Monitoring
Your Organisational Guidance
ebpracticenet urges you to prioritise the following organisational guidance:
Behandeling acuut coronair syndroom in een urgente situatie (in afwachting van hospitalisatie)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022La prise en charge du syndrome coronarien aigu (SCA) en situation d'urgence (en attente d'hospilatisation)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022Close monitoring and treatment is essential. An outpatient follow-up should be arranged within the first 1 to 2 weeks of discharge. Monthly visits should be scheduled thereafter. Lipids should be monitored at least every 6 months until a target low-density lipoprotein <1.8 mmol/L (<70 mg/dL) is reached in patients who have had a myocardial infarction or have coronary artery disease. The need for follow-up echocardiography is at the discretion of the physician. However, echocardiography is necessary to evaluate and monitor ventricular function.[1]
Psychosocial risk factors such as anxiety and depression should be addressed. Depression in particular has been associated with a poor prognosis.[56] All medicines should be reviewed at every follow-up visit to encourage patient compliance and optimal dosing.[1]
Ejection fraction is assessed by echocardiography during the index hospital admission, possibly 3 months after the acute episode (depending on physician discretion and/or institutional protocols) and then periodically thereafter, depending on left ventricular (LV) function and symptoms.[87] Patients with ejection fraction <35% at 3 months' follow-up should be referred to an electrophysiologist for consideration of an implantable cardioverter defibrillator, as there is a high risk for arrhythmias in this population. Patients who develop diminished LV function and congestive heart failure should be followed up and managed appropriately.
In patients who have undergone direct reperfusion, further non-invasive stress testing or further imaging is indicated only if stenosis of intermediate severity (luminal narrowing of 50% to 70%) is present in a non-culprit artery. Patients with recurrent ischaemic-type pain after reperfusion may need invasive coronary angiography after medical therapy to evaluate for further stenosis or occlusion.[185]
All patients, regardless of whether a stent was placed, should be treated with a P2Y₁₂ inhibitor for up to 12 months and low-dose aspirin daily as long as tolerated. There is some evidence that patients treated with bare metal stents (BMS) are at an increased risk for repeat procedural care compared to those treated with drug-eluting stents (DES). P2Y₁₂ inhibitors for patients with acute coronary syndrome NSTEMI should be continued for at least 12 months in all patients despite treatment strategy of medical management, balloon angioplasty, lytic therapy, BMS placement, or DES placement. For selected patients with stable coronary artery disease receiving percutaneous coronary intervention, shorter duration (1-3 months) of dual antiplatelet therapy may be considered with subsequent transition to P2Y₁₂ inhibitor monotherapy to reduce the risk of bleeding events.[185][186] A scientific advisory from several major health organisations describes the risks of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents.[182]
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