• See Also
  1. Chest Pain
  2. Cardiac Risk Factors
  3. Angina
  4. Angina Diagnosis
  5. Unstable Angina
  6. TIMI Risk Score
  7. Acute Coronary Syndrome
  8. Acute Coronary Syndrome Immediate Management
  9. Acute Coronary Syndrome Adjunctive Therapy
  10. High Risk Acute Coronary Syndrome Management
  11. Moderate Risk Acute Coronary Syndrome Management
  12. Low Risk Acute Coronary Syndrome Management
  13. Myocardial Infarction Stabilization
  14. Serum Cardiac Markers
  15. Electrocardiogram in Myocardial Infarction
  16. Echocardiogram in Myocardial Infarction
  17. Goldman Criteria for ICU Chest Pain Admission
  • Evaluation
  1. Echocardiogram
    1. Ejection Fraction is best predictor of prognosis
  2. Stress Test
    1. Indicated for Myocardial Infarction if angiography was not performed
      1. Class I evidence - standard of care (most recurrent cardiovascular events occur in the first month after Myocardial Infarction)
    2. Precautions
      1. Do not perform if revascularization was performed
      2. Must be stable for 48-72 hours prior to testing
    3. Protocols
      1. Submaximal test 3-6 days post-Myocardial Infarction (prior to discharge) or
      2. Symptom limited, maximal stress test at 2-3 weeks if not performed prior to discharge
  3. Coronary Angiogram Indications
    1. Check Re-perfusion after:
      1. Large or Anterior Myocardial Infarction
      2. Thrombolytic use
  • Management
  • Formal, consistent hospital education process
  1. See Cardiac Risk Management
  2. Review lifestyle interventions below
  3. Primary care and cardiology follow-up
  4. Review of hospital diagnoses
  5. Emergent symptoms and signs
    1. Unstable Angina
      1. Review Nitroglycerin home protocol
    2. Congestive Heart Failure
      1. Review weight monitoring
      2. Significant weight gain is 2 pounds in one day or 5 pounds overall over baseline
    3. Cerebrovascular Accident
      1. Risk increased 44 fold in first 30 days post-MI
      2. Witt (2005) Ann Intern Med 143:785-92 [PubMed]
  6. Medication Compliance is critical (review their importance and risk of stopping)
    1. Antiplatelet agents (Aspirin, Clopidogrel)
      1. See Antiplatelet Therapy for Vascular Disease
    2. Beta Blockers
    3. Statins
    4. ACE Inhibitor (or ARB Agents)
    5. Nitroglycerin as needed
    6. Consider SGLT2 Inhibitor
    7. Vaccinations (e.g. Influenza Vaccine, covid Vaccine)
  7. Identify and manage barriers to compliance
    1. Transportation to appointments
    2. Medication Cost (e.g. limit number of medications and stick to generics)
    3. Use medication Pillbox, alarms
    4. Address Major Depression (see below)
  • Management
  • Lifestyle recommendations and education
  1. Mediterranean Diet
  2. Tobacco Cessation
    1. Strongly consider Nicotine Replacement on discharge
  3. Activity
    1. Cardiac Rehabilitation
    2. Brisk walking or similar moderate intensity Exercise for 150 minutes per week
  4. Treat Comorbid Major Depression (present in 15-22%, up to 50% in some studies)
    1. See Major Depression Management after Myocardial Infarction
    2. Risk of MI related death increased 3.5 fold
    3. Screen for Major Depression in the first few months after Myocardial Infarction
  1. Walking
    1. Initiate soon after discharge
  2. Sexual activity
    1. May begin at one week following discharge
    2. Stress test predicts safety and risk of ischemia
      1. Drory (1995) Am J Cardiol 75:835-7 [PubMed]
  3. Driving
    1. May begin at 3 weeks following discharge
  4. Air travel
    1. May begin flying at 2 weeks
    2. Exception for flight earlier than 2 weeks:
      1. Symptom free AND
      2. Has Nitroglycerin AND
      3. Has a traveling partner AND
      4. Avoids increased physical exertion
  • References
  1. Anderson (2007) J Am Coll Cardiol 50(7): e1-157 [PubMed]
  2. Jneid (2012) J Am Coll Cardiol 60(7): 645-81 [PubMed]
  3. Mercado (2013) Am Fam Physician 88(9): 581-8 [PubMed]
  4. Frasure-Smith (1993) JAMA 270:1819-25 [PubMed]