Q& A With the Expert on: Coronary Artery Disease

Management of the Older Person with a Clinically Unrecognized Myocardial Infarction 

Q: A 72-year-old asymptomatic woman taking no medications had a routine 12-lead electrocardiogram obtained in her physician’s office, which showed an old anterior Q-wave myocardial infarction. She was an ex-smoker. Her body mass index was 24 kg/m2. Her blood pressure was 126/80 mm Hg. Her cardiovascular examination showed no abnormalities except for a fourth heart sound heard at the apex. Her fasting blood sugar was 95 mg/dL. Her fasting serum lipids showed a serum total cholesterol of 195 mg/dL, a serum low-density lipoprotein (LDL) cholesterol of 130 mg/dL, a serum high-density lipoprotein cholesterol of 39 mg/dL, and serum triglycerides of 130 mg/dL. A two-dimensional echocardiogram showed a left ventricular ejection fraction of 35%. How should she be managed?

A: Studies have shown that 22% to 68% of myocardial infarctions in older persons are clinically unrecognized but are diagnosed by routine 12-lead electrocardiograms. These studies have demonstrated that a clinically unrecognized myocardial infarction has the same prognosis as a clinically recognized myocardial infarction. Older persons with a clinically unrecognized or recognized myocardial infarction should have an exercise stress test performed for diagnostic and prognostic reasons.

Modifiable coronary risk factors should be treated. This woman should participate in an exercise training program if the exercise stress test shows that it is safe for her to do so.

This woman should be treated with an antiplatelet drug such as aspirin or clopidogrel indefinitely to reduce recurrent myocardial infarction, ischemic stroke, and vascular death. She needs to be treated with a low saturated fat, low cholesterol diet, and with a statin drug to reduce her serum LDL cholesterol to <70 mg/dL.

This woman should be treated with an angiotensin-converting enzyme inhibitor and with a beta blocker indefinitely to reduce all-cause mortality, new coronary events, stroke, congestive heart failure, and cardiovascular death. Beta blockers with intrinsic sympathomimetic activity should not be used. Efficacious beta blockers such as metoprolol, carvedilol, propranolol, and timolol should be used. Hormone replacement therapy and calcium channel blockers should be avoided.

Recommended Reading

Aronow WS, Fleg JL. Diagnosis of coronary artery disease in the elderly. In: Aronow WS, Fleg JL, eds. Cardiovascular Disease in the Elderly. 3rd ed, rev. New York, NY: Marcel Dekker, Inc; 2004:251-271.

Aronow WS. Management of the older patient after myocardial infarction. In: Aronow WS, Fleg JL, eds. Cardiovascular Disease in the Elderly. 3rd ed, rev. New York, NY: Marcel Dekker, Inc; 2004:329-352.

Frishman WH, Aronow WS, Cheng-Lai A. Cardiovascular drug therapy in the elderly. In: Aronow WS, Fleg JL, eds. Cardiovascular Disease in the Elderly. 3rd ed, rev. New York, NY: Marcel Dekker, Inc; 2004:95-130.