Unstable angina / non ST elevation myocardial infarction post-discharge follow-up

Overview of Post-Discharge Follow-Up in Unstable angina/NSTEMI
Patients with UA/NSTEMI, specially those with high risk factors during hospital stay, have high mortality which can be as high as 14 fold compared to those with absence of risk factors.

Clinical trial data

 * In a GUSTO IIa substudy of UA/NSTEMI patients, prior MI, Troponin-T positivity, accelerated angina before admission, and recurrent pain or Electrocardiogram changes were independently associated with risk of death at 2 years. Patients who were managed with initial conservative strategy should be reassessed at the time of follow up for the need for catheterization and revascularization. The degree and severity of angina should be assessed.


 * In a study by Van Domburg et al, a long term follow up of patients with UA demonstrated that the mortality rate in the first year was 6%, revascularization rate was 47% in the first year and that of MI was 11% in first year with rapid drop in subsequent yrs. Their study reported a good long-term outcome even after a complicated early course.

The overall long-term risk for death or MI 2 months after an episode of UA/NSTEMI is similar to that of other CAD patients with similar risk factors.
 * The study using GRACE registry database, nine predictive variables were identified: older age, history of MI, history of HF, increased pulse rate at presentation, lower systolic blood pressure at presentation, elevated initial serum creatinine level, elevated initial serum cardiac biomarker levels, ST-segment depression on presenting ECG, and not having a PCI performed in the hospital. This simple tool can be used to predict risk of death at 6 month post-discharge. Certain patients at high risk of ventricular tachyarrhythmia after UA/NSTEMI may be candidates for an implantable cardioverter defibrillator. Indications and timing of an implantable cardioverter defibrillator in this setting are the same as in patients with STEMI and are discussed under STEMI guidelines.

Follow-up recommendation

 * During follow up visits, cardiac catheterization with coronary angiography is recommended for any of the following situations:
 * 1) significant increase in anginal symptoms, including recurrent UA
 * 2) high-risk pattern (e.g., at least 2 mm of ST-segment depression, systolic blood pressure decline of at least 10 mm Hg) on exercise stress test
 * 3) heart failure
 * 4) angina with mild exertion (inability to complete stage 2 of the Bruce protocol for angina)
 * 5) survivors of sudden cardiac death.


 * Revascularization is recommended based on the coronary anatomy and ventricular function and recommendations are similar as for stable angina patients.


 * Compliance towards medications and risk factor modification should be assessed and reinforced at each follow up visit. Involving family members in the plan of treatment and adherence to treatment regimen can improve outcomes.


 * Cardiac Rehabilitation should also be recommended.

==ACC / AHA Guidelines- Postdischarge Follow-up care(DO NOT EDIT) ==

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Class I
1. Detailed discharge instructions for post UA / NSTEMI patients should include education on medications, diet, exercise, and smoking cessation counseling (if appropriate), referral to a cardiac rehabilitation / secondary prevention program (when appropriate), and the scheduling of a timely follow-up appointment. Low risk medically treated patients and revascularized patients should return in 2 to 6 weeks, and higher risk patients should return within 14 days. (Level of Evidence: C)

2. Patients with UA / NSTEMI managed initially with a conservative strategy who experience recurrent signs or symptoms of unstable angina or severe (Canadian Cardiovascular Society class III) chronic stable angina despite medical management who are suitable for revascularization should undergo timely coronary angiography. (Level of Evidence: B)

3. Patients with UA / NSTEMI who have tolerable stable angina or no anginal symptoms at follow-up visits should be managed with long term medical therapy for stable CAD. (Level of Evidence: B)

4. Care should be taken to establish effective communication between the post UA / NSTEMI patient and health care team members to enhance long term compliance with prescribed therapies and recommended lifestyle changes. (Level of Evidence: B)}}