.
- The use of high-dose aspirin (>200 mg daily) after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction may increase the rate of major bleeding without providing additional ischemic benefit 5.
- Clinical decision making with myocardial perfusion imaging in patients with known or suspected coronary artery disease should be based on individual patient characteristics, such as functional capacity and pretest likelihood of disease 6.
Prognostication and Revascularization
- Assessment of myocardial blood flow with PET is particularly powerful for prognostication as it reflects the end result of many processes that lead to atherosclerosis 6.
- The presence of viable myocardium as assessed by PET or MRI appears to identify patients who benefit from revascularization, but well-executed randomized trials are lacking 6.
- Decision making with respect to revascularization is limited for cardiac MRI and PET MPI, and retrospective radionuclide studies have identified an ischemic threshold, but randomized trials are needed 6.