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Forum Name: Ischemic Heart Disease

Question: Acute MI -- having trouble w/prognosis


 omara_croft - Fri Dec 03, 2004 12:23 pm

Hi:

On November 8, my wife (age 43) was rushed to hospital, where she was treated for an acute MI resulting from a 100% occlusion of the left anterior descending artery (at the top of the artery). She underwent an emergency cardioplasty and a stent was placed. She had no significant occlusion of any other arteries. She had a follow-up angiogram 15 days after her MI, and it showed no improvement in ejection fraction, which remained at 25%. After the attack, she quit smoking and made several other lifestyle changes, including a move to a reduced-fat diet; she has no family history of heart disease and has never suffered from hypertension.

She was put on Atenolol and Lisinopril, as well as Plavix and Zocor. She could not tolerate the Atenolol or Lisinopril, which reduced her blood pressure to the point where she worried about fainting whenever she was on her feet. After a week off of both ACE inhibitors and beta blockers, she was put on Coureg, which has so far not had the same negative effect on her blood pressure. She is also on Coumadin, because doctors feared she was at elevated risk for clot-related problems. She is participating in cardiac rehab, and walks (with some breathlessness) for 30 mins with me most days.

Recently, because of the low ejection fraction and its lack of improvement, my wife's cardiologist suggested that my wife would likely be a good candidate for an ICD (internal defibrillator). She will soon meet with an electrocardiologist.

We have been doing as much Web-based research as we can about her longer-term prognosis, and have been finding the messages mixed and confusing. Some sites suggest her low EF means she already must have heart failure (even though breathlessness is her only real symptom to date), while other sites suggest she is at higher risk for eventual heart failure (as soon as scarring sets in). Some sites say that 44% of women die within one year of an MI, while others say that if you survive the first week or so your longer-term prognosis is encouraging. Other sites suggest her future may be dire because of her intolerance of the ACE inhibitors and beta blockers. What we seem to find most often are messages that suggest the low ejection fraction (still at 25% at 30 days after the MI) means it is very likely she will be permanently disabled to some extent.

My wife's doctors say that although she had a massive heart attack and her EF is very low, she "should be okay." We're worried that they are painting a more encouraging picture so as not to cause us to worry excessively -- however, we're not the type of people who want anything sugar-coated. Does anyone have any clear statistics or experience to suggest what my wife's odds are, over the long run? Is the fact that she generally feels well, one month after her MI, encouraging, or is this usually just the calm before the storm (i.e., cardiac remodeling)? Any insights (or directions to other resources) would be greatly appreciated. We know that it's impossible to call anything with precision...we'd just like a more clear picture of what we're likely up against.

Thanks...Brian

p.s. This is my first-ever posting to this site, so please forgive me if I did anything wrong.
 Dr. Yasser Mokhtar - Tue Dec 07, 2004 1:12 pm

User avatar Dear Brian,

The question that you are posing is not the easiest to answer.

One of the most important factors (if not the single most important) for risk stratification after an acute myocardial is how much left ventricular function is negatively affected after the event. Other factors include age, having other diseases such as diabetes and hypertension and whether there is any residual coronary ischemia.

Different studies give nearly similar percentages for annual mortality which for ef% of 21-30% was 7.7%.

In a recent study, if the ef% was < 30%, the mortality risk is decreased by one third if the patient had an aicd implanted and the benefit was greater when the ef% was < 25%.

The reason being that hald of the mortalilites is caused by deadly arrhythmias that are taken care of by the aicd.

Implanting an aicd in your wife's case is a very positive and important step in the right direction.

At the same time, your wife has to be continued on all the medications that have been found to decrease mortality as well such as the ace inhibitors and the Coreg or any of the beta blockers group and the lipid lowering agents. If your wife did not tolerate the atenolol and the lisinopril together, may be this was not a good combination for her or may be the doses were too high, i think she should be tried on lower doses of lisinopril or other medication of the ace inhibitor group, in addition she should be started on another medication that is being used widely nowadays which is aldactone if her cardiologist thinks that this is in her best interest.

At this point, i would not worry about her long term prognosis if i were you. i would make all the possibe efforts to do what her cardiologist recommend to the best of your abilities and may be add the suggestions of retrying the ace inhibitors once more as these interventions are very well proven to decrease mortality and improve the ef% and the quality of life as well.

Also, there is a fairly recent intervention called resynchronization therapy, that i am sure the electrophysiologist will talk to you about, and if he/she does not, you can mention it and see what is his/her thoughts about it.

Heart failure is a clinical syndrome, at this point your wife with just the breathlessness that she is experiencing is in a very mild degree of heart failure in my personal opinion, caused by left ventricular dysfunction with this low ef% .

The treatment of heart failure is progressing as we speak, and the future is still holding a lot of hopefully positive interventions for heart failure patients.

This is a one of the very good reviews about the predictors of mortality in patients after mi that i have bumped into recently, if you find the time, read it all, if not, you can just look through and read whatever you think is necessary. It is a little bit technical but i think that you are aware of most of the terms in it.

This is the link

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped and if you still have any clarifications don't hesitate to post them.

Yasser Mokhtar, M.D.

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