Transcript The Post MI patient Risk stratification, management and

Dr. Mervyn Fernando
Historical aspect
 1930 – 6 weeks in the bed
 1940 – 6 weeks chair therapy
 1950 – 3-5minutes of walking
 1960 – cardiac rehabilitation
 1970 – 1980 specific medications
 1980 – now.... Coronary intervention era.
Goals of secondary prevention
 Medical goals
 Psychological goals
 Social goals
 Health service goals
Goals of secondary prevention
 Medical goals
 Prevent sudden death
 Reduce mortality
 Reduce reinfarctions
 Reduce symptoms
Goals of secondary prevention
 Psychological goals
 Relieve anxiety – patient & family
 Self confidence
 Improve quality of life
 Getting back to society
Goals of secondary prevention
 Social goals
 Resume work
 Achieve independence
 Health service goals
 Reduce medical cost
 Reduce admissions
 Early discharge
 Use fewer drugs as possible
Key components of secondary
prevention
 Communication of diagnosis and advice
 Life style advice
 Cardiac rehabilitation
 Drug therapy
 Risk stratification
Communication of diagnosis and
advice
After an acute MI, every discharge summary should
include,
 confirmation of the diagnosis of acute MI
 results of investigations
 future management plans
 advice on secondary prevention.
Lifestyle advice
Patients should be advised to:
• Be physically active for 20–30 minutes a day. Patients
who are not achieving this should be advised to
increase their activity in a gradual way
• Quit smoking
• Eat a Mediterranean-style diet.
Components of cardiac
rehabilitation
Cardiac rehabilitation should include:
• education
• exercise
• stress management
Exercise
 Symptom limited exercise for the patient with angina
 40 minute aerobic exercise (eg. Brisk walk) for patients
without angina.
Benefits of exercise
 Metabolic benefits
 Neo angiogenesis
 Physical & psychological well being
 Early warning if CAD progresses
Drug therapy – for all
All patients who have had an acute MI should be offered
treatment with the following drugs:
• ACE inhibitor
• aspirin
• beta-blocker
• statin
Drug therapy – Dual antiplatelet
therapy
The combination of aspirin and clopidogrel should be
prescribed:
• for 12 months after a non-ST-segment-elevation MI
 for at least 4 weeks in patients after an ST-segmentelevation MI.
Drug therapy – aldosterone
antagonists
 Patients with symptoms and signs of heart failure will
require an early assessment of LV function.
 Those with symptoms or signs of heart failure and
LVSD should be offered an aldosterone antagonist
within 3–14 days of the acute MI.
Risk stratification – Why?
 Identify the high risk group.
 Identify the group which would benefit from early
revascularization.
Who is at high risk?
 Persistent ischaemia/failed thrombolysis
 Poor LV function
 Increased age
 Diabetese mellitus
 Anterior MI
Risk stratification – When?
 Acute stage
 At discharge
 Post discharge
Risk stratification in the acute stage
 History of previous MI
 Region of MI (anterior Vs others)
 Resolution of pain
 Resolution of ST segments after thrombolysis,
dynamic ST changes, electrical instability
 Risk factors (DM, RI, anaemia)
 LV function
 Biomarkers – troponin, CRP, BNP
Risk stratification at discharge
 Recurrence of symptoms
 6 minute walking ECG
 2D echo
 Submaximal Ex. ECG
Risk stratification after discharge
from hospital
 Reassessment of LV function
 Standard Exercise ECG
 Dobutamine stress echo
 Thallium scan
 Cardiac MRI (adenosine stress and viabilty)
 Patients at risk should be assessed for
revascularization
 Secondary prevention should continue regardless of
revascularization as it could slow, halt or reverse
underlying atherosclerosis.
 Thank you