How to treat an old septal infarct (myocardial infarction)?

From the Guidelines

The treatment of an old septal infarct should prioritize a comprehensive approach focused on preventing future cardiac events and managing complications, with a strong emphasis on medical therapy, lifestyle modifications, and regular follow-up with a cardiologist, as recommended by the most recent guidelines 1. The goal of treatment is to prevent remodeling of the heart, reduce the risk of heart failure, and minimize the chance of future cardiac events by addressing the underlying atherosclerotic disease process.

• Medical therapy includes:
  • Daily aspirin (81-325mg) for antiplatelet therapy
  • A statin medication like atorvastatin (20-80mg daily) to lower cholesterol
  • An ACE inhibitor such as lisinopril (5-40mg daily) or ARB if ACE inhibitors aren't tolerated
  • Beta-blockers like metoprolol (25-200mg daily) to reduce heart workload
• For patients with reduced ejection fraction, additional medications may include:
  • Aldosterone antagonists like spironolactone (25mg daily)
  • SGLT2 inhibitors
• Lifestyle modifications are essential, including:
  • Smoking cessation
  • Regular moderate exercise (30 minutes most days)
  • Heart-healthy Mediterranean diet
  • Weight management
  • Stress reduction
• Regular follow-up with a cardiologist is necessary to monitor cardiac function through echocardiograms and adjust medications as needed, as supported by guidelines from the European Society of Cardiology 1. In cases where mechanical complications arise, such as ventricular septal rupture, definitive surgical correction is frequently the treatment of choice, with the use of temporary mechanical circulatory support (MCS) devices to enhance hemodynamic stabilization and allow for consideration of delayed corrective strategy 1.

From the FDA Drug Label

Myocardial Infarction Metoprolol tartrate injection is indicated in the treatment of hemodynamically stable patients with definite or suspected acute myocardial infarction to reduce cardiovascular mortality.

DOSAGE & ADMINISTRATION Myocardial Infarction Early Treatment During the early phase of definite or suspected acute myocardial infarction, initiate treatment with metoprolol tartrate as soon as possible after the patient’s arrival in the hospital.

The treatment for old septal infarct is not directly addressed in the provided drug labels. However, for myocardial infarction, metoprolol tartrate can be initiated as soon as the patient's clinical condition allows, or within 3 to 10 days of the acute event 2. The dosage and administration for myocardial infarction are outlined in the drug label, including intravenous administration and oral maintenance dosage 2.

• Key points:
  • Initiate treatment as soon as possible after the patient's arrival in the hospital
  • Start with intravenous administration of metoprolol tartrate injection
  • Monitor blood pressure, heart rate, and electrocardiogram during intravenous administration
  • Initiate oral maintenance dosage after intravenous dose However, since the question is about old septal infarct, and there is no direct information in the drug labels to support the treatment of this specific condition, a conservative clinical decision would be to not make any conclusions about the treatment of old septal infarct based on the provided information 2, 2.

From the Research

Treatment of Old Septal Infarct

• The treatment of old septal infarct is not directly addressed in the provided studies, but some information can be inferred from the discussion of related topics.
• According to 3, ACE inhibitors such as lisinopril have been shown to reduce mortality and cardiovascular morbidity in patients with myocardial infarction when administered as early treatment.
• The study 4 discusses the efficacy of septal ablation in patients with hypertrophic obstructive cardiomyopathy, which may be relevant to the treatment of septal infarcts.
• The combination of beta-blockers and ACE inhibitors is discussed in 5 as a potential treatment for various cardiovascular diseases, including hypertension and heart failure.
• The study 6 provides an overview of hypertension and acute myocardial infarction, and notes that renin-angiotensin-aldosterone system blockade may be beneficial in high-risk hypertensive patients.
• The conservative management of patients with acute myocardial infarction and spontaneous acute patency of the infarct-related artery is discussed in 7, which may be relevant to the treatment of old septal infarct.

Potential Treatment Options

• ACE inhibitors such as lisinopril may be beneficial in reducing mortality and cardiovascular morbidity in patients with old septal infarct.
• Septal ablation may be considered in patients with hypertrophic obstructive cardiomyopathy and septal infarct.
• The combination of beta-blockers and ACE inhibitors may be a potential treatment option for patients with old septal infarct and related cardiovascular conditions.
• Conservative management may be appropriate in some cases, particularly if the patient has spontaneous patency of the infarct-related artery.