Medical management following myocardial infarction
Follow-up
Patients should be followed regularly following MI, approximately every two to three months for the first year and then twice yearly.
History and physical exam
- Ask about recurrent chest pain, dyspnea, palpitations, and syncope. Focus on early recognition of anginal symptoms and further evaluation as needed.
- Measure blood pressure at each follow-up visit and maintain at 135/85 mm Hg (lower in selected patients).
- Perform a cardiac exam including auscultation looking for new arrhythmias at every visit.
- Look for new murmurs or gallops and signs of congestive heart failure at every visit.
Laboratory testing
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Measure total cholesterol, LDL, HDL, and triglyceride levels at six to 12 weeks after discharge and at subsequent visits until goal LDL cholesterol is < 100 mg/dL is reached. HDL should be > 40 mg/dL and triglycerides <150 mg/dL. Once goal is reached, measure annually. Keep in mind that if a statin drug is prescribed, liver function tests should be drawn before starting therapy and at 12 weeks, then annually thereafter. A creatinine kinase level should be obtained before starting therapy and if muscle soreness or tenderness develops during treatment.
Measure total cholesterol, LDL, HDL, and triglyceride levels at six to 12 weeks after discharge - Measure C-reactive protein (serum value, normal < 2.0 mg/L) to identify other potential risk factors for atherosclerotic disease on initial visit after discharge. Elevated levels may indicate a higher risk for a second event.
- Perform submaximal electrocardiogram (ECG) stress testing with or without nuclear testing or echocardiogram (ECHO) stress testing at four to six days after discharge or symptom limited stress test 10-14 days after discharge.
- Perform echocardiography before discharge and then as clinical signs and symptoms dictate. Perform ECHO to assess regional wall motion abnormalities, valvular incompetency, and LV function.
Patient education
- Urge exercise either by referral to a formal cardiac rehabilitation program or by establishing a home exercise program.
- Counsel regarding a heart healthy diet and consider providing a referral to dietician.
- Counsel patients who smoke about smoking cessation.
- Review symptoms requiring physician notification or need for emergency room visit.
Drug therapy
- Review medications begun in the hospital, including beta-blockers, ACE inhibitors, aspirin, statins, nitrates, and anticoagulants, and continue as appropriate. Review dose and adherent to regimen at each visit. Measure international normalized ratio (INR) every two to four weeks once levels are stable; long-term anticoagulation is only recommended in patients who are in persistent atrial fibrillation post-MI or in patients with LV thrombus by ECHO.
- Consider prescribing folic acid (1 mg/d), which has been shown to reduce serum levels of homocysteine. Evidence for the benefit of lowering homocysteine is lacking but preliminary data suggests that folic acid therapy may be beneficial in some high-risk patients.
- Review hormone therapy (HT) in women. Initiation of HT in post-menopausal women with CAD is contraindicated. Whether HT should be stopped in women who are already receiving it is unknown.
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