Management of patients after myocardial infarction and thrombolytic therapy

Abstract

On the basis of the available data concerning the indications for and the timing of arteriography after thrombolysis, the inevitable conclusion is that conservative instead of aggressive management is indicated for the 40% to 50% of patients at low risk who do not have spontaneous myocardial ischemia or myocardial ischemia that was provoked. Factors to be considered in treatment decisions for individual patients after thrombolytic therapy include risk factors before and after thrombolytic therapy, the results of studies assessing conservative versus aggressive postthrombolytic management, the accuracy of risk stratification by noninvasive testing, and the relevance of the “open artery” hypothesis. The low-risk patient with a left ventricular ejection fraction above 40% and no ischemia during adequate stress testing has a low 3-year mortality rate. Although benefits of routine coronary arteriography exist relative to determining the severity of coronary artery disease and whether the infarct-related artery is patent, selective coronary arteriography is a more feasible and less expensive approach for appropriate patients. The low annual mortality rate with this approach is equal to that obtained when patients undergo routine coronary arteriography with myocardial revascularization based upon the result of the routine procedure. The modification of various coronary risk factors appears as valuable able for patients who have undergone thrombolytic therapy as for those who did not. Specifically, the cessation of smoking, the control of hypertension, and the treatment of hypercholesterolemia are indicated for patients after thrombolysis when any of these modifiable risk factors are present. Secondary prevention with pharmacologic agents appears to be similar for those who have undergone standard or thrombolytic therapy. Long-term aspirin therapy is routine for secondary prevention; long-term β-blocker therapy is useful for high-risk patients; and long-term treatment with angiotensin-converting enzyme inhibitors is indicated for patients after thrombolysis who have a low left ventricles ejection fraction.