The Post MI patient Risk stratification and rehabilitation

1. The Post MI patientRisk stratification and rehabilitation Dr. Mervyn Fernando

2. 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.

3. Goals of secondary prevention • Medical goals • Psychological goals • Social goals • Health service goals

4. Goals of secondary prevention • Medical goals • Prevent sudden death • Reduce mortality • Reduce reinfarctions • Reduce symptoms

5. Goals of secondary prevention • Psychological goals • Relieve anxiety – patient & family • Self confidence • Improve quality of life • Getting back to society

6. 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

7. Key components of secondary prevention • Communication of diagnosis and advice • Lifestyleadvice • Cardiacrehabilitation • Drugtherapy • Risk stratification

8. 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.

9. Lifestyleadvice 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.

10. Components of cardiac rehabilitation Cardiac rehabilitation should include: • education • exercise • stress management

11. Exercise • Symptom limited exercise for the patient with angina • 40 minute aerobic exercise (eg. Brisk walk) for patients without angina.

12. Benefits of exercise • Metabolic benefits • Neo angiogenesis • Physical & psychological well being • Early warning if CAD progresses

13. Drugtherapy– forall All patients who have had an acute MI should be offered treatment with the following drugs: • ACE inhibitor • aspirin • beta-blocker • statin

14. 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-segment-elevation MI.

15. Drugtherapy– aldosteroneantagonists • 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.

16. Risk stratification – Why? • Identify the high risk group. • Identify the group which would benefit from early revascularization.

17. Who is at high risk? • Persistent ischaemia/failed thrombolysis • Poor LV function • Increased age • Diabetese mellitus • Anterior MI

18. Risk stratification – When? • Acute stage • At discharge • Post discharge

19. 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

20. Risk stratification at discharge • Recurrence of symptoms • 6 minute walking ECG • 2D echo • Submaximal Ex. ECG

21. Risk stratification after discharge from hospital • Reassessment of LV function • Standard Exercise ECG • Dobutamine stress echo • Thallium scan • Cardiac MRI (adenosine stress and viabilty)

22. Patients at risk should be assessed for revascularization • Secondary prevention should continue regardless of revascularization as it could slow, halt or reverse underlying atherosclerosis.

23. Thank you