VOLGOGRAD STATE MEDICAL UNIVERSITY

DEPARTMENT OF AMBULATORY & EMERGENCY CARE

"Post-myocardial infarction Rehabilitation"

Name: Muhamad Anuar W. Hassan Group: 35 Year: 6th Course: General Medicine

Post Myocardial Infarction Secondary prevention in primary and secondary care for patients following a myocardial infarction
Key priorities for implementation
A number of key priority recommendations have been identified for implementation listed below. These recommendations are considered by the GDG (Guideline Development Group) to have the most significant impact on patients care and patients outcomes. After an acute myocardial infarction (MI), confirmation of the diagnosis of acute MI and results of investigations, future management plans and advice on secondary prevention should be part of every discharge summary (GPP). Patients should be advised to undertake regular physical activity sufficient to increase exercise capacity (Grade B). Patients should be advised to be physically active for 20-30 mins a day to the point of slight breathlessness. Those who are not achieving this should be advised to increase their activity in a gradual step by step fashion, aiming to increase exercise capacity. They should start at a level that is comfortable and increase the duration and intensity of activity as they gain fitness (GPP). All patients who smoke should be advised to quit and be offered assistance from a smoking cessation service in line with Brief interventions and referral for smoking cessation in primary care and other settings (NICE public health intervention guidance 1) (Grade A). Patients should be advised to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils) (Grade A). Cardiac rehabilitation should be equally accessible and relevant to all patients after an MI; particularly people from groups that are less likely to access this service. These include people from black and minority ethnic groups, older people, people from lower socioeconomic groups, women, people from rural communities and people with mental and physical health comorbidities. All patients who have had an acute MI should be offered treatment with a combination of the following drugs (Grade A): ACE (angiotensin-converting enzyme) inhibitor aspirin

 beta blocker statin. For patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment should be initiated within 314 days of the MI, preferably after ACE inhibitor therapy (Grade B). Treatment with clopidogrel in combination with low-dose aspirin should be continued for 12 months after the most recent acute episode of non-ST segmentelevation acute coronary syndrome. Thereafter, standard care, including treatment with low-dose aspirin alone, is recommended unless there are other indications to continue dual antiplatelet therapy (Grade A). After an ST-segment-elevation MI, patients treated with a combination of aspirin and clopidogrel during the first 24 hours after the MI should continue this treatment for at least 4 weeks. Thereafter, standard treatment including lowdose aspirin should be given, unless there are other indications to continue dual antiplatelet therapy (Grade A). All patients should be offered a cardiological assessment to consider whether coronary revascularisation is appropriate. This should take into account comorbidity (Grade A). The criteria the GDG used to select these key priorities for implementation included whether a recommendation is likely to: have a high impact on patients outcomes in particular mortality and morbidity have a high impact on reducing variation in the treatment offered to patients lead to a more efficient use of NHS (National Health Service) resources enable patients to reach important points in the care pathway more rapidly

Management
Cardiac rehabilitation programmes have been consistently shown to reduce mortality rates in CHD patients (Canadian Coordinating Office for Health Technology Assessment, 2003). Cardiac rehabilitation is the coordinated sum of interventions required to ensure the best possible physical, psychological and social conditions to enable the CHD patient to preserve or resume optimal functioning in society. It also aims to slow or reverse progression of the disease. Cardiac rehabilitation cannot be regarded as an isolated form or stage of therapy, but must be integrated within secondary prevention services, of which it forms only one facet (WHO definition, 1993). Lifestyle factors also have an impact on the prognosis of CHD patients. Healthy eating, regular exercise and smoking cessation are important elements in the prevention of further cardiovascular events. A number of drugs have been shown to improve outcome after MI; beta blockers, ACE inhibitors, anti-platelet agents and statins.

