Myocardial infarction: prognosis and rehabilitation

Rehabilitation and treatment at an outpatient stage

Physical activity gradually increases during the first 3-6 weeks after discharge. The resumption of sexual activity, which often worries the patient, and other moderate physical activities are encouraged. If good cardiac function persists for 6 weeks after an acute myocardial infarction, most patients can return to normal activity. A rational program of physical activity, taking into account the lifestyle, age and condition of the heart, reduces the risk of ischemic events and increases overall well-being.

Acute period of the disease and treatment of ACS should be used to develop a patient's persistent motivation to modify risk factors. When assessing the patient's physical and emotional status and discussing them with the patient, it is necessary to talk about lifestyle (including smoking, diet, work and rest, exercise), since eliminating risk factors can improve the prognosis.

Medicinal products. Some drugs reliably reduce the risk of mortality after myocardial infarction, they should always be used if there are no contraindications or intolerance.

Acetylsalicylic acid reduces the mortality and frequency of recurrent myocardial infarction in patients with myocardial infarction from 15 to 30%. Instant aspirin at a dose of 81 mg once a day is recommended for a dopant. Data suggest that simultaneous administration of warfarin with or without acetylsalicylic acid reduces the mortality and frequency of recurrent myocardial infarction.

B-adrenoblockers are considered standard therapy. The most available β-blockers (such as acebutolol, atenolol, metoprolol, propranolol, timolol) reduce mortality after myocardial infarction to about 25% for at least 7 years.

ACE inhibitors are prescribed for all patients who underwent myocardial infarction. These drugs can provide long-term protection of the heart, improving endothelial function. If ACE inhibitors are intolerant, for example because of a cough or allergic rash (but not vascular edema or kidney failure), they can be replaced with angiotensin II receptor blockers.

Patients are also shown inhibitors of HMG-CoA reductase (statins). Reducing the amount of cholesterol after myocardial infarction reduces the incidence of recurrent ischemic events and mortality in patients with elevated or normal cholesterol levels. Probably, statins benefit patients who underwent myocardial infarction, regardless of the original cholesterol content. Patients after myocardial infarction who have a dyslipidemia associated with low HDL cholesterol or an increase in the number of triglycerides may have shown fibrates, but their effectiveness has not yet been confirmed experimentally. Lipid-lowering therapy is indicated for a long time, if there are no significant adverse effects from it.

Prognosis of myocardial infarction

Unstable angina. Approximately 30% of patients with unstable angina develop myocardial infarction within 3 months of the episode; a sudden death occurs. Identified changes in ECG data together with chest pain indicate a higher risk of subsequent myocardial infarction or death.

Myocardial infarction without ST segment elevation and with its elevation. The overall mortality rate is approximately 30%, with 50 to 60% of these patients dying in the prehospital stage (usually due to ventricular fibrillation). Hospital mortality is approximately 10% (mainly due to cardiogenic shock), but it differs significantly depending on the severity of heart failure. The majority of patients dying due to cardiogenic shock have a combination of a heart attack with postinfarction cardiosclerosis, or a new myocardial infarction affects at least 50% of the left ventricular mass. Five clinical characteristics predict 90% mortality in patients with STHM: advanced age (31% of total mortality), low systolic blood pressure (24%), grade> 1 (15%), high heart rate (12%) and anterior localization (6%) . Mortality among patients with diabetes and women is slightly higher.

Mortality among patients who underwent primary hospitalization is 8-10% in the first year after an acute myocardial infarction. Most deaths occur in the first 3-4 months. Constant ventricular arrhythmia, heart failure, low ventricular function and persistent ischemia are high-risk markers. Many experts recommend the implementation of a stress test with an ECG before discharge of the patient from the hospital or within 6 weeks after it. A good test result without changes in ECG data is associated with a favorable prognosis; In the future, a survey is usually not necessary. Low tolerance to physical activity is associated with a poor prognosis.

The state of cardiac function after recovery largely depends on how much the functioning myocardium has survived after an acute attack. Scars from previous myocardial infarction attach to a new lesion. In the event of damage> 50 of the left ventricular mass, a long life expectancy is unlikely.

Classification of Killip and mortality from acute myocardial infarction *

Class	PO 2	Symptoms	Hospital mortality,%
1	Normal	There are no signs of left ventricular failure	3-5
II	Slightly reduced	Mild to moderate LV failure	6-10
III	Decreased	Severe left ventricular failure, pulmonary edema	20-30
IV	Severe degree of insufficiency	Cardiogenic shock: arterial hypotension, tachycardia, impaired consciousness, cold extremities, oliguria, hypoxia	> 80

Determine when repeated examinations of the patient during the illness. Determine if the patient breathes room air.