The mortality rate after
myocardial infarction fell sharply with the advent of reperfusion methods and the use of efficient antithrombotic and antiischemic drugs. However, new
infarcts,
heart failure, arrythmias and
sudden death remain frequent, especially in the first two years after the initial event. Large clinical studies have defined and validated
therapies for
secondary prevention, but the recommended measures are not always properly implemented. Patients with and without ST elevation after
myocardial infarction share the same pathophysiologic mechanism, namely
atherosclerotic plaque rupture or erosion, with different degrees of superimposed
thrombosis and distal embolization.
Secondary prevention is the same for these two patient categories.
Acute coronary syndromes are associated with an increased risk of adverse cardiovascular outcomes (new
myocardial ischemia,
left ventricular dysfunction or
sudden death) and require aggressive
secondary prevention. However, risks factors such as smoking,
hypertension,
obesity,
hypercholesterolemia and diabetes frequently persist. In addition, medical practice does not always respect consensus guidelines. Early risk stratification is necessary to detect residual
myocardial ischemia in viable myocardium. After the acute phase, the prognosis depends on the degree of
left ventricular dysfunction and the extent and severity of residual
ischemia. Exercise and ambulatory electrocardiography, stress echocardiography, perfusion scintigraphy using
vasodilator stress, magnetic resonance imaging and coronary angiography are all useful for identifying high-risk patients.
Secondary prevention should include risk factor management with lifestyle modifications such as
weight reduction, a reduction in saturated
fats and an increase in
monounsaturated fatty acids. Smoking cessation is crucial, and regular physical activity (30 min per day at least 5 days a week) is beneficial.
Cardiac rehabilitation has been shown to improve exercise tolerance and cardiovascular outcome.