Care pathway
Two clinical care pathways have been designed to indicate the essential components in the secondary prevention of patients after an MI, one for patients with a recent MI, and one for patients with a proven MI in past. Each pathway has

three main sections. These are; secondary prevention drug treatment, specialist cardiological assessment, and lifestyle and cardiac rehabilitation. Recommendations for key secondary prevention measures in each section are indicated.

What is the optimal duration of treatment with the combinationof aspirin and clopidogrel, compared with aspirin alone, in patients with ST elevation MI treated with thrombolysis?
The addition of clopidogrel to other standard treatment, including aspirin and thrombolysis, in patients presenting with ST elevation MI has been shown to improve coronary patency and clinical outcome. This effect appears to be mediated by preventing re-occlusion of the open infarct related artery rather than by facilitating early reperfusion. The trials examining the effects of the addition of clopidogrel in patients with ST elevation MI were of short duration (about 4 weeks or less). The trial which reported a clinical benefit of treating patients with non ST elevation MI with the combination of aspirin and clopidogrel, compared to aspirin alone, was for duration up to 12 months, mean 9 months. The optimal duration of treatment with the combination of aspirin and clopidogrel in patients with ST elevation MI is unknown.

Could a discontinuation trial of ACE inhibitors in patients without LV dysfunction determine the clinical and cost effectiveness of long-term secondary prevention treatment in patients after an MI?
Most trials of secondary prevention drugs after a myocardial infarction follow up patients for a limited period of time, rarely more than 5 years after the event. In current guidance there is an assumption that the benefit demonstrated in these trials persists indefinitely and therefore, provided they are tolerated, secondary prevention drugs such as beta blockers, statins, aspirin and ACE inhibitors should be continued long-term. Further research is needed to test this assumption. Specific patient groups may not benefit from extended treatment, for example groups based on baseline left ventricular function, the extent of coronary disease and the presence of coronary risk factors. It would be ethically and logistically difficult to study withdrawal of drug therapy using the traditional randomized controlled trial design. Alternative designs, such as large cohort studies, based on routinely collected (or enhanced) data would allow comparison of people stopping one or more secondary prevention drugs with a cohort continuing their secondary prevention therapy. Close attention would need to be paid to confounders. This question is particularly

pertinent for ACE inhibitors and beta blockers, as it is not clear to what extent patients without significant LV dysfunction benefit from long-term use of these agents after a myocardial infarction.

What is the clinical and cost effectiveness of omega-3-acid ethyl esters treatment in all patients after MI
One trial has shown a benefit of treatment with omega-3-acid ethyl esters in patients within 3 months of an MI. However, other secondary prevention treatment had not been optimised in this trial and the majority of patients had preserved left ventricular function. There is some uncertainty about how much additional benefit patients after acute MI optimally managed for secondary prevention, including those with left ventricular systolic dysfunction, will obtain from the addition of omega-3-acid ethyl esters treatment. There is also a paucity of evidence for the effectiveness of treating patients who have had an MI in the past, at least 3 months earlier. The efficacy of omega-3-acid ethyl esters treatment in patients both early and later after MI deserves further research.

Lifestyle
Changing dietary regimen recommendations
Patients should be advised not to take supplements containing betacarotene (Garde B), and should not be advised to take antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk (Grade A). Patients should be advised to consume at least 7 g of omega 3 fatty acids per week from two to four portions of oily fish per week (oily fish consumption required to provide 7 g of omega 3 fatty acids per week) (Grade B). For patients who have had an MI within 3 months and who are not achieving this, consider providing at least 1g daily of omega-3-acid ethyl esters treatment licensed for secondary prevention post MI for up to 4 years (Grade B). Initiation of omega-3-acid ethyl esters supplement treatment is not routinely recommended in patients that have had an MI more than 3 months earlier (GPP). Patients should be advised to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils) (Grade A).

Alcohol consumption recommendations

Patients who drink alcohol should be advised to keep weekly consumption within safe limits (no more than 21 units of alcohol per week for men, or 14 units per week for women) and to avoid binge drinking (more than 3 alcoholic drinks in 12 hours) (GPP).

