Chapter 3 ST-Elevation Myocardial InfarctionFig. 3.12 In patients with known cardiovascular disease or who are at risk for ischemic heart disease, clinicians should use a stepped-care
approach to pharmacological therapy, focusing on agents with the lowest reported risk of cardiovascular events and then progressing toward
other agents with consideration of the risk–benefi t balance at each step. Once the decision is made to prescribe an NSAID (below the
horizontal line), additional considerations assume importance as illustrated by the recommendations at the bottom left and right of the
diagram.
- Addition of ASA may not be suffi cient protection against thrombotic events. ASA indicates aspirin; COX-2, cyclooxygenase-2; NSAIDs,
nonsteroidal anti-infl ammatory drugs; and PPI, proton pump inhibitors. Reproduced with permission from Antman et al. Circulation.
2007;115;1634.
the year after hospital discharge. (Level of Evidence:
A)
B. Cardiac rehabilitation
Class IIa
Cardiac rehabilitation/secondary prevention pro-
grams, when available, are recommended for
patients with STEMI, particularly those with multi-
ple modifi able risk factors and/or those moderate-
to high-risk patients in whom supervised exercise
training is warranted. (Level of Evidence: C)
C. 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 patient’s 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. 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. (Level
of Evidence: C)
4 The healthcare provider should review and empha-
size the principles of secondary prevention with the
patient and family members. (Level of Evidence: C)
5 The psychosocial status of the patient should be
evaluated in follow-up, including inquiries regard-
ing symptoms of depression, anxiety, or sleep disor-
ders 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 fl ying. The metabolic
equivalent values for various activities are provided
as a resource in Table 34 of the full-text guideline.
(Level of Evidence: C)