Unstable angina non ST elevation myocardial infarction post-discharge follow-up: Difference between revisions
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==Overview of Post-Discharge Follow-Up in UA / NSTEMI== | ==Overview of Post-Discharge Follow-Up in UA / NSTEMI== | ||
Patients with UA/NSTEMI, specially those with high risk factors during hospital stay, have high mortality which can be as high as 14 fold compared to those with absence of risk factors. In a GUSTO IIa substudy<ref name="pmid9799204">{{cite journal |author=Newby LK, Christenson RH, Ohman EM, ''et al.'' |title=Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromes. The GUSTO-IIa Investigators |journal=Circulation |volume=98 |issue=18 |pages=1853–9 |year=1998 |month=November |pmid=9799204 |doi= |url=}}</ref> of UA/NSTEMI patients, prior MI, TnT positivity, accelerated angina before admission, and recurrent pain or ECG changes were independently associated with risk of death at 2 years. | Patients with UA/NSTEMI, specially those with high risk factors during hospital stay, have high mortality which can be as high as 14 fold compared to those with absence of risk factors. In a GUSTO IIa substudy<ref name="pmid9799204">{{cite journal |author=Newby LK, Christenson RH, Ohman EM, ''et al.'' |title=Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromes. The GUSTO-IIa Investigators |journal=Circulation |volume=98 |issue=18 |pages=1853–9 |year=1998 |month=November |pmid=9799204 |doi= |url=}}</ref> of UA/NSTEMI patients, prior MI, TnT positivity, accelerated angina before admission, and recurrent pain or ECG 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''<ref name="pmid9626831">{{cite journal |author=van Domburg RT, van Miltenburg-van Zijl AJ, Veerhoek RJ, Simoons ML |title=Unstable angina: good long-term outcome after a complicated early course |journal=J. Am. Coll. Cardiol. |volume=31 |issue=7 |pages=1534–9 |year=1998 |month=June |pmid=9626831 |doi= |url=}}</ref>, 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. | |||
The study using GRACE registry database<ref name="pmid15187054">{{cite journal |author=Eagle KA, Lim MJ, Dabbous OH, ''et al.'' |title=A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry |journal=JAMA |volume=291 |issue=22 |pages=2727–33 |year=2004 |month=June |pmid=15187054 |doi=10.1001/jama.291.22.2727 |url=}}</ref>, 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 presenting ECG, 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 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. | |||
During follow up visits, cardiac catheterization with coronary angiography is recommended for any of the following situations: | |||
:1) significant increase in anginal symptoms, including recurrent UA | |||
:2) high-risk pattern (e.g., at least 2 mm of ST-segment depression, systolic blood pressure decline of at least 10 mm Hg) on exercise test | |||
:3) Heart failure | |||
:4) angina with mild exertion (inability to complete stage 2 of the Bruce protocol for angina) | |||
:5) survivors of sudden cardiac death. | |||
Revascularization is recommended based on the coronary anatomy and ventricular function and recommendations are similar as for stable angina patients. | |||
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Overview of Post-Discharge Follow-Up in UA / NSTEMI
Patients with UA/NSTEMI, specially those with high risk factors during hospital stay, have high mortality which can be as high as 14 fold compared to those with absence of risk factors. In a GUSTO IIa substudy[1] of UA/NSTEMI patients, prior MI, TnT positivity, accelerated angina before admission, and recurrent pain or ECG 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. The study using 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 presenting ECG, 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 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.
During follow up visits, cardiac catheterization with coronary angiography is recommended for any of the following situations:
- 1) significant increase in anginal symptoms, including recurrent UA
- 2) high-risk pattern (e.g., at least 2 mm of ST-segment depression, systolic blood pressure decline of at least 10 mm Hg) on exercise test
- 3) Heart failure
- 4) angina with mild exertion (inability to complete stage 2 of the Bruce protocol for angina)
- 5) survivors of sudden cardiac death.
Revascularization is recommended based on the coronary anatomy and ventricular function and recommendations are similar as for stable angina patients.
ACC / AHA Guidelines (DO NOT EDIT) [4]
| “ |
Class I1. 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) |
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See Also
Sources
- The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction [4]
References
- ↑ Newby LK, Christenson RH, Ohman EM; et al. (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. Unknown parameter
|month=ignored (help) - ↑ van Domburg RT, van Miltenburg-van Zijl AJ, Veerhoek RJ, Simoons ML (1998). "Unstable angina: good long-term outcome after a complicated early course". J. Am. Coll. Cardiol. 31 (7): 1534–9. PMID 9626831. Unknown parameter
|month=ignored (help) - ↑ Eagle KA, Lim MJ, Dabbous OH; et al. (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. 291 (22): 2727–33. doi:10.1001/jama.291.22.2727. PMID 15187054. Unknown parameter
|month=ignored (help) - ↑ 4.0 4.1 Anderson JL, Adams CD, Antman EM; et al. (2007). "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/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". JACC. 50 (7): e1–e157. PMID 17692738. Text "doi:10.1016/j.jacc.2007.02.013 " ignored (help); Unknown parameter
|month=ignored (help)