Regular physical activity recommendations

Patients should be advised to undertake regular physical activity sufficient to increase exercise capacity (Grade B). Patients should be advised to be physically active for 2030 minutes a day to the point of slight breathlessness. Patients who are not achieving this should be advised to increase their activity in a gradual, step by step way, aiming to increase their exercise capacity. They should start at a level that is comfortable, and increase the duration and intensity of activity as they gain fitness (GPP). Advice on physical activity should involve a discussion about current and past activity levels and preferences. The benefit of exercise may be enhanced by tailored advice from a suitably qualified professional (GPP).

Smoking cessation recommendations

All patients who smoke should be advised to quit and be offered assistance from a smoking cessation service in line with Brief interventions and referral for smoking cessation in primary care and other settings (NICE public health intervention guidance 1) (Grade A). All patients who smoke and who have expressed a desire to quit should be offered support and advice, and referral to an intensive support service (for example the NHS Stop Smoking Services) in line with Brief interventions and referral for smoking cessation in primary care and other settings (NICE public health intervention guidance 1) (Grade A). If a patient is unable or unwilling to accept a referral they should be offered pharmacotherapy in line with the recommendations in Nicotine replacement therapy (NRT) and bupropion for smoking cessation (NICE technology appraisal guidance 39) (Grade A).

Weight management recommendations

After an MI, all patients who are overweight or obese should be offered advice and support to achieve and maintain a healthy weight in line with Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE clinical guideline 43 (Grade A).

Cardiac rehabilitation

All patients (regardless of their age) should be given advice about and offered a cardiac rehabilitation programme with an exercise component (Grade A). Cardiac rehabilitation programmes should provide a range of options, and patients should be encouraged to attend all those appropriate to their clinical needs. Patients should not be excluded from the entire programme if they choose not to attend certain components (GPP). If a patient has cardiac or other clinical conditions that may worsen during exercise, these should be treated if possible before the patient is offered the exercise component of cardiac rehabilitation. For some patients, the exercise component may be adapted by an appropriately qualified healthcare professional (GPP). Patients with left ventricular dysfunction who are stable can safely be offered the exercise component of cardiac rehabilitation (Grade B).

Health education and information needs recommendations

Comprehensive cardiac rehabilitation programmes should include health education and stress management components (Grade A). A home based programme validated for patients who have had an MI (such as The Edinburgh heart manual; see http://www.cardiacrehabilitation.org.uk/heart_manual/heartmanual.htm) that incorporates education, exercise and stress management components with follow-ups by a trained facilitator may be used to provide comprehensive cardiac rehabilitation (Grade A). Most patients who have had an MI can return to work. Any advice should take into account the physical and psychological status of the patient, the nature of the work and the work environment (GPP). Healthcare professionals should be up to date with the latest Driver and Vehicle Licensing Agency guidelines. Regular updates are published on the website (www.dvla.gov.uk) (GPP). After an MI without complications, patients can usually travel by air within 2 3 weeks. Patients who have had a complicated MI need expert individual advice (GPP). Patients who hold a pilots licence should seek advice from the Civil Aviation Authority (GPP). Most patients can return to normal activities of daily living. Any advice about the timing of this should take into account the patients physical and psychological status, as well as the type of activity planned (GPP). An estimate of the physical demand of a particular activity, and a comparison between activities, can be made using tables of metabolic equivalents (METS) of

different activities (for further information please refer to http://www.cdc.gov/nccdphp/dnpa/physical/measuring/met.htm). Patients should also be advised how to use a perceived exertion scale to help monitor physiological demand. Patients who have had a complicated MI may need expert advice (GPP). Advice on competitive sport may need expert assessment of function and risk, and is dependent on what sport is being discussed and the level of competitiveness (GPP).

