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- ACE, angiotensin converting enzyme
- ARB, angiotensin II receptor blocker
- ATLAS, assessment of treatment with lisinopril and survival
- BNP, B-type natriuretic peptide
- CPAP, continuous positive airway pressure
- CONSENSUS, cooperative North Scandinavian enalapril survival study
- EPHESUS, eplerenone neurohormonal efficacy and survival study
- GMS, General Medical Services
- LVDD, left ventricular diastolic dysfunction
- LVSD, left ventricular systolic dysfunction
- MI, myocardial infarction
- MINAP, Myocardial Infarction National Audit Project
- NICE, National Institute for Clinical Excellence
- NYHA, New York Heart Association
- RALES, randomized aldactone evaluation study
- TRACE, trandolapril cardiac evaluation
Question: Regarding the timing of assessment of left ventricular function after myocardial infarction, many of the speakers have talked about the need to pick this up early and some have talked about the use of diuretics being a strong indicator for poor prognosis. What would be the best approach to identifying this high risk group of patients after myocardial infarction and when should we be doing this?
Professor Karl Swedberg: As we do not have a good surrogate for measuring left ventricular function in this context, we have to look at left ventricular function in all patients after MI using imaging such as echocardiography. We know that a high BNP level is associated with increased risk, however at present we are uncertain how to handle that in the context of treatment decisions. Hopefully, the routine measurement of BNP might be a tool for guiding care.
Professor Martin Cowie: But there is a problem in that BNP goes up in big infarcts and then you might not know quite what you are dealing with.
Dr Theresa McDonagh: I think obviously measuring left ventricular function as early as possible is good but the problem can be that some patients do improve—they have heart failure temporarily but myocardial stunning can be the initial problem, leading to decreased left ventricular function which may then recover. I would have thought the minimum standard is that every patient should have left ventricular function assessed at six weeks because that gets over that particular problem. Ideally, they should have an echocardiogram in hospital, but if this is not possible you have to screen at six weeks.
Professor John Cleland: The implication of that is that people need to be assessed twice: they need to be assessed acutely within three days, and then several weeks later to pick …