What is the recommended discharge plan for patients post myocardial infarction (MI)?

Discharge Planning Post Myocardial Infarction

All post-MI patients must be discharged on aspirin (75-325 mg daily), beta-blockers, ACE inhibitors (especially if ejection fraction ≤40% or heart failure present), and statin therapy with LDL goal <100 mg/dL, along with sublingual nitroglycerin for rescue use. 1

Medication Regimen at Discharge

Core Medications (ABCDE Mnemonic)

Aspirin, Antianginals, and ACE Inhibitors:

• Aspirin 75-325 mg daily indefinitely (most evidence supports 81 mg for maintenance dosing to reduce bleeding risk while maintaining cardiovascular protection) 1, 2
• Dual antiplatelet therapy for up to 12 months: Add clopidogrel 75 mg daily or ticagrelor 90 mg twice daily for patients treated medically without stenting 1
• ACE inhibitors are mandatory for patients with: heart failure, left ventricular dysfunction (ejection fraction <40%), hypertension, or diabetes 1
• Sublingual or spray nitroglycerin must be provided to all patients with instructions for use 1

Beta-blockers and Blood Pressure:

• Beta-blockers should be continued indefinitely unless contraindications exist, as they reduce both morbidity and mortality 1
• Target blood pressure <140/90 mmHg with lifestyle modifications and pharmacotherapy 1

Cholesterol and Cigarettes:

• **Statin therapy with goal LDL <100 mg/dL** (initiate if LDL >130 mg/dL despite diet) 1
• Mandatory smoking cessation counseling with offers of nicotine replacement, varenicline, or bupropion 1

Diet and Diabetes:

• Mediterranean diet with <10% saturated fat, <5g salt daily, 30-45g fiber, 200g fruits and vegetables daily 1
• Tight glucose control for diabetic patients 1

Education and Exercise:

• Enrollment in cardiac rehabilitation program is strongly recommended for all patients 1
• Target 20 minutes of brisk walking at least 3 times weekly 1

Patient and Family Education

Symptom Recognition and Emergency Response

Critical instruction for recurrent chest pain:

• If anginal discomfort lasts >2-3 minutes, stop all physical activity immediately 1
• Take 1 dose of sublingual nitroglycerin 1
• If pain is unimproved or worsening after 5 minutes, call 9-1-1 immediately (do not wait for additional nitroglycerin doses) 1
• While awaiting EMS, may take additional nitroglycerin at 5-minute intervals (maximum 2 additional doses) while lying down or sitting 1

Contact physician without delay if:

• Pattern or severity of anginal symptoms changes (more frequent, more severe, precipitated by less effort, or occurs at rest) 1

Medication Instructions

Provide written, culturally sensitive instructions including:

• Medication type, purpose, dose, frequency, and pertinent side effects 1
• Face-to-face instruction reinforced with written materials 1

Pre-Discharge Risk Stratification

Exercise stress testing should be performed:

• Submaximal testing at 4-7 days post-MI, OR
• Symptom-limited testing at 10-14 days post-MI 1

Purpose of stress testing:

• Assess functional capacity for home and work activities 1
• Evaluate efficacy of current medical regimen 1
• Stratify risk for subsequent cardiac events 1

Follow-Up Care Structure

Outpatient appointments:

• Low-risk medically treated and revascularized patients: return in 2-6 weeks 1
• Higher-risk patients: return in 1-2 weeks 1

Telephone follow-up system:

• Weekly calls for first 4 weeks after discharge to reinforce education, monitor recovery, and assess risk factor modification progress 1

Multidisciplinary Team Involvement

Coordinate discharge planning with:

• Physicians, nurses, dietitians, pharmacists, rehabilitation specialists, care managers, and physical/occupational therapists 1

Return to Activities

• Sexual activity can be resumed early if adjusted to physical ability 1
• Return to work decisions based on: LV function, completeness of revascularization, rhythm control, and job characteristics 1
• Extended sick leave is usually not beneficial; light-to-moderate physical activity should be encouraged 1

Common Pitfalls to Avoid

Do not discharge patients without:

• Sublingual nitroglycerin and clear instructions on its use 1
• Written medication instructions in understandable language 1
• Clear emergency action plan for recurrent symptoms 1

Avoid:

• Using high-dose aspirin (325 mg) for maintenance therapy when 81 mg provides similar cardiovascular protection with less bleeding risk 2
• Omitting ACE inhibitors in patients with reduced ejection fraction or heart failure 1
• Failing to address smoking cessation with pharmacotherapy offers 1
• Discharging without cardiac rehabilitation referral 1