Psychological and social support recommendations

Stress management should be offered in the context of comprehensive cardiac rehabilitation (Grade A). Complex psychological interventions such as cognitive behavioural therapy should not be offered routinely (GPP). There should be provision to involve partners or carers in the cardiac rehabilitation programme if the patient wishes (GPP). For recommendations on the management of patients with clinical anxiety and/or depression, refer to Anxiety. NICE clinical guideline 22 and Depression. NICE clinical guideline 23 (Grade A).

Sexual activity recommendations

Patients should be reassured that after recovery from an MI, sexual activity presents no greater risk of triggering a subsequent MI than if they had never had an MI (Grade C). Patients who have made an uncomplicated recovery after their MI can resume sexual activity when they feel comfortable to do so, usually after about 4 weeks (GPP). The subject of sexual activity should be raised with patients within the context of cardiac rehabilitation and aftercare (GPP). When treating erectile dysfunction, treatment with a PDE5 (phosphodiesterase type 5) inhibitor may be considered in patients who had an MI more than 6 months earlier and who are now stable (Grade A). PDE5 inhibitors must be avoided in patients treated with nitrates and/or nicorandil because this can lead to dangerously low blood pressure (GPP).

The system of rehabilitation of patients with myocardial infarction involves three successive stages, corresponding to the phases of myocardial infarction (WHO, 1968):

1) a hospital; 2) the recovery or convalescence phase, carried out in specialized departments of local health centers or cardiac rehabilitation hospitals; 3) phase post-convalescent or maintenance, which lasts throughout the life of the patient and carried out under dispensary observation. Chazov E. (1971) defines a hospital and pos-hospital stages.Hospital phase corresponds to a period of stabilization (consolidation) of myocardial infarction; post-hospital - the period of mobilization - mainly carried out in health centers and places of the greatest problems of compensatory capacity of the organism during the period of rehabilitation related to the patient's return to professional activities. Each stage of the rehabilitation of patients with myocardial infarction puts the problem, based pathophysiological features of the different phases of the disease.It is quite clear that the choice of physical methods of treatment and methods of their conduct based on the pathophysiological features of the various phases of myocardial infarction. The hospital phase (I phase) In the acute phase of myocardial infarction (hospital phase I) medical actions are carried out to limit the area of necrosis, hemodynamic stabilization, the elimination of heart failure, cardiac arrhythmias, to preserve the life of the patient.Methods of physical therapy in this phase, currently in use is limited.On this issue, the literature contains only a single operation.Thus, the applied electric sleep with the frequency of the pulse current 15 - 60 Hz, up to 2 h (Mikhno LE, 1979] and electrophoresis of heparin to prevent thromboembolic complications [LN Oleynikov, 1979]. According to LE Mikhno, electro-therapy reduces pain, shortens the ECG signs of myocardial necrosis. reported on the effective application of the central electroanalgesic (LENAR apparatus, the pulse rate from 1000 to 2000 Hz, the current 1.5-3 mA) to relieve pain in myocardial infarction Prehospital [Mkrtychyan VR, 1981]. Starting from 10-12 days, it is advisable to apply the massage of the lower extremities lasting from 2 to 4-5 minutes each leg to improve peripheral circulation, venous return and prevention of thromboembolic complications, prepare the patient for the expansion motor mode [Nikolaev VV et al, 1979]. Massage is carried out only in patients who have no clinical signs of heart failure, heart aneurysms, thromboembolic complications. In our observations, a marked effect on the action apgianginalny UHF electromagnetic fields (DMV) applied at 15-20-day myocardial infarction. In some studies there are indications of the use of UHF electromagnetic field [Kowarschik W., 1974], magnesium intracardial electrophoresis technique [KbPeg, 1979], starting from the third day of a heart attack for the relief of angina attacks. However, the lack of proper description of the methodology and analysis of clinical data makes it difficult to judge the appropriateness of these treatments. In all likelihood, the development of methods of physical therapy of acute myocardial infarction is a problem of the future. Sanatorium stage (II phase) Physical methods of treatment become particularly important and often leading role in the recovery phase, from 4 to 6 weeks of the disease and over the next 8-16 weeks, because the essence of their actions is to promote compensatory-adaptive mechanisms in many organ systems affected by myocardial infarction.Restorative treatment in this phase II rehabilitation is carried out in local cardiac health centers (in specialized units), and sometimes in hospitals or rehabilitation clinics. The clinical picture of disease in this phase are varying degrees of severity of disorders of

