8.
Long-Term Management
8.1. Psychosocial Impact of STEMI
Class I
The psychosocial status of the patient should be evaluated, including
inquiries regarding symptoms of depression, anxiety, or sleep disorders
and the social support environment. (Level of Evidence: C)
Class
IIa
Treatment with cognitive-behavioral therapy and selective serotonin
reuptake inhibitors can be useful for STEMI patients with depression
that occurs in the year after hospital discharge. (Level of
Evidence: A)
Depression is a common consequence of STEMI, with major depression
occurring in 15% to 20% of patients with STEMI and some degree of
clinically significant depression occurring in up to half (1339).
Most studies have found depression to be a significant independent
predictor of post-MI mortality (1340-1345),
although others have not (1346,1347).
An ancillary follow-up study from the ENRICHD trial (Enhancing Recovery
in Coronary Heart Disease) of a subsample of 358 depressed patients
with an acute MI compared with 408 nondepressed patients found that
the depressed patients were at higher risk for all-cause mortality
but not until nearly 12 months after the acute event. Depression
did not predict nonfatal recurrent infarction (1348).
The excess risk associated with depression soon after STEMI remains
significant for a longer time than previously thought, and a dose-response
relationship exists between depression and mortality. The level
of depression symptoms at the time of STEMI admission is more closely
linked to long-term (5-year) survival than the level at 1 year,
notably so in patients with moderate to severe levels of depression.
Even minimal degrees of depression appear to confer risk, and risk
increases with degree of depression as measured on the Beck Depression
Inventory (1340). Depression markedly
decreases quality of life for post-STEMI patients (1339,1346,1347,1349,1350)
and is associated with substantially greater costs (1341).
Fatigue does not explain the impact of STEMI in producing depression
(1343), nor do infarct size, LV
function, or other physiological variables predict the degree of
depression (1345,1339).
Depression rather than physiological variables predicts failure
to return to usual activity and failure of social role resumption
after MI (1351). Depressed patients
are less likely to complete cardiac rehabilitation and less likely
to adhere to important lifestyle changes and medications. (1352,1353).
Treatment of depression with combined cognitive-behavioral therapy
and selective serotonin reuptake inhibitors improves outcome in
terms of depression symptoms and social function (1350,1354,1355).
A double-blind study comparing sertraline and placebo found that
sertraline was associated with clinically meaningful improvement
in multiple quality-of-life domains in patients hospitalized with
acute coronary syndrome (74% of which was acute MI) in the previous
month who had recurrent depression (1350).
Although one randomized controlled trial showed no reduction in
mortality or reinfarction (1355),
a reanalysis suggested its follow-up was not long enough to demonstrate
effect, and indeed, depression was associated with mortality in
that study (1348). Therefore,
it appears prudent to assess patients with STEMI for depression
during hospitalization and during the first month after STEMI and
to intervene and reassess yearly in the first 5 years, as appropriate.
There is evidence that
the STEMI experience, with its sudden and unexpected onset, dramatic
changes in lifestyle, and the additive effort of comorbid life events,
is a relatively traumatic event and may produce impaired coping
during subsequent ischemic events (1356).
Social integration and social support repeatedly have been shown
to influence outcomes after STEMI. Social integration refers to
the existence of social ties (e.g., spouse, close family members,
or friends) and degree of participation in group activities (e.g.,
family gatherings, religious affiliations). Social support refers
to the actual or perceived receipt of information, materials, and/or
emotional support.
Mortality from all causes, including ischemic heart disease, is
lower in socially integrated individuals (1357).
Recurrent cardiac events are also significantly lower among persons
reporting high levels of social integration than among socially
isolated persons (1358,1359).
When social support was clearly defined and measured and the effect
of depression was controlled for, a large prospective trial (1360)
demonstrated that support did not directly predict post-MI mortality.
However, high levels of support mitigated the effect of depression
on post-MI mortality. A randomized controlled trial of a social
support and depression management intervention similarly did not
demonstrate reduced mortality (1355)
but did significantly reduce social isolation.
The most effective social support interventions occur naturally.
The quality of the support provided is key; support has been shown
to facilitate treatment compliance, but only when policing is minimized
(1362). Overprotectiveness and
withholding of information or worries, either of the patient by
family members or vice versa, is associated with worse outcomes
(1363,1364).
Telephone follow-up, cardiac rehabilitation, or other group events
can be effective methods of support for socially isolated individuals
(1365).
Anxiety is prevalent among hospitalized patients with STEMI but
declines relatively rapidly after discharge to levels typical of
the general medical population (1366).
