ST-elevation myocardial infarction

Survivors of acute myocardial infarction should be closely followed up for adequate modification of risk factors and development of complications.[3]Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023 Oct 12;44(38):3720-826. https://academic.oup.com/eurheartj/article/44/38/3720/7243210 http://www.ncbi.nlm.nih.gov/pubmed/37622654?tool=bestpractice.com [69]O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):e362-425. https://www.ahajournals.org/doi/10.1161/CIR.0b013e3182742cf6 http://www.ncbi.nlm.nih.gov/pubmed/23247304?tool=bestpractice.com ​​​ Patients should be evaluated within 2 to 3 weeks of discharge and evaluated periodically based on the extent of myocardial damage and patient condition.[Figure caption and citation for the preceding image starts]: 12-Lead ECG showing inferior and anterior ST-elevation with reciprocal changes in the lateral leadsFrom the personal collection of Dr Mahi Ashwath; used with permission [Citation ends].[Figure caption and citation for the preceding image starts]: 12-Lead ECG immediately after successful revascularization showing ST segments returning to baselineFrom the personal collection of Dr Mahi Ashwath; used with permission [Citation ends].​​[Figure caption and citation for the preceding image starts]: 12-