myocardial contractile function, coronary circulation and the reserves, systemic and regional hemodynamics, metabolism in the myocardium and immunologic reactivity. Significant dysfunction of the central nervous system, autonomic regulation of the heart, the mental status of the patient. The condition of patients with myocardial infarction at an early period in the clinical poslehospital terms differently. To determine the indications for the use of a physical factor treatment and the choice of adequate methods of its conduct must be guided by the severity of functional disorders of the cardiovascular system. According to the classification of the USSR Academy of Medical Sciences VKNTS [Aronov DM, et al., 1982], isolated grade 4 severity of the clinical condition of patients with myocardial infarction (Table 8). Table 8. Classification of the severity of the clinical condition of patients with myocardial infarction in the sanatorium stage

coronary insufficiency Latent (ie, angina, a given amount of physical activity is absent)

complications

When nonWhen transmural transmural myocardial infarction myocardial infarction I II III IV II II III IV

None Complications of the first group Complications of the second group Complications of the third group

I degree (ie, angina None is rare and quite pronounced physical Complications of the exertion) first group Complications of the second group Complications of the third group II degree (ie, angina occurs with low physical effort, and even in a state relative rest) None Complications of the first group Complications of second group

II II

II III

III IV

III IV

III III III

III III IV

Complications of the third group III degree (angina at rest, night or frequent angina) Regardless of whether or absence of complications

IV IV IV IV

It seems possible to distinguish in the form of three main schemes differentiated programs of rehabilitation therapy with the use of physical factors for myocardial infarction patients in the convalescence phase of varying severity. The first program. Among the surveyed part of the patients as a result of a myocardial infarction suffered a physical activity, reduction of which we were engaged. These were young adults (35-45 years) without prevalent atherosclerosis and chronic coronary insufficiency, without heart failure, usually physically active before a heart attack, without any complications in the acute phase of disease. As the severity of the clinical condition of these patients could be classified as Class I when non-transmural or class II with transmural infarction. For training, we administered a gradual dosage walking, gymnastics, walking and massage of the lower limbs and a relatively rapid increase in motor mode. Some patients required removal of asthenic-neurotic reactions and abnormalities in mental status. For this purpose we used and the electric sleep therapy. In this nursing home patients climatotherapy used, starting with the 4-5th day on the treatment of moderate impact with air baths, sleeping in the open air, walking, sunbathing dose and tempering treatments: walking on water or dew (at sea), metered sea bathing (in a coastal climate) from 7-8-day stay in a sanatorium, foot and hand contrasting baths, as well as chamber (carbon dioxide, sulfide, iodine-bromine baths. reported favorable effects of water treatments (douches, showers), massage (or self-massage) brushes. The second program. Patients with myocardial infarction, including transmural, with rare and mild attacks of angina, the initial (latent) or stage I heart failure (II class of gravity), including those with concomitant hypertension, along with the restoration of motor activity and massage of the lower extremities and testimony and psychotherapy is suitable for correcting violations hemodynamics chamber used balneotherapy baths, UHF-therapy for segmental method (Cv-Thv from the back), electric or electrophoresis of drugs (as indicated). In the nursing home - they spend climatotherapy from 6-7-day regimens of the weak and the 14-15th day of moderate impact. The third program. Patients with class III severity, along with an adequate extension of the motor mode and massage of the lower extremities demonstrates the use of "dry" carbon dioxide baths, UHF-therapy (the segmental method or on the projection area of the heart), electro-medicine electrophoresis.Climatotherapy carried out with the 7-8th day of the regimes of weak effects mostly in the form of walking, warm or neutral air baths, partial sun. All physical treatments administered on a background of drugs, selected according to

