What are the discharge planning recommendations for a patient with an inferior myocardial infarction (MI)?

Discharge Planning for Inferior Myocardial Infarction

All patients with inferior MI should receive comprehensive discharge planning that includes initiation of secondary prevention medications (aspirin, statin, beta-blocker, ACE inhibitor), structured patient education about symptom recognition and emergency response, and early follow-up within 2-6 weeks, with particular attention to identifying and managing right ventricular involvement which occurs in up to 50% of inferior MIs. 1, 2

Medication Regimen at Discharge

Antiplatelet Therapy

• Aspirin 75-325 mg daily should be continued indefinitely in all patients without contraindications 1
• Clopidogrel 75 mg daily for 12 months after PCI, or as alternative if aspirin contraindicated 1, 3
• All patients must receive sublingual or spray nitroglycerin with instructions for use 1

Lipid Management

• Statin therapy should be prescribed at discharge to all patients regardless of baseline LDL-C level, with target LDL-C substantially less than 100 mg/dL 1
• Patients with LDL-C ≥100 mg/dL require statin therapy with preference given to high-intensity statins 1, 3
• Lipid profile should be obtained within 24 hours of admission if not previously available 1

Beta-Blockers and ACE Inhibitors

• Beta-blockers should be continued after discharge in patients who required them for ischemia control during hospitalization 1
• ACE inhibitors should be started within 24 hours and continued long-term, particularly in patients with heart failure, LV dysfunction, diabetes, or anterior infarction 3
• Medications required for ischemia control in hospital must be continued after discharge, with dose titration as needed 1

Additional Pharmacotherapy

• Aldosterone antagonists should be considered at discharge for appropriate patients 3
• Avoid nitrates in patients with right ventricular infarction as they can cause profound hypotension 2

Patient and Family Education

Symptom Recognition and Emergency Response

• Patients must be instructed that chest discomfort lasting more than 2-3 minutes should prompt them to stop activity immediately and take one dose of sublingual nitroglycerin 1
• If pain does not subside within 5 minutes after the first nitroglycerin dose, or if symptoms are unimproved or worsening 5 minutes after onset, patients should call 9-1-1 immediately 1
• Patients should take a second and third nitroglycerin dose at 5-minute intervals if needed, but seek emergency care if pain persists beyond 15-20 minutes or after 3 doses 1
• Family members should be advised to learn CPR and referred to CPR training programs with social support components 1

Medication Instructions

• Before discharge, patients and caregivers must receive clear, culturally sensitive written instructions about each medication's type, purpose, dose, frequency, and side effects 1
• Instructions should be supportable and easily understood 1

Lifestyle Modifications and Cardiac Rehabilitation

Dietary Recommendations

• Diet should be low in saturated fat (<7% of total calories) and cholesterol (<200 mg/day) starting at discharge 1
• Increase consumption of omega-3 fatty acids, fruits, vegetables, soluble fiber, and whole grains 1
• Calorie intake should be balanced with energy output to achieve and maintain healthy weight 1

Exercise and Rehabilitation

• All patients should be referred to cardiac rehabilitation programs, which reduce all-cause mortality and improve functional status 1, 3
• Referral to cardiac rehabilitation is independently associated with lower risk of persistent smoking (OR 0.60), insufficient physical exercise (OR 0.70), and inadequate dietary habits 4
• Regular exercise of at least 20 minutes of brisk walking three times weekly should be encouraged 3

Smoking Cessation

• Smoking cessation counseling should be provided with support including nicotine replacement therapies, varenicline, and bupropion 3
• Post-discharge cardiac visits and cardiac rehabilitation referral are independently associated with lower smoking persistence (OR 0.68 and 0.60 respectively) 4

Follow-Up Planning

Timing of Follow-Up

• Low-risk medically treated patients and revascularized patients should return in 2-6 weeks, while higher-risk patients should return within 14 days 1
• A post-discharge cardiac visit is independently associated with better adherence to healthy lifestyles 4

Communication with Primary Care

• Contact the primary care physician within 2 days post-discharge regarding the patient's hospitalization and follow-up care plan 5
• Ensure a follow-up plan is in place prior to discharge 5
• Effective communication between patient and healthcare team enhances long-term compliance with therapies and lifestyle changes 1

Special Considerations for Inferior MI with Right Ventricular Involvement

Assessment Requirements

• All patients with inferior MI and hemodynamic compromise must be assessed with right precordial lead V4R to detect ST-segment elevation and echocardiogram to screen for RV infarction 1, 2
• ST-segment elevation ≥1mm in V4R has 88% sensitivity and 78% specificity for RV infarction 2
• Early recording of V4R is critical as ST elevation can resolve within 10 hours 2

Discharge Precautions

• Patients with RV infarction require specific instructions to avoid nitrates and diuretics which reduce preload 2
• After RV infarction with clinically significant dysfunction, delay CABG surgery for 4 weeks to allow recovery 1
• Maintain AV synchrony and monitor for conduction disturbances 1, 2

Length of Stay Considerations

Low-Risk Patients

• Uncomplicated patients after successful primary PCI can be safely discharged at 72 hours if early rehabilitation and adequate follow-up are arranged 1, 6
• Patients meeting PAMI-II criteria (age <70 years, LVEF >45%, one- or two-vessel disease, successful PCI, no persistent arrhythmias) are candidates for early discharge 1
• Approximately 40-50% of STEMI patients may be suitable for discharge at 2 days after successful PPCI 6

Higher-Risk Patients

• Patients with complications, unsuccessful revascularization, or recurrent symptoms require longer hospitalization with vigilant monitoring 1
• Minimum 24 hours in coronary care unit for all patients, followed by 24-48 hours in step-down monitored bed 1

Critical Pitfalls to Avoid

• Never administer nitrates to patients with suspected RV infarction without first assessing for RV involvement, as this can cause profound hypotension 2
• Do not discharge patients without ensuring they have sublingual nitroglycerin and understand its proper use 1
• Avoid volume depletion in RV infarction patients, which may mask signs of RV involvement 2
• Do not fail to initiate discharge planning upon admission—comprehensive discharge processes should start on day 1 5
• Ensure multidisciplinary case management services are utilized throughout hospitalization 5