WHAT TREATMENT IS REQUIRED FOLLOWING MYOC ARDIAL-INFARCTION WITH LEFT-VENTRICULAR DYSFUNCTION

The essential goal of medical treatment following myocardial infarctio n with left ventricular dysfunction must be the prevention of secondar y cardiac failure. The existence of left ventricular dysfunction, in p articular when it is not accompanied by clinical cardiac failure, is a virtually formal indication for beta-blocker treatment after an infar ction. Beta-blockers with intrinsic sympathomimetic activity (ISA) are possibly better tolerated in this context. However, experience shows that cardiologists and general practitioners often remain reluctant to prescribe beta-blockers whenever left ventricular function is impaire d. Converting enzyme inhibitors decrease the risk of onset of secondar y cardiac failure, reduce sudden deaths by ventricular arrhythmias, re duce recurrences of myocardial infarction or unstable coronary insuffi ciency, and more generally reduce overall and cardiovascular mortality . This is a class effect. While there is no urgency to prescribe them during the acute phase, it is generally considered that it is extremel y useful to give them fairly quickly, i.e. during the first 72 hours. At the end of the hospital phase, around two weeks, it is desirable, w henever possible, to prescribe a dose of the order of 75 mg/day of cap topril or 2.5 mg/day of ramipril. The administration of aspirin can be considered virtually routine. Oral anticoagulants are desirable in th e presence of a large akinetic pocket, a frequent starting point of th rombosis and/or systemic emboli, or in the presence of atrial fibrilla tion. Digitalis/diuretic treatment does not appear to be indicated at this stage. Other types of anti-ischemic treatment are not theoretical ly indicated as a matter of principle at this stage in the absence of residual ischemia. Coronary revascularisation by surgery or by angiopl asty of a coronary territory may greatly improve the patient's left ve ntricular function and it increasingly emerges that routine repermeabi lisation of the coronary artery responsible for the infarct has benefi cial effects on left ventricular remodelling, and hence on the develop ment of secondary left ventricular failure.