Good afternoon Prof. Ramakrishnan. Thanks for taking out time. It is our pleasure that despite the busy schedule, you have been able to take some time and come here and discussed very important topics. We all know that reperfusion is the biggest priority during the initial period but once that gets over and the patient is a little stable, the reperfusion is no more a priory, what becomes the priority for the physician.
I think the most important thing is reassuring the patient and getting the patient back to his normal self, introducing the diet and rest of the things are important. Pharmacotherapy is one of the most important thing in this phase. I think statins are an absolute essential along with antiplatelet agents including dual antiplatelet either clopidogrel, prasugrel and ticagrelor along with aspirin and apart from that, this is the right phase to initiate and up titrate the therapy of beta-blockers and ACE inhibitors. So these are the important hemodynamic therapies that we need to initiate and the patient’s ventricular function and what is the blood pressure, so any heart failure is there, these things should be kept in mind before you start and upgrade the therapy with all these agents.
Okay. What would be the most complications we should be watched for.
So all of a sudden like especially in India the patients are managed in nursing home, suddenly the patient collapses after he was doing well, there could be a lot of issues coming up because of that. You should always be aware that postsphygmic period is also a critical phase, where lot of things can go wrong even if the patient is reperfused, even if the ventricular function is reasonably okay, the patient is otherwise also normal. So, the patient should be under Intensive Care Unit care until a few days, especially if it is a complicated MI, it should be more days, but if it is an uncomplicated MI, at least for two days he should be in ICU setting and later on it should be stepped by ICU then followed by a routine ward. So, most important things to be monitored where suddenly something can be happen will be an arrhythmic event or a mechanical complication of MI. These are the two dreaded things that can suddenly all of sudden can strike you. Unfortunately, even with thrombolysis, these complications have come down a little but still these complications happen like mechanical complications like mitral regurgitation, a ventricular septal rupture are very rarely the cardiac rupture also do happen. They will strike you out of the blue. The patient will be doing otherwise fine, suddenly he develops an acute episode of pulmonary edema or develops cardiogenic shock and then it could be a lot of difficulty, so that should be always watched for. The other thing that you should always be looking out especially if you are thrombolysed and the angioplasty has not been done is reinfarction and recurrent ischemia. So that is the another thing that you should be always looking for and now in today’s time reinfarction and recurrent ischemias are generally very aggressively managed with an angiography followed by a revascularization procedure.
So once the discharge day comes the patient is looking back to go back home and resume their normal life. The doctor has prescribed a lot of medicines to them and the biggest worry in the patient’s mind is that how they will go back to their work and how they can prevent the second attack. What are the things which are the most critical during that period?
So in that period apart from pharmacotherapy which is very essential again the same including the important drugs, including the antiplatelet, dual antiplatelets, the statins, the ACE inhibitors and the beta-blockers along with if there is a ventricular dysfunction, the aldosterone antagonists. These are essential drugs that have to be prescribed on discharge in almost in all patients with ST elevation myocardial infarction in today’s time. This I think is the most important time where the real rehabilitation starts. It is not just about pharmacotherapy, it is much more beyond pharmacotherapy. One of the most important advices that repeatedly should go into the patient’s mind is stop smoking, if he was a smoker. So, this is the right time to repeatedly reinforce that if you do not want a reinfarction, absolutely quit smoking just now. You already smoked your last cigarette and many of them are worried about when I will get a next attack, what will happen if I have a next attack and always the patients have even if their LV function is normal, always the fear is that if I get the next attack that will be the end of it. So that is not always the case but even recurrent infarctions are much more common in the early phases than in the later phases and when they occur, they occur they most of the time in the same fashion like the patient has chest pain and immediately they should rush to the hospital, but one important thing that every physician should re-ensure the patient is that chances of reinfarction is roughly around in a nondiabetic routine myocardial infarction will be say 5% in five years, so that is not much, that is not a lot. So, I used to tell my patients your chance of having an attack is 5% in five years. Your chance of not having an attack is 95% why are you always bothered about that 5%. So that most of the time reassures the patients and then apart from that this is the right time to start initiate a lot of lifestyle modification, so that is a very key component, most of he hospitals even in India they forget it like. It is better that is never will be done by a physician, it is better that you appoint a dietician or a paramedic to do that job. Not only this should happen with the discharge, this process should have started two three days prior to discharge, so that the patient is into confidence with the paramedics, so they get to converse what he does in routine lifestyle and his lifestyle is modifies according to his needs, not that you give a chart for everybody to follow. So just think about the diet chart. So you take diet chart, it will be very hard for any doctor to follow the diet chart. So, it is better that individualize the diet chart according to the patient’s need and if at all anybody follows lifestyle modification, the chances of them following it is much, much more when they are given at the time of discharge following a myocardial infarction and then another important advice that has to go in exercise prescription. So that is a very important thing many of them they stop working going to work and many of them they stop walking. They are feared what will happen if they walk, if they exert and that is an important thing where according to the patient’s condition the hemodynamic as well as the ventricular function and other things, a detailed exercise rehabilitation program should be individualized to each patient. That should be clearly spelt out what they can do, what they should not do for one week, for month and so on.
