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(Circulation. 1997;95:1352-1354.)
© 1997 American Heart Association, Inc.

Articles

Risk Stratification After Myocardial Infarction

Clinical Science Versus Practice Behavior

Miguel A. Quiñones, MD

the Department of Medicine, Section of Cardiology, Baylor College of Medicine, and The Methodist Hospital, Houston, Tex.

Correspondence to Miguel A Quiñones, MD, Echocardiography Laboratory, Baylor College of Medicine, The Methodist Hospital, 6550 Fannin, SM-677, Houston, TX 77030. E-mail quelq@bcm.tmc.edu

Key Words: Editorials • myocardial infarction • echocardiography

	Introduction

 
The survival of patients with acute myocardial infarction (MI) has improved considerably during the past 15 years with the advent of thrombolytic therapy, including better utilization of anticoagulants, aspirin, and cardioprotective drugs such as ß-blockers and ACE inhibitors. Despite this improvement, mortality rates after MI continue to demonstrate an early rise during the first 3 months, with a slower but steady increase afterward.¹ The principal cardiac factors influencing survival after MI are the size of the infarct and its impact on left ventricular (LV) function, the presence of residual ischemia, recurrent infarction, and ventricular arrhythmias. These factors can coexist in the same patient and exert a negative synergistic effect on survival.

There is general consensus that reduction of the risk of recurrent ischemia improves long-term survival of post-MI patients. However, there is controversy regarding the best strategy for achieving this, particularly in low-risk patients with an uncomplicated MI. A conservative strategy uses noninvasive testing to identify important risk factors and modify therapy accordingly, including the selective use of coronary revascularization procedures, whereas a more aggressive strategy involves the routine use of coronary angiography followed by revascularization of areas supplied by significant stenotic lesions.

Ejection fraction is without doubt a strong predictor of mortality in patients with acute MI. Mortality rates increase rapidly as ejection fraction falls below 40%.² Currently, ejection fraction is determined primarily with noninvasive techniques. In 1979, Theroux and associates³ reported on the use of submaximal exercise testing early after MI and demonstrated the negative impact of exercise-induced . . . [Full Text of this Article]