Heart Attack Management after hospital discharge

Post-Myocardial Infarction care

Prolonged hospitalization and enforced bed rest for any illness may lead to complications (particularly in elderly patients) such as constipation, decubitus ulcerus, excessive resorbtion of bone with formation of renal calculi, atelectasis, thromboflebitis, pulmonary emboli, urinary retention, mild anemia due to repetitive blood sampling for diagnostic tests, impaired oral intake of fluids, bleeding from the gastrointestinal tract due to stress ulcers, and deconditioning of cardiovascular reflex responses to postural changes.

Because of the precarious status of the heart recovering from Heart Attack, avoidance of such complications is of primary importance. For example, constipation may lead to straining, transitory reduction of venous return and diminution of cardiac output, impaired coronary perfusion, and ventricular arrhythmias, occasionally culminating with ventricular fibrillation. Early use of bedside commode, stool softeners, and a bed-chair regimen appear to be useful in avoiding many of the difficulties encountered previously among patients with Myocardial Infarction confined to bed for several weeks.

Although concern has been raised from studies in animals that early physical activity might unfavorably influence ventricular remodelating, perhaps by causing infarct extension, no evidence indicates that this concern is relevant to patients, and early mobilization appears to be warranted in most stable Heart Attack patients. For the patient with an uncomplicated Heart Attack, washing and personal case may begin with the first 12 to 24 hours. If the convalescence continues uneventfully, limited ambulation within the room can be begun on the second or third day. Once early ambulatory activities are begun, advancement in the activity should be allowed some time after the third day.

Timing of hospital discharge

The time of discharge from the hospital is variable. Patients who have undergone aggressive reperfusion protocols and have no significant ventricular arrhythmias, recurrent ischemia, or congestive heart failure have been safely discharged in less than 5 days. More commonly, discharge occurs 5 or 6 days after admission for patients who experience no complications. Who can be followed readily at home, and those whose family setting is conductive to convalescence.

Most complications that would prelude early discharge occur within the first day or two from admission: therefore, patients suitable for early discharge can be identified early during the hospitalization. However, as noted previously, even if no complications have occurred by hospital day 3, many clinicians find it useful to keep the patient hospitalized for another 1 to 2 days to finalize the discharge prescriptions, provide additional patient education, and confirm the adequacy of the patient's support systems at home.

For patients who have experienced a complication, discharge is deferred until their condition has been stable for several days and it is clear that they are responding appropriately to necessary medication such as antiarrhythmic agents, vasodilators, or positive inotropic agents or that they have undergone the appropriate work-up for recurrent ischemia.

Counseling

Before discharge from the hospital, all patients should receive detailed instruction concerning physical activity. Initially, this should consist of ambulation at home but avoidance of isometric exercises such as lifting; several rest periods should be taken daily. In addition, the patient should be given fresh nitroglycerin tablets and instructed in their use and should receive careful instructions about the use of any other medications prescribed. Many approaches have been used, ranging from formal rigid guidelines to general advice advocating moderation and avoidance of any activity that evokes symptoms.

Sexual counseling is often overlooked during recovery of Heart Attack and should also be included as part of educational process. Such counseling should begin early after Myocardial Infarction and should include the recommendation that sexual activity be resumed after successful completion of either early submaximal or later symptom-limited exercise stress testing.

Some evidence indicates that behavioral alteration is possible after recovery from MI and that this may improve prognosis. A cardiac rehabilitation program with supervised physical exercise and an educational component has been recommended for most Myocardial Infarction patients after discharge. Although the overall clinical benefit of such programs continues to be debated, there is little question that most people derive considerable knowledge and psychological security from such interventions and they continue to be endorsed by the experienced clinicians. Psychosocial intervention programs alone have not proven to be helpful, but they are useful adjunct to standard cardiac rehabilitation programs after Heart Attack.

References:
Heart Disease, Volume 2, Eugene Braunwald, Douglas P Zipes, Peter Libby

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