The message is loud and clear about the lifestyle modification. When it comes to drugs, the patients also have to take a lot of medicines. Any particular way or strategy you have so that the patients are able to comply and adhere to the complex medicines or complex therapies they have.
So unfortunately, till the time you achieve a dose which is absolutely essential, till the time it is better that you prescribe the drug individually but once you know this is the maximum dose that this patient is tolerating and this patient needs then in India at least potentially we have a lot of combination drugs that are available that can reduce the pill burden and the purse burden, but that should be done only when you are absolutely sure that the dosing is appropriate for the patient.
When is generally that done.
See generally there is no fixed time for that, but I generally do it at three months’ time.
At three month’s time?
Three months following an MI, I generally combine drugs.
So till the time patients get individualized drugs like.
Till that time they have to be on the individual therapy then they can go?
So that they are better tirtratable.
Once they reached the stable dose then the fixed dose combinations can be given. What are the other things which patients must do during the recovery phase.
I think the back to normalcy is the most important thing. You get back to your work. You start behaving as if nothing has happened that gives you much more faster pace of recovery than sitting at home worrying about why did I get it, what if this would have happened , what if that would have happened, when will I get it next time. So just take away all this, just think that nothing has happened and start moving forward in your life.
What are the investigations which are must to do during that period.
It also depends whether the patient has had an angiogram and revascularization or not. If the patient did not get the angiogram and a revascularization, definitely the patient should have a pre-discharge stress test. A symptom limited pre-discharge stress test is generally recommended. So in a uncomplicated MI in a low risk MI sometimes Indian doctors tend to do it later on like may be two weeks later that also could be possible, but inpatients who are thrombolysed then in today’s time it is better that even then they could undergo a stress test to find whether the thrombolysis is successful or not. Because the success rate of thrombolysis may not be well predicted by ECG alone, so that could be one but most of the patients who have undergone a revascularization procedure generally nothing much is needed. So just you measure your sugar, blood pressure under control, under check and most of the time you will have an ejection fraction which is known at the time of the discharge that should be good enough for a few years like. Till the time you get a symptom or your symptom status changes or new symptoms develop, definitely you should be investigated thoroughly but routinely getting just beyond that may not be needed and if you are on a good dose of statin which the most of the recommendations recommend then potentially repeating the lipid profile again and again may not be needed.
How long these medicines should be continued, all four of them.
Life long is generally what we recommend but dual antiplatelet therapy can be made to a single antiplatelet agent with aspirin alone after one year that is the generally the recommendation and then later on statin has to be life long and ACE inhibitors and the beta-blockers. You can reassess them later. If the ejection fraction is absolutely normal, you can think over it, at least for a year everything has to be taken.
Alright and after that slowly the number of medicines can be reduced?
Yeah absolutely then in that case, there could be good combinations where most of the patients can be managed with just two drugs a day.
One of the common complications is the heart fail where a couple of patients, their heart does not function and over a period of time during the remodeling period, especially there are chances that ejection fraction may come down, any particular medicines or any particular strategy you have to avoid that and how do you manage if it is already low?
If the patient has an existing heart failure definitely that should be carefully managed with an optimal use of diuretics and they should avoid strenuous activity if the patient has an heart failure following myocardial infarction and then definitely in these cases, diuretic like an aldosterone antagonist definitely helps surely to reduce to mortality so that should be definitely used along with all the other agents.
There are two main forms of therapies other than antiplatelets you have mentioned, one is the RAAS blocker group and the second is the beta-blocker group. In the RAAS blocker group, any particular preference that you have in terms of medicines.
So generally I prefer especially in the post immediate postsphygmic period, generally I prefer ramipril because large database evidence is there and similarly beta-blocker, I think generally metoprolol is much more preferred than a de novo heart failure whereas somehow we always prescribe carvedilol, so in a patient with a heart failure following myocardial infarction most of the time we end up starting metoprolol sustained release preparations whereas if the patient is really serious heart failure or decompensated heart failure, you want to start with a low dose and up titrate generally we may prefer carvedilol.
Right. So your decision also varies depending on the ejection fraction of the patient with the choice of medicine or not.
Definitely, obviously, anybody less than 45% should be prescribed a lifelong ACE inhibitors and a beta blocker also, but whereas if the patient’s ejection fraction is normal and he is not a normotensive with an inferior wall MI which is uncomplicated, had eight years back, there is no data to suggest that longer term these agents are of any benefit, in a very specific situation.
So in that case you will continue for some time like you did.
Definitely, I think there is no doubt that we should continue it for a year. For a year almost all ST elevation myocardial infarction should be on both ACE inhibitors and beta-blockers.