Cardiac Rehabilitation, Follow-Up and Preventing the Next Heart Attack

There are three glycoprotein 2b3a inhibitors: abciximab, tirofiban and eptifibatide. These were used far more commonly a decade ago, before stents and catheterization labs were as standardized and widely available as they are now. Today their use has decreased and they are reserved for high-risk patients, such as those with a high thrombotic burden or delayed presentation, because of the increased risk of bleeding in the brain, stomach and at the local puncture site.

The prognosis is poor when a patient with ST-elevation MI cannot be thrombolyzed because of a contraindication. Ideally these patients should be sent for primary angioplasty; if that is also unavailable, they should be managed medically in an ICU with aspirin, clopidogrel or ticagrelor, statins, beta blockers, ACE inhibitors, nitrates and heparin or low molecular weight heparin, using whatever resources are available. Outcomes can be described as roughly 50/50: some patients respond well to this treatment, while others deteriorate and need referral to a higher-level facility.

Management of aortic dissection depends on which part of the aorta is involved. If the dissection involves the ascending aorta or the arch, it needs surgical management. If it involves the descending thoracic aorta or the descending abdominal aorta, percutaneous repair of the aneurysm is possible instead.

Once symptoms begin, the earliest ST elevation can appear on ECG within 15 to 30 minutes. This ST elevation persists if there is complete occlusion of the artery, and can still be present up to 48 hours later. If blood flow is restored spontaneously, whether from medicines or other reasons, the ST elevation resolves; otherwise it persists until the artery is reopened.

Mortality in ST-elevation MI can be quite high if the patient is not treated properly, up to 30 to 50%, which is why adequate and timely treatment matters so much. Cardiac echo, alongside ECG and cardiac enzymes, is very important and can pick up early signs of heart damage; it is now one of the first-line investigations at tertiary care hospitals in suspected cases.

Dr. Goel's guidance is 3 to 6 months of continued medication and risk factor reduction, not a short course, alongside a structured cardiac rehabilitation program.

Primary prevention targets people with risk factors who have not yet developed vascular disease, aiming to prevent a first event. Secondary prevention targets patients who already have vascular disease and focuses on preventing a repeat event.