Heart Failure Prevention Post–Myocardial Infarction: 5 Things to Know

Musa A. Sharkawi, MBBCh; Ajar Kochar, MD, MHS

May 28, 2020

Editorial Collaboration

Medscape &

Heart failure (HF), a common complication of myocardial infarction (MI), occurs in 14%-36% of hospitalized patients. Patients with HF can present with a wide spectrum of clinical severity, ranging from asymptomatic left ventricular (LV) dysfunction to cardiogenic shock. Regardless of the degree of severity, the development of symptomatic HF is the most powerful predictor of short- and long-term mortality following MI.

Prognostic tools such as the Killip Classification for Heart Failure can crudely stratify the severity and prognosis of HF presentation post-MI. In addition, the size of the infarction has been correlated to the development of HF. Management of post-MI HF continues to evolve, with new therapeutic options on the horizon.

Here are five things to know about the prevention and management of HF in patients after MI.

1. Early revascularization in patients with ST-elevation MI (STEMI) and cardiogenic shock is key to improving patient outcomes.

Early revascularization is the only therapy proven to reduce mortality in patients with MI who present with cardiogenic shock. Compared with fibrinolytic therapy, primary percutaneous coronary intervention (PCI) is associated with a reduction in mortality, reinfarction, and stroke.

Infarct size correlates to a patient's risk of developing HF; as such, there is an association between prompt PCI and a reduction in infarct size and reduced 1-year mortality. It is therefore presumed that shorter door-to-balloon times decrease the risk for HF.

Other intraprocedural therapies to reduce infarct size and prevent adverse outcomes are aimed at treating patients who develop no-reflow phenomenon post-PCI (ie, insufficient myocardial perfusion is present even though the coronary artery appears patent). No-reflow can result in poor healing of the infarcted myocardium and adverse LV remodeling, increasing the risk for major adverse cardiac events, including congestive HF, and death.

There are various strategies to prevent and treat no-reflow phenomenon. Preventive strategies include:

Shortening door-to-balloon time
Treating patients prophylactically with intracoronary dilators
Selective use of thrombectomy as a bailout strategy during PCI

Treatment strategies for no-reflow phenomenon include the use of these intracoronary dilators:

Adenosine
Nitroprusside
Nicardipine
Verapamil

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