Once that first day is over, however, much work remains to be done to optimize your chances of long-term survival – and this is where doctors all too often drop the ball. In the rush to discharge the “uncomplicated” heart attack survivor 3 or 4 days after admission, vital steps are being neglected, and as a result thousands of patients are dying unnecessarily every year. In this article, we will review the important steps that must be taken in assuring that survivors of acute myocardial infarctions become long-term survivors. If you or a loved one has had a heart attack, you need to make sure that your doctors have paid attention to all these steps.
As we have seen, an acute myocardial infarction is caused by a sudden occlusion of a diseased coronary artery. That occlusion causes some or all of the heart muscle supplied by that artery to die. (The amount of muscle that dies is largely determined by the size of the occluded artery, and by whether the artery is successfully re-opened – by thrombolytic drugs or by angioplasty – within the first few hours.) So after you’ve successfully negotiated the first 24 hours of a heart attack, we know at least three things about you that we probably didn’t know before: 1) We know you’ve got coronary artery disease (a chronic, progressive problem) affecting at least one – and possibly multiple – coronary arteries. 2) We know that some portion of your heart muscle is being converted to scar tissue, and that the remaining normal heart muscle is working overtime to pick up the slack. 3) We know that, by virtue of the fact that you’ve now got scar tissue on your heart muscle, you may be at higher-than-normal risk for sudden death from heart arrhythmias.
Knowing these things, it’s obviously too early to pat ourselves on the back with a “Job well done!” We’ve still got a lot of work to do. We need to: a) assess the risk that your existing coronary artery disease will cause another heart attack in the near future, and take steps to prevent that from happening; b) accurately assess the amount of heart damage that has already occurred, and take steps to prevent heart failure; c) institute drugs and lifestyle changes to slow or halt the progression of your underlying coronary artery disease; and d) assess your risk of sudden death, and institute preventive therapy if necessary.
In this article we will address each one of these steps.
How can we prevent another heart attack in the near future?
Patients who survive a heart attack often have a high risk of experiencing another heart attack within weeks or months. Therefore, before you go home from the hospital after a heart attack, it is important to determine your risk of an early coronary event. This risk assessment can be of one of two types – invasive, or noninvasive.The invasive approach – cardiac catheterization and coronary angiography – is clearly the most direct and straightforward. All the coronary arteries are visualized, and any critical blockages can be noted and treated (with angioplasty and/or stents, or with bypass surgery). The advantage of the invasive approach is that any guesswork about the overall status of a patient’s coronary arteries is removed. The disadvantages are that this approach is very expensive if widely used, and that with any invasive procedure there are risks and complications.
The noninvasive approach involves exercise stress testing. If signs of ischemia are seen, then the patient is referred for cardiac catheterization.If signs of ischemia are not seen during exercise, the odds of having critical coronary artery disease (or an early recurrent heart attack) are statistically low.
A reasonable compromise between these approaches is to use the noninvasive approach in patients who are judged on clinical grounds to fall into a low-risk category for recurrent coronary events, and to send the remaining patients for catheterization.
But the point is, when you’ve had a heart attack, whichever method is used, SOME method of assessing the risk of early coronary events MUST be performed prior to discharge. Unfortunately, this rule is being violated more and more often by the imperative toward early hospital discharge.
