Unstable angina non ST elevation myocardial infarction post-discharge follow-up

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Unstable angina non ST elevation myocardial infarction post-discharge follow-up On the Web

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

In patients with UA/NSTEMI, edpecially those with high risk factors during their hospital stay, have high mortality which can be as high as 14 fold compared to those with absence of risk factors.

Clinical Trial Data

  • In a GUSTO IIa substudy[1] of UA/NSTEMI patients, prior MI, troponin-T positivity, accelerated angina before admission, and recurrent pain or electrocardiogram changes were independently associated with risk of death at 2 years. Patients who were managed with initial conservative strategy should be reassessed at the time of follow up for the need for catheterization and revascularization. The degree and severity of angina should be assessed.
  • In a study by Van Domburg et al[2], a long term follow up of patients with UA demonstrated that the mortality rate in the first year was 6%, revascularization rate was 47% in the first year, and that of MI was 11% in first year with rapid drop in subsequent yrs. Their study reported a good long-term outcome even after a complicated early course.
  • In the study using the GRACE registry database[3], nine predictive variables were identified: older age, history of MI, history of HF, increased pulse rate at presentation, lower systolic blood pressure at presentation, elevated initial serum creatinine level, elevated initial serum cardiac biomarker levels, ST-segment depression on ECG at presentation, and not having a PCI performed in the hospital. This simple tool can be used to predict risk of death at 6 month post-discharge. Certain patients at high risk of ventricular tachyarrhythmia after UA/NSTEMI may be suitable candidates for an implantable cardioverter defibrillator. Indications and timing of an implantable cardioverter defibrillator in this setting are the same as in patients with STEMI and are discussed under STEMI guidelines.

The overall long-term risk for death or MI 2 months after an episode of UA/NSTEMI is similar to that of other CAD patients with similar risk factors.

Follow-up Recommendations

  • Revascularization is recommended based on the coronary anatomy and ventricular function and recommendations are similar as for stable angina patients.
  • Medication compliance and risk factor modification should be assessed and reinforced at each follow up visit. Involving family members in the treatment plan, and adherence to the treatment regimen can improve outcomes.

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)[4]

Postdischarge Follow-Up (DO NOT EDIT)[4]

Class I

"1. Detailed discharge instructions for post UA / NSTEMI patients should include education on medications, diet, exercise, and smoking cessation counseling (if appropriate), referral to a cardiac rehabilitation / secondary prevention program (when appropriate), and the scheduling of a timely follow-up appointment. Low risk medically treated patients and revascularized patients should return in 2 to 6 weeks, and higher risk patients should return within 14 days. (Level of Evidence: C)"

"2. Patients with UA / NSTEMI managed initially with a conservative strategy who experience recurrent signs or symptoms of unstable angina or severe (Canadian Cardiovascular Society class III) chronic stable angina despite medical management who are suitable for revascularization should undergo timely coronary angiography. (Level of Evidence: B)"

"3. Patients with UA / NSTEMI who have tolerable stable angina or no anginal symptoms at follow-up visits should be managed with long term medical therapy for stable CAD. (Level of Evidence: B)"

"4. Care should be taken to establish effective communication between the post UA / NSTEMI patient and health care team members to enhance long term compliance with prescribed therapies and recommended lifestyle changes. (Level of Evidence: B)"

References

  1. Newby LK, Christenson RH, Ohman EM, Armstrong PW, Thompson TD, Lee KL, Hamm CW, Katus HA, Cianciolo C, Granger CB, Topol EJ, Califf RM (1998). "Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromes. The GUSTO-IIa Investigators". Circulation. 98 (18): 1853–9. PMID 9799204. Retrieved 2011-04-13. Unknown parameter |month= ignored (help)
  2. van Domburg RT, van Miltenburg-van Zijl AJ, Veerhoek RJ, Simoons ML (1998). "Unstable angina: good long-term outcome after a complicated early course". Journal of the American College of Cardiology. 31 (7): 1534–9. PMID 9626831. Retrieved 2011-04-13. Unknown parameter |month= ignored (help)
  3. Eagle KA, Lim MJ, Dabbous OH, Pieper KS, Goldberg RJ, Van de Werf F, Goodman SG, Granger CB, Steg PG, Gore JM, Budaj A, Avezum A, Flather MD, Fox KA (2004). "A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry". JAMA : the Journal of the American Medical Association. 291 (22): 2727–33. doi:10.1001/jama.291.22.2727. PMID 15187054. Retrieved 2011-04-13. Unknown parameter |month= ignored (help)
  4. 4.0 4.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE; et al. (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 123 (18): e426–579. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888.

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