MANAGEMENT OF OLDER PERSONS AFTER MYOCARDIAL-INFARCTION

OBJECTIVE: To review the management of the older person after myocardi al infarction (MI). DATA SOURCES: A computer-assisted search of the En glish language literature (MEDLINE database) followed by a manual sear ch of the bibliographies of pertinent articles. STUDY SELECTION: Studi es on the management of persons after MI were screened for review. Stu dies in persons older than 60 years and recent studies were emphasized . DATA EXTRACTION: Pertinent data were extracted from the reviewed art icles. Emphasis was on studies involving older persons. Relevant artic les were reviewed in depth. DATA SYNTHESIS: Available data about thera py of persons after MI, including control of risk factors, use of aspi rin and beta-blockers, and indications for use of angiotensin-converti ng enzyme inhibitors, long-term anticoagulant therapy, nitrates, calci um channel blockers, hormone replacement therapy, antiarrhythmic drugs , the automatic implantable cardioverter-defibrillator, and revascular ization, with emphasis on studies involving older persons, were summar ized. CONCLUSIONS: Risk factors for coronary artery disease should be controlled after MI in older persons. A serum low-density lipoprotein (LDL) cholesterol >125 mg/dL after MI should be treated with lipid-low ering drug therapy to decrease the serum LDL cholesterol to <100 mg/dL . Aspirin in a dose of 160 mg to 325 mg daily should be given indefini tely. Indications for long-term anticoagulant therapy with warfarin af ter MI to maintain an international normalized ratio between 2.0 and 3 .0 include secondary prevention of MI in persons unable to tolerate da ily aspirin, persistent atrial fibrillation, and left ventricular thro mbus. Beta blockers should be given indefinitely. Angiotensin-converti ng enzyme inhibitors should be given to persons who have congestive he art failure, an anterior MI, or a left ventricular ejection fraction l ess than or equal to 40%. Calcium channel blockers should not be used unless there is persistent angina pectoris despite beta-blockers and n itrates. Antiarrhythmic drugs other than beta-blockers should not be u sed. An automatic implantable cardioverter-defibrillator should be use d in persons who have a history of ventricular fibrillation or serious sustained ventricular tachycardia or who are at very high risk for de veloping sudden cardiac death. Until data from the Heart Estrogen/Prog estin Replacement Study are available, use of an estrogen/progestin re gimen is recommended in the treatment of postmenopausal women after MI unless they are at increased risk for developing breast cancer. The t wo indications for revascularization in older persons after MI are pro longation of life and relief of unacceptable symptoms despite optimal medical management.