What is the ideal clinical course for myocardial infarction (MI) patients in the wards, including medications, monitoring, and discharge criteria?

Ideal Clinical Course for MI Patients in the Wards

All MI patients should remain in the CCU/ICCU for a minimum of 24 hours with continuous ECG monitoring, followed by 24-48 hours in a step-down monitored bed, with selected low-risk patients eligible for discharge within 48-72 hours if early rehabilitation and adequate follow-up are arranged. 1

Initial Ward Management (First 24-48 Hours)

Continuous Monitoring Requirements

• ECG monitoring is mandatory for a minimum of 24 hours to detect arrhythmias, which are most common in the early post-MI period 1
• Monitor vital signs frequently, including heart rate, blood pressure, oxygen saturation, and urine output 1
• Watch for signs of hemodynamic instability, ongoing ischemia, or heart failure 1

Pharmacotherapy During Hospitalization

Antiplatelet Therapy:

• Continue aspirin 75-325 mg daily (most evidence supports 81 mg for maintenance) indefinitely 2, 3
• Dual antiplatelet therapy with clopidogrel 75 mg daily or ticagrelor 90 mg twice daily should be initiated and continued 2, 4

Beta-Blockers:

• Patients receiving beta-blockers within the first 24 hours without adverse effects should continue them during the early convalescent phase 1
• Patients without contraindications who did not receive beta-blockers in the first 24 hours should have them started in the early convalescent phase 1
• Do not administer beta-blockers to patients with frank cardiac failure evidenced by pulmonary congestion or signs of low-output state 1

ACE Inhibitors:

• Initiate within the first 24 hours for patients with heart failure, LVEF <40%, diabetes, or anterior infarction 3, 5
• Start with low-dose short-acting ACE inhibitor (e.g., captopril 1-6.25 mg) and titrate upward 1
• Continue indefinitely in all patients with LVEF <40% or heart failure 3

Intravenous Nitroglycerin:

• Administer for 24-48 hours for persistent ischemia, heart failure, large anterior MI, or hypertension 1
• Avoid completely in right ventricular infarction due to risk of profound hypotension 5
• Do not use as substitute for narcotic analgesics 1

Statin Therapy:

• High-intensity statin therapy should be started immediately and continued long-term 3, 5
• Target LDL <70 mg/dL (1.8 mmol/L) or at least 50% reduction from baseline 3

Critical Complications to Monitor

Recurrent Ischemia

• Recurrent chest pain thought to be myocardial ischemia requires intravenous nitroglycerin, analgesics, and antithrombotic medications (aspirin, heparin) 1
• Consider urgent coronary angiography with subsequent revascularization 1

Heart Failure/Pulmonary Congestion

• Administer oxygen supplementation to maintain arterial saturation >90% 1
• Give morphine sulfate for pulmonary congestion 1
• Administer diuretics (low- to intermediate-dose furosemide, torsemide, or bumetanide) if volume overload is present, but use caution in patients who have not received volume expansion 1
• Initiate ACE inhibitors starting with low doses unless systolic BP <100 mmHg or >30 mmHg below baseline 1
• Administer nitrates unless systolic BP <100 mmHg or >30 mmHg below baseline 1
• For refractory pulmonary congestion, consider intra-aortic balloon pump insertion 1

Cardiogenic Shock

• Insert hemodynamic support device (intra-aortic balloon pump) 1
• Perform emergency coronary angiography followed by PCI or CABG 1
• Administer vasopressor support for hypotension that does not resolve after volume loading 1
• Perform urgent echocardiography to estimate LV and RV function and exclude mechanical complications 1

Right Ventricular Infarction

• Treat vigorously with intravascular volume expansion using normal saline 1
• Administer inotropic agents if hypotension persists after volume expansion 1
• Completely avoid nitroglycerin due to risk of profound hypotension 5

Pericarditis

• Administer high-dose aspirin (650 mg every 4-6 hours) for recurrent chest pain believed due to pericarditis 1

Arrhythmias

• Maintain continuous ECG monitoring for minimum 24 hours 1
• Treat arrhythmias promptly according to ACLS protocols 1

Pre-Discharge Risk Stratification

Exercise Stress Testing:

• Perform submaximal exercise testing at 4-7 days post-MI OR symptom-limited testing at 10-14 days post-MI 1, 2, 3
• Three purposes: (1) assess functional capacity for home and work activities, (2) evaluate efficacy of current medical regimen, (3) stratify risk for subsequent cardiac events 1, 2

Echocardiography:

• Routine echocardiography is required during hospital stay to assess LV and RV function, detect early post-MI mechanical complications, and exclude LV thrombus 3
• Perform urgently if heart failure or mechanical complications are suspected 1

