Post-MI Care and Management

Michael D. Eisenhauer MD MBA FACC FSCAI FACHE

Montana STEMI Conference

12 February, 2020

Disclosures

• No financial disclosures

• Content is attributable to the presenter only and reflect my own personal views and approach to post-MI care, as extrapolated from available clinical practice guidelines • Not representing current employer (Benefis Healthcare System)

Clinical Practice Guidelines?

• ACC CPG for STEMI • Sections 8-11

• Look to the ESC for additional guidance…also contained within their STEMI guidelines.

• Will attempt to cover high-points today of interest to CAH providers

Overview

Management principles at time

of Discharge

Routine Medical Therapies

Secondary Risk Factor

Modification

Complications post-MI

• Mechanical, Electrical, Inflammatory

Risk Assessment post-MI

Importance of LV assessment post-MI

Activity/Rehab recommendations

Immediate post-MI in

hospital

PCI performed, or received Thrombolysis?

•CCU/ICU observation is preferred > PCU or step-down, for at least 24 hours

Telemetry for at least 24 hours

•Consider longer for patients with intermediate- or high-risk for arrhythmia

•Hemodynamically unstable, presenting dysrhythmia, LVEF <40%, failed reperfusion, add‟l untreated coronary stenoses, PCI complications

Early Ambulation (day 1)

Length of Stay can be individualized

•Several studies show low-risk patients = 2-3 days after revascularization

•Don‟t rush it:

•Proper education, discharge planning, rehab initiation, address co-morbidities

•In large cities, not uncommon to return patient to referring facility same-day

All patients require LV function assessment

Routine Medical

Therapies

Routine Medical Therapies

• B-Blockade • Class I: start in first 24 hours!

• Unless s/sx‟s of HF, low output state, increased risk cardiogenic shock, high grade AVBlock, reactive airways (?)

• Reassess at 24 hours if had initial contraindications

• CONTINUE FOR ALL patients during and after hospitalization (w/o contraindication)

Routine Medical Therapies

• Renin-Angiotensin-Aldosterone System Inhibitors • Class I: start in first 24 hours!

• ACE-I for all STEMI with anterior MI, EF <40%, clinical HF if not contraindicated • (hypotension, shock, bilateral RAS, h/o worsening renal function, acute renal failure,

allergy)

• ARB should be given if intolerant of ACE-I • Valsartan (VALIENT trial)

• Class I: • Aldosterone antagonist for all STEMI who are already receiving an ACE-I + BB and who

have LVEF <40% and have either symptomatic HF or Diabetes. • Spironolactone, Eplerenone (EPHESUS trial) within 7 days

• Class IIa: • ACE-I reasonable for all STEMI and no contraindications

Routine Medical Therapies

• Lipid Management • Class I:

• High-intensity statin should be initiated or continued in ALL patients with STEMI and no contraindication

• Class IIa:

• Reasonable to obtain a fasting lipid profile in STEMI, preferably within 24 hours of presentation

• Statin therapy is beneficial even if LDL <70 !

Routine Medical Therapies

• Nitrates • “…although nitrates can ameliorate symptoms and signs of myocardial

ischemia by reducing LV preload and increasing coronary blood flow, it generally does not attenuate myocardial injury associated with epicardial coronary occlusion…unless vasospasm plays a role”

• Avoid: hypotension, marked tachy or brady, RV infarction, or 5‟PDE Inhibitors within prior 24-48 hours.

• No role for routine use of nitrates in the convalescent phase of STEMI

Routine Medical Therapies

• Calcium Channel Blockers • “…an overview of 28 RCT‟s involving 19,000 patients demonstrated no

beneficial effect on infarct size or the rate of reinfarction…”

• May be useful to relieve ongoing ischemia, treat HTN, or control ventricular response rate to Afib in patients intolerant of BBlockade.

• The use of inmmediate-release Nifedipine is contraindicated in STEMI patients due to hypotension and reflect sympathetic activation with tachycardia

Routine Medical Therapies

• Oxygen • “…few data exist to support or refute the value of routine use of oxygen in

the acute phase of STEMI…more research is needed…” • Cochrane Metaanalysis of 3 trials demonstrated a 3-fold higher risk of death in patients

with proven STEMI treated with oxygen vs. room air.