the clinical manifestations of disease. Polyclinic stage (lll phase) VS Yurasova (1983), NM Kulikova (1977) proposed the division of outpatient phase in the four periods. In the first period - a preparatory or transitional - from the end of the preceding stage of rehabilitation (health or stationary) prior to the resumption of work the patient ends up phase of recovery [Shhvatsabaya , 1978]. The following three phases: the period work the resumption of employment (2 - 4 weeks), partial restriction workload and fully operational (for most patients after 5-6 months of work) are post-convaslescency and make maintenance phase of rehabilitation. Spa treatment-rehabilitation stage care of patients with myocardial infarction Spa treatment at the polyclinic stage of rehabilitation of patients with myocardial infarction significantly enhances rehabilitation and prevention activities, and so it currently is of great importance both in our country [Daniel E. Yu, 1968; Poltoranov VV, 1982; Bohutskyy BV, Akhmedzhanov M., 1982, Bogolyubov VM, 1983; Gasilin VS, Kulikova N., 1984] and abroad [Mobius R., 1971; Reinhold D., 1979; Jordan H., 1983]. The advantage of spa treatment in a program of rehabilitation of patients with myocardial infarction is a relatively long time and a good vacation, medical supervision and multilateral combined treatment, in a complex impact on the patient raising a number of health factors. In fact, methods of spa treatment to a greater extent its shape aspects of medical rehabilitation, affecting the natural and preformed factors. The major objective of the Phase III rehabilitation is to compensate for coronary and cardiac insufficiency, it is possible to make use of the spa treatments. Improved circulation to the heart muscle due to a decrease of hypoxemia, decreased oxygen consumption of cardiac muscle and economization of cardiac activity by improving the functions of the central mechanisms of regulation, thermoregulation processes, reduce emotional stress, as well as normalization of the mental function of patients who have lost faith in his recovery, reduce and where possible refusal of medical treatment - are the main tasks of sanatorium treatment. It is now recognized that the spa. Within the system of rehabilitation of patients with myocardial infarction is secondary preventive nature. Many studies note the preservation of ability to work within 6 - 12 months after a spa treatment, holding a steady state functional capacity of the cardiovascular system in 78,6% [Sohr Ch., 1977], 80-90% of patients [Men-son N., 1975]. The authors believe that the optimization of co-operation rehabilitation facilities in the "Clinic - Spa-Clinic" was reflected in the increasing number of saves in postinfarction patients with disability for 5 years from 48 to 70%. Extensive experience gained in the rehabilitation of the resort UXO. It is shown that the spa treatment of patients with myocardial infarction in the Black Sea coast (Varna) in phase III rehabilitation increases the functionality of the circulatory system, to reduce hypercholesterolemia and hypertension [Doina M., 1977, Nikolova-Yarmlykova P., 1979; 1982].

Under existing rules for selecting patients for sanatorium treatment, the predominant number of patients after myocardial infarction, treatment is carried out in local cardiac health centers (I, II and III classes of gravity). In addition, for patients with latent and I degree of coronary insufficiency, cardiac arrhythmias without a stable and expedient treatment of hypertension in the climatic health resorts. Treatment at the spa resorts of patients after myocardial infarction in our country do not use. Treatment in local sanatoriums cardiology (outside of specialized departments for followup care of patients with myocardial infarction) is used in the final phase of the recovery period, beginning with the 3-4th month of the disease, as well as maintenance phase of rehabilitation at a later date myocardial infarction. In conclusion, we emphasize that physical factors, including spa treatments are effective at all stages of rehabilitation of patients with myocardial infarction and should be more broadly to include a landmark system recovery from an early period reconvalescency.