Discharge Criteria

Low-Risk Patients Eligible for Early Discharge (48-72 hours):

• Age <70 years 1
• LVEF >45% 1
• One- or two-vessel disease 1
• Successful PCI 1
• No persistent arrhythmias 1
• No signs or symptoms of ongoing myocardial ischemia 1
• Hemodynamically stable, not requiring vasoactive or mechanical support 1
• Not scheduled for further early revascularization 1
• Early rehabilitation and adequate follow-up must be arranged 1

Higher-Risk Patients:

• Remain hospitalized longer if complications present, hemodynamic instability, ongoing ischemia, or significant arrhythmias 1
• Transfer to step-down unit after 24 hours in CCU/ICCU if stable 1

Mandatory Discharge Medications

All patients must be discharged on:

• Aspirin 75-100 mg daily indefinitely 2, 3
• Dual antiplatelet therapy for 12 months (clopidogrel 75 mg daily, ticagrelor 90 mg twice daily, or prasugrel if appropriate) 2, 3
• High-intensity statin therapy with target LDL <70 mg/dL 2, 3
• ACE inhibitor (mandatory for heart failure, LVEF <40%, diabetes, or anterior infarction; continue indefinitely) 2, 3
• Beta-blocker (mandatory for heart failure or LVEF <40%; continue indefinitely) 2, 3
• Sublingual or spray nitroglycerin with explicit instructions for use 2, 3

Additional Medications for Selected Patients:

• Long-term aldosterone blockade for patients with LVEF ≤40% and symptomatic heart failure or diabetes, provided creatinine ≤2.5 mg/dL (men) or ≤2.0 mg/dL (women) and potassium ≤5.0 mEq/L 1

Patient Education Before Discharge

Emergency Action Plan:

• Stop all physical activity immediately if anginal discomfort lasts >2-3 minutes and take 1 dose of sublingual nitroglycerin 2
• If pain is unimproved or worsening after 5 minutes, call 9-1-1 immediately 2
• Patients can take up to 3 nitroglycerin tablets (one every 5 minutes), but should not delay calling 9-1-1 if symptoms persist 1

Medication Instructions:

• Provide written, culturally sensitive instructions including medication type, purpose, dose, frequency, and pertinent side effects 2
• Consider fixed-dose combination pills to improve adherence 3

Lifestyle Modifications:

• Mandatory smoking cessation counseling with offers of nicotine replacement, varenicline, or bupropion 2, 3
• Target blood pressure <140/90 mmHg 2, 3
• Diet low in saturated fat and cholesterol, achieve ideal weight 1
• Mandatory enrollment in formal cardiac rehabilitation program 2, 3

Return to Activities:

• Sexual activity can resume early if adjusted to physical ability 2, 3
• Return to work decisions based on LV function, completeness of revascularization, rhythm control, and job characteristics 2, 3
• Light-to-moderate physical activity should be encouraged; extended sick leave is usually not beneficial 2

Follow-Up Care Structure

Outpatient Appointments:

• Low-risk medically treated and revascularized patients return in 2-6 weeks 2, 3
• Higher-risk patients return in 1-2 weeks 2, 3
• Early post-discharge consultations with cardiologist, primary care physician, or specialized nurse should be scheduled before discharge 1

Telephone Follow-Up:

• Implement weekly telephone calls for the first 4 weeks after discharge to reinforce education, monitor recovery, and assess risk factor modification progress 2, 3

Multidisciplinary Team:

• Coordinate discharge planning with physicians, nurses, dietitians, pharmacists, rehabilitation specialists, care managers, and physical/occupational therapists 2

Critical Pitfalls to Avoid

Medication Errors:

• Never discharge without sublingual nitroglycerin and clear instructions on its use 2, 3
• Never discharge without written medication instructions in understandable language 2
• Never omit ACE inhibitors in patients with reduced ejection fraction or heart failure 2, 3
• Never omit dual antiplatelet therapy for 12 months after PCI unless excessive bleeding risk 3

Discharge Planning Errors:

• Never discharge without a clear emergency action plan for recurrent symptoms 2
• Never discharge without cardiac rehabilitation referral 2, 3
• Never neglect smoking cessation counseling with pharmacotherapy offers 2, 3

Clinical Management Errors:

• Never administer beta-blockers or calcium channel blockers acutely to patients with frank cardiac failure evidenced by pulmonary congestion or low-output state 1
• Never use nitroglycerin in right ventricular infarction 5
• Never delay coronary angiography in patients with recurrent ischemia or cardiogenic shock 1