• Appropriate if O2 sat <90%

• Placebo effect?

• May increase coronary vascular resistance

• Use caution if h/o COPD or CO2 retention

Routine Medical Therapies

• Analgesics: Morphine, NSAID, Cox-II Inhibitors • Morphine is drug of choice (especially if acute pulmonary edema)

• “…epidemiological studies and retrospective analyses of RCTs have suggested that NSAIDs and Cox-II Inhibitors may be associated with an increased risk of death, reinfarction, cardiac rupture, hypertension, renal insuffiency, and CHF…”

Complications after STEMI

Cardiogenic Shock

• Class I: Early Revascularization!

• Class IIa: IABP can be useful for patients with CS after STEMI who do not quickly stabilize with Rx therapies

• Class IIb: LV Assist devices (Impella, LVAD, ECMO) for circulatory support may be considered for refractory CS

Mechanical Complications post-MI

• Bimodal, temporal distribution: • First 24 hours, and then within the first week or so

• New systolic murmur • Mitral regurgitation: Papillary muscle rupture, or LV remodeling with pap

muscle displacement, leaflet tethering, and/or annular dilatation

• Posteromedial pap muscle more common: singular blood supply

• Acute, Severe MR: pulmonary edema +/- shock, the murmur may not always be easy to auscultate

• Temporize with IABP, meds early surgery.

• 20% surgical mortality

• Functional/ischemic MR: reperfusion, diuresis, afterload reduction

Mechanical Complications post-MI

• New systolic murmur (cont.) • Ventricular septal rupture (VSD): loud systolic murmur, CHF/shock,

depending upon size of shunt • Temporize with inotropes, IABP, vasodilators early surgery (favored strongly

over perc closure)

• 20% surgical mortality

• LV free wall rupture: chest pain, ecg changes, rapid hemodynamic collapse, EMD, frequent death. • More frequent with 1st MI, women, elderly, severe HTN, absence of collateral

coronary supply

• Avoid steroids, NSAIDs, fibrinolytics > 14 hours post-onset

• 60% surgical mortality

Mechanical complications post-MI

• LV Aneurysm • Occurs <5% of STEMI, more frequent if anteroapical MI.

• Incidence has fallen with improvements in timely revasc

• Surgery is rarely needed

• Reserved for CHF, refractory arrhythmia, recurrent thromboembolism

• Consider anticoagulation for 3-6 months post MI

Electrical Complications; hospital phase

• Ventricular arrhythmias • Class I: ICD therapy before discharge in patients with sustained VT/VF more

than 48 hours after STEMI, provided not due to continuing ischemia, reinfarction or metabolic anomalies

• Non-sustained VT, PVC, or Idioventricular rhythms that emerge after reperfusion are not indicative of SCD risk and do not require specific therapy

• Atrial Fib, other SVT • Afib 8-22% of post-STEMI patients

• If hemodynamically unstable DCCV

• Bradycardia, AVBlock, Conduction defects • Class I: temporary pacing indicated for symptomatic bradyarrhythmias

unresponsive to medical treatment

• Sinus brady is common.

• CHB <7% incidence

Pericarditis post-MI

• Dressler‟s Syndrome: • Incidence has decreased with reperfusion therapies

• Recurrent chest pain: positional, pleuritic, radiates, + friction rub, ecg changes • Dressler‟s = malaise, fatigue, fever, inflammatory biomarkers, and CP persisting

> 1 week post-MI

• Class I: Glucocorticoids and NSAIDs are potentially harmful for treatment of pericarditis post-STEMI.

• Colchicine

• Be careful with anticoagulants

Thromboembolic and Bleeding complications post-MI

Thromboembolic complications

post-MI

Heparin-induced Thrombocytopenia

•1-5% of patients who receive heparin

Bleeding Complications

• Independently associated with recurrent MI, CVA, death, longer hospital stay, increased cost

•GI, CVA/ICH, Vascular access site, etc.

