What is the discharge medical plan for a patient post ST-Elevation Myocardial Infarction (STEMI) and Percutaneous Coronary Intervention (PCI)?

Discharge Medical Plan for Post-STEMI and PCI Patients

All patients surviving STEMI and PCI must be discharged on dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor), high-intensity statin therapy, beta-blockers, and ACE inhibitors (if indicated), along with comprehensive patient education about symptom recognition and emergency response. 1

Mandatory Discharge Medications

Antiplatelet Therapy

• Aspirin 75-325 mg daily must be continued indefinitely in all patients without contraindications 1, 2
• Clopidogrel 75 mg daily for at least 12 months after stent placement, or as an alternative if aspirin is contraindicated 1, 3
  • A 300 mg loading dose should have been given initially if not already administered 3
  • Avoid concomitant use with omeprazole or esomeprazole due to CYP2C19 inhibition 3
  • Consider alternative P2Y12 inhibitors (prasugrel or ticagrelor) in CYP2C19 poor metabolizers 3

Lipid Management

• High-intensity statin therapy must be initiated or continued at discharge in all patients regardless of baseline LDL-C level 1
• Target LDL-C should be substantially less than 100 mg/dL 1
• Obtain fasting lipid profile within 24 hours of admission if not already available 1
• For patients with LDL-C ≥100 mg/dL, prescribe statin therapy with preference for high-intensity statins 1, 2
• Even patients with LDL-C <100 mg/dL should receive statin therapy at discharge 1

Beta-Blockers

• Beta-blockers should be continued during and after hospitalization for all patients without contraindications 1
• Patients with initial contraindications in the first 24 hours should be reevaluated for subsequent eligibility 1
• Continue beta-blockers that were required for ischemia control during hospitalization 1, 2

ACE Inhibitors/ARBs

• ACE inhibitors should be administered within the first 24 hours to patients with anterior STEMI, heart failure, ejection fraction ≤0.40, or diabetes 1
• ACE inhibitors are reasonable for all STEMI patients without contraindications 1
• Angiotensin receptor blockers should be given to patients with indications for but intolerance of ACE inhibitors 1

Aldosterone Antagonists

• Prescribe to patients already on ACE inhibitor and beta-blocker who have ejection fraction ≤0.40 and either symptomatic heart failure or diabetes 1

Nitroglycerin

• All patients must receive sublingual or spray nitroglycerin with detailed instructions for use 1, 2

Critical Patient and Family Education

Symptom Recognition and Emergency Response

• Instruct patients that chest discomfort lasting more than 2-3 minutes should prompt immediate cessation of activity and taking one dose of sublingual nitroglycerin 1, 2
• If pain is unimproved or worsening 5 minutes after one nitroglycerin dose, the patient or family member must call 9-1-1 immediately 1, 2
• While activating EMS, additional nitroglycerin may be taken at 5-minute intervals (maximum 2 additional doses) while lying down or sitting 1
• If the pattern or severity of anginal symptoms changes (more frequent, more severe, precipitated by less effort, or occurs at rest), contact physician without delay 1

Medication Instructions

• Provide written, culturally sensitive instructions about each medication's type, purpose, dose, frequency, and pertinent side effects to patients and designated caregivers 1, 2

Family CPR Training

• Family members should be advised to learn about AEDs and CPR and be referred to a CPR training program, ideally with a social support component 1

Lifestyle Modifications

Dietary Therapy

• Initiate diet low in saturated fat (<7% of total calories) and cholesterol (<200 mg/day) at discharge 1, 2
• Encourage increased consumption of omega-3 fatty acids, fruits, vegetables, soluble fiber, and whole grains 1
• Balance calorie intake with energy output to achieve and maintain healthy weight 1

Weight Management

• Measure waist circumference and calculate body mass index 1
• Desirable BMI range is 18.5 to 24.9 1
• Waist circumference >40 inches in men and >35 inches in women warrants evaluation for metabolic syndrome and weight-reduction strategies 1

Smoking Cessation

• Assess tobacco use and strongly encourage complete cessation 1
• Provide counseling, pharmacological therapy (including nicotine replacement and bupropion), and formal smoking cessation programs 1

Cardiac Rehabilitation

• All eligible patients should be referred to cardiac rehabilitation programs, which reduce all-cause mortality and improve functional status 2
• Formal programs typically begin 4-8 weeks post-event 4

Blood Pressure Management

• If blood pressure ≥120/80 mm Hg, initiate lifestyle modifications (weight control, physical activity, alcohol moderation, moderate sodium restriction, emphasis on fruits, vegetables, and low-fat dairy products) 1
• If blood pressure ≥140/90 mm Hg (or ≥130/80 mm Hg with chronic kidney disease or diabetes), add blood pressure medication 1

Special Considerations for Anticoagulation

• Anticoagulant therapy with vitamin K antagonist should be provided to patients with atrial fibrillation (CHADS2 score ≥2), mechanical heart valves, venous thromboembolism, or hypercoagulable disorder 1
• The duration of triple-antithrombotic therapy (vitamin K antagonist, aspirin, and P2Y12 inhibitor) should be minimized due to bleeding risk 1

Timing of Hospital Discharge

Low-Risk Patients

• Low-risk STEMI patients treated with primary PCI can be safely discharged within 48-72 hours 5
• The risk of late ventricular arrhythmias (≥1 day after PCI) is low at 2.4% overall and 1.7% in uncomplicated STEMI 6
• Late ventricular arrhythmias with cardiac arrest are rare (0.4% overall, 0.1% in uncomplicated STEMI) 6

Standard Discharge Timeline

• Patients undergoing successful PCI with uncomplicated course are usually discharged the next day 1
• Median length of stay is typically 3 days 6

Common Pitfalls to Avoid

• Never discharge patients without ensuring they have sublingual nitroglycerin and understand proper use 1, 2
• Do not prescribe omeprazole or esomeprazole with clopidogrel due to significant drug interaction reducing antiplatelet effect 3
• Avoid premature discontinuation of dual antiplatelet therapy, which increases risk of cardiovascular events 3
• Do not discharge without confirming statin therapy is prescribed, regardless of baseline LDL-C level 1
• Ensure beta-blockers are not withheld due to temporary contraindications without reevaluation for subsequent eligibility 1