Anxiety is predictive of in hospital recurrent ischemia and arrhythmias
after MI (707), and physicians’
and nurses’ subjective judgments of patient anxiety are not
accurate compared with measurement on validated scales (709).
At least one randomized controlled trial demonstrates that in-hospital
anxiety and depression can be reduced by a structured nursing support
intervention (714), and secondary
analysis of a longer-term trial suggests that both long-term psychosocial
distress and health outcomes may benefit (1367).
Anxiety should be assessed at the time of hospital discharge of
patients hospitalized for STEMI. A number of studies have examined
psychological intervention programs designed to help post-MI patients’
psychosocial and emotional adjustment. Two large post-MI programs
(1341,1368)
failed to achieve positive outcomes on psychological factors or
prognosis. Some have observed that the type of approach used with
patients recovering from MI varies in terms of its association with
anxiety reduction (1367,1369).
Nevertheless, one meta-analysis reported that the addition of psychosocial
interventions to standard treatment resulted in significantly less
depression, anxiety, morbidity, and mortality (1370).
Psychosocial interventions in cardiac rehabilitation were found
in another review to improve the odds for mortality and recurrence
of nonfatal MI, but not necessarily with regard to females and older
participants (1369). A secondary
analysis of a longerterm trial suggests that both long-term psychosocial
prognosis and health outcomes may improve in patients whose psychological
status improves (1367).
8.2. Cardiac Rehabilitation
Class I
Cardiac rehabilitation/secondary prevention programs, when available,
are recommended for patients with STEMI, particularly those with
multiple modifiable risk factors and/or those moderate- to high-risk
patients in whom supervised exercise training is warranted. (Level
of Evidence: C)
Cardiac rehabilitation programs are designed to limit the physiological
and psychological effects of cardiac illness, reduce the risk for
sudden death or reinfarction, control cardiac symptoms, stabilize
or reverse the atherosclerotic process, and enhance the psychosocial
and vocational status of selected patients (1184,1371,1372).
Cardiac rehabilitation is a comprehensive long-term program that
involves medical evaluation, prescribed exercise, cardiac risk factor
modification, education, and counseling (1184,1373).
Cardiac rehabilitation can occur in a variety of settings, including
supervised groups in a hospital, physician’s office, or community
facility. In clinically stable lower-risk patients, rehabilitation
can be undertaken independently, with regular guidance from a cardiac
rehabilitation healthcare professional (1184).
The exercise can be supervised or unsupervised and can involve a
stationary bicycle, treadmill, calisthenics, walking, or jogging.
Home exercise training programs have been shown to be beneficial
in certain low-risk patient groups. They offer the advantages of
convenience and low cost but lack the valuable elements of education
and group interaction (1374).
The pooled effect estimate for total mortality for the exercise-only
intervention demonstrated a reduction in all-cause mortality (random
effects model OR 0.73 [0.54, 0.98]) compared with usual care. Comprehensive
cardiac rehabilitation reduced all-cause mortality but to a lesser
degree (OR 0.87 [0.71, 1.05]). Neither of the interventions had
any effect on the occurrence of nonfatal MI. The authors concluded
that exercise-based cardiac rehabilitation appeared to be effective
in reducing cardiac deaths but that it was still unclear whether
an exercise-only or a comprehensive cardiac rehabilitation intervention
was more beneficial. The population studied was predominantly male,
middle-aged, and low risk. The authors suggested that those who
may have benefited from the intervention were excluded owing to
age, gender, or comorbidity. The authors cautioned that the results
were of limited reliability because the quality of reporting in
the studies was generally poor, and there were high losses to follow-up
(1373).
Cardiac rehabilitation comprising exercise training and education,
counseling, and behavioral interventions yielded improvements in
exercise tolerance with no significant cardiovascular complications,
improvements in symptoms (decreased anginal pain and improved symptoms
of heart failure such as shortness of breath and fatigue), and improvements
in blood lipid levels; reduced cigarette smoking in conjunction
with a smoking cessation program; decreased stress; and improved
psychosocial well-being (1184).
In addition to reductions in total cholesterol and LDL-C, increases
in HDL levels have been reported (1197).
Existing community studies reveal that fewer than one third of patients
with STEMI receive information or counseling about cardiac rehabilitation
before being discharged from the hospital (1184,1375).
Only 16% of patients in a study of 5 hospitals in 2 Michigan communities
were referred to a cardiac rehabilitation program at discharge,
and only 26% of the patients later interviewed in the community
reported actual participation in such a program. However, 54% of
the patients referred at discharge did participate at the time of
their follow-up interview (1375).
Physician referral (to a cardiologist/cardiac surgeon) was the most
powerful predictor of patient participation in a cardiac rehabilitation
program.
In a longitudinal study of the use of inpatient cardiac rehabilitation
in 5204 Worcester, MA, residents hospitalized with MI in 7 1-year
periods between 1986 and 1997, patients not referred to inpatient
cardiac rehabilitation were less likely to be prescribed effective
cardiac medications and to undergo risk factor modification counseling
before discharge (1376).
Patient reasons for nonparticipation and noncompliance include affordability
of service, possible insurance coverage, social support from a spouse
or other caregiver, gender-specific attitudes, patient-specific
internal factors such as anxiety or poor motivation, and logistical
and financial constraints, or a combination of these factors (1375,1377).
Women and the elderly have been reported to be referred less frequently
to cardiac rehabilitation programs, even though they have been reported
to derive benefit (1378-1380).
8.3. Follow-Up Visit With Medical
Provider
Class I
1. A follow-up visit should delineate the presence or absence of
cardiovascular symptoms and functional class. (Level of Evidence:
C)
2. The patients’ list of current medications should be reevaluated
in a follow-up visit, and appropriate titration of ACE inhibitors,
beta-blockers, and statins should be undertaken. (Level of Evidence:
C)
3. The predischarge risk assessment and planned workup should be
reviewed and continued (Figure 36).
This should include a check of LV function and possibly Holter monitoring
for those patients whose early post-STEMI ejection fraction was
0.31 to 0.40 or lower, in consideration of possible ICD use (Figure
32). (Level of Evidence: C)
4.
The healthcare provider should review and emphasize the principles
of secondary prevention with the patient and family members (Table
32) (68). (Level of Evidence:
C)
5. The psychosocial status of the patient should be evaluated in
follow-up, including inquiries regarding symptoms of depression,
anxiety, or sleep disorders and the social support environment.
(Level of Evidence: C)
6. In a follow-up visit, the healthcare provider should discuss
in detail issues of physical activity, return to work, resumption
of sexual activity, and travel, including driving and flying. The
MET values for various activities are provided as a resource (Table
34). (Level of Evidence: C)
7. Patients and their families should be asked if they are interested
in CPR training after the patient is discharged from the hospital.
(Level of Evidence: C)
8. Providers should actively review the following issues with patients
and their families:
a. The patient’s heart attack risk. (Level of Evidence:
C)
b. How to recognize symptoms of STEMI. (Level of Evidence: C)
c. The advisability of calling 9-1-1 if symptoms are unimproved
or worsening after 5 minutes, despite feelings of uncertainty about
the symptoms and fear of potential embarrassment. (Level of
Evidence: C)
d. A plan for appropriate recognition and response to a potential
acute cardiac event, including the phone number to access EMS, generally
9-1-1. (Level of Evidence: C)
9. It is reasonable that patients be referred to a structured cardiac
rehabilitation program after hospital discharge. (Level of Evidence:
C)
A caring and supportive doctor-patient relationship is vital to
the well-being of the survivor and their families. It is common
practice to see these patients 3 to 6 weeks after hospital discharge
to assess their progress.
The physician should listen to the concerns of their patients and
their patients’ families and respond flexibly. Future appointments
should be scheduled and should reflect the goals set for each individual
patient in accordance with their needs and current guidelines.
8.4. Return to Work and Disability
Return-to-work rates, which currently range from 63% (1381)
to 94% (1382), are difficult to
influence because they are confounded by factors such as job satisfaction,
financial stability, and company policies (1383).
In PAMI-II, a study of primary PTCA in low-risk patients with STEMI
(i.e., age less than 70 years, ejection fraction greater than 0.45,
1- or 2-vessel disease, and good PTCA result), patients were encouraged
to return to work at 2 weeks. The actual timing of
return to work was not reported, but no adverse events occurred
as a result of this strategy (1384).
Disability. There is some evidence that a cardiac rehabilitation
program after STEMI contributes to reduction of mortality and improved
physical and emotional well-being (see Section 8.2). Patients whose
expectations for return to work were addressed in rehabilitation
returned to work at a significantly faster rate than the control
group in a prospective study (1385).
A low level of depressive symptoms before STEMI increases the odds
of recovery of functional status (1386).
Patients with high pre-STEMI functional independence measurement
have shorter length of stay and greater likelihood of discharge
to home (1387). Pre-STEMI peak
aerobic capacity and depression score are the best independent predictors
of post-STEMI physical function. Women tend to have lower physical
function scores than men of similar age, depression score, and comorbidity.
Resting LVEF is not a predictor of physical function score.
Patients’ cardiac functional states are not a strong predictor
of their probability of returning to work. Diabetes, older age,
Q-wave MI, and preinfarction angina are associated with failure
to resume full employment (1388).
However, psychological variables such as trust, job security, patient
feelings about disability, expectations of recovery by both physician
and patient, and degree of somatizing are more predictive (1389,1390).
Physical requirements of the job play a role as well (1388,1390).
To aid occupational physicians in making return-to-work decisions,
Froom et al. (1388) studied the
incidence of post- MI events at 1, 2, 4, 6, 9, and 12 months. The
events included cardiac death, recurrent infarction, CHF, and unstable
angina. They found that the incidence of events reached a low steady
state at 10 weeks.
Return to work can be determined by employer regulations rather
than by the patient’s medical condition. It behooves the physician
to provide data to prove that the patient’s job does not impose
a prohibitive risk for a cardiac event. An example is the case of
the Canadian bus drivers reported by Kavanagh et al. (1391).
The patients were evaluated with a stress test. The physician and
technologist studied the drivers at work and showed that the cardiac
stress values during driving were only half of the average values
obtained in the stress laboratory. The calculated risk of sudden
cardiovascular incidence causing injury or death to passengers,
other road users, and the drivers in the first year after recovery
from an MI was 1 in 50 000 driving years. The bus drivers were allowed
to return to work after they satisfied the Canadian Cardiovascular
Society guidelines.
Women have entered the job market and are faced not only with the
gender difference but in procedure difference and mortality. Covinsky
et al. (1392) performed a mail
survey study of patients with MIs. Three months after discharge,
women reported worse physical and mental health and were more likely
to work less than before the MI. Similarly, women were less likely
to return to work than men.
The
current aggressive interventional treatment of STEMI will have an
impact on mortality, morbidity, and hospital length of stay (696).
It remains to be determined whether earlier improvement in cardiac
condition after STEMI will have an effect on the rate of return
to work because of the multiple noncardiac factors that influence
disability and return to work.
8.5. Other Activities
In patients who desire to return to physically demanding activities
early, the safety of activity can be determined by comparing performance
on a graded exercise test with the MET level required for the desired
activity. Table 34 presents energy
levels, expressed in METs, required to perform a variety of common
activities (1393). This and similar
tables can be helpful in translating a patient’s performance
on a graded exercise test into daily activities that may be undertaken
with reasonable safety.
The physician should provide explicit advice about when to return
to previous levels of physical activity, sexual activity, and employment.
Daily walking can be encouraged immediately (1394).
In stable patients without complications (class I), sexual activity
with the usual partner can be resumed within 1 week to 10 days.
Driving can begin 1 week after discharge if the patient is judged
to be in compliance with individual state laws. Each state’s
Department of Motor Vehicles or its equivalent has mandated certain
criteria, which vary from state to state and must be met before
operation of a motor vehicle after serious illness (1395)
These include such caveats as the need to be accompanied and to
avoid stressful circumstances such as rush hour, inclement weather,
night driving, heavy traffic, and high speeds. For patients who
have experienced a complicated STEMI (one that required CPR or was
accompanied by hypotension, serious arrhythmias, highdegree block,
or CHF), driving should be delayed 2 to 3 weeks after symptoms have
resolved.
Most commercial aircraft are pressurized to 7500 to 8000 feet and
therefore could cause hypoxia due to the reduced alveolar oxygen
tension. The maximum level of pressurization is limited to 8000
feet (2440 meters) by Federal Aviation Administration regulation
(1396). Therefore, air travel
within the first 2 weeks of STEMI should be undertaken only if there
is no angina or dyspnea at rest or fear of flying. The individual
must have a companion, carry nitroglycerin, and request airport
transportation to avoid rushing (personal communication, R.P. Gardner,
PhD, November 2002). Air travel for cardiac patients should gradually
become safer. Availability of an emergency medical kit and AED has
been mandated for April 12, 2004, (1398)
in all aircraft that carry at least approximately 30 passengers
and have at least 1 flight attendant.
STAFF
American College of Cardiology
Christine W. McEntee, Chief Executive Officer
Katherine D. Doermann, Specialist, Knowledge Development
Kristina N. Petrie, MS, Research Analyst, Knowledge Development
American Heart Association
M. Cass Wheeler, Chief Executive Officer
Rose Marie Robertson, MD, FACC, FAHA, Chief Science Officer
Kathryn A. Taubert, PhD, FAHA, Vice President, Science and Medicine
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