Thromboembolic complications post-MI

• Anticoagulation Recommendations: • Class I: Coumadin for STEMI = Afib with CHADS2 score >2, mechanical

valves, DVT, or hypercoagulable disorder

• Duration of “triple therapy” should be minimized to extent possible to reduce bleeding

• Class IIa: Coumadin is reasonable for STEMI patients with asymptomatic LV mural thrombi

• Class IIb: A/C therapy may be considered for STEMI with anteroapical akinesis or dyskinesis

• Targeting a lower INR 2-2.5 might be considered in STEMI patients receiving DAPT

Metabolic complications post-MI

Metabolic complications

post-MI

Acute Kidney Injury

• Contrast-induced nephropathy

• Hydration, minimize contrast load

• Dialysis usually transient

Hyperglycemia

• Mortality rate associated with hypoglycemia appears to be as high as with hyperglycemia.

• Increased mortality seen with „tight‟ control (BG 80-108) [NICE-SUGAR trial]

• „Modest‟ control is advised (BG <180)

• No role established for glucose-insulin-potassium infusions

Risk Assessment after MI

Non-Invasive testing for ischemia before D/C

• Individualize strategies: • Class I: non-invasive testing for ischemia indicated prior to d/c to assess

presence and extent of ischemia in STEMI patients who have not had coronary angiography and do not have high-risk features for which angiography would be warranted

• Class IIb: non-invasive testing might be considered before d/c to evaluate the functional significance of a non-infarct artery stenosis previously identified at angiography • Non-invasive testing for ischemia might be considered before d/c to guide post-D/C

to guide an exercise prescription

• Wait a minimum of 48-72 hours post-MI • Traditionally, 3-5 days post-MI

• “Low-level” stress; “Symptom-limited” stress

Assessment of LV Function before D/C

• Class I: LVEF should be measured in all patients with STEMI

• Ventriculography during cath, or

• ECHO on day 2 or 3

• If LVEF <40%, should be re-evaluated >40 days later • To address potential need for ICD therapy

• Allows for recovery of myocardial stunning

Assessment of LV Function after D/C

• Class I: STEMI with an initial LVEF <40% who are potential candidates for ICD therapy should have reassessment of LVEF 40 or more days after discharge

• DINAMIT trial: ICD between days 6-40 showed no benefit

• IRIS trial: early ICD post-MI with (1) LVEF<40 + tachycardia, or (2) NSVT regardless of LVEF did not improve survival

• VEST trial: utility of a wearable cardioverter-defibrillator vest in high-risk patients in the first 4-6 weeks is supported

Device Therapy >40 days post-MI

• MADIT 2 and SCDHeFT • ICD recommended for primary prophylaxis against SCD:

• If LVEF <35% and NYHA II-III symptoms

• If LVEF <30% irrespective of symptoms

• Resynchronization Therapy • Residual LVEF <30%, NYHA > Class I, QRS duration (>150ms), LBBB

morphology

Posthospitalization Plan of Care

Posthospitalization Plan of Care

• Class I: • Systems of care designed to prevent hospital readmissions should be used to

facilitate the transition to effective, coordinated outpatient care for all STEMI patients

• Exercise-based cardiac rehabilitation/secondary prevention programs are recommended for ALL patients with STEMI

• A clear, detailed, and evidence-based plan of care that promotes medication adherence, timely follow-up, appropriate dietary and physical activities, and compliance with interventions should be provided

• Encouragement and advice to stop smoking and to avoid second-hand smoke should be provided

Smoking Cessation

• Metanalysis of cohort studies in patients post-MI demonstrated that cessation reduced subsequent CV mortality rate by nearly 50%.

• Reasonable evidence from RCTs indicate that counseling hospitalized smokers post-MI increases cessation rates

• Depressed patients may require more support and effort

• Counseling and accesst to formal programs should be provided to the patient and family

• Pharmacologic adjunctive therapy, if deemed safe to use

Cardiac Rehabilitation

• Objectives: • Increase functional capacity • Alleviate anginal symptoms • Reduce disability • Improve QOL • Modify cardiac risk factors • Reduce morbidity and mortality rates

• Core Components: • Patient assessment • Ongoing medical surveillance • Nutritional counselling • BP, Lipid, Diabetes support • Smoking cessation • Psychosocial counseling

• Physical activity counseling • Exercise training • Rx treatment, as necessary…++Access to medical care!

European Society of Cardiology

Guidelines for Post-STEMI care

Slide 1 of 3

European Society of Cardiology

Guidelines for Post-STEMI care

Slide 2 of 3

European Society of Cardiology

Guidelines for Post-STEMI care

Slide 3 of 3

Questions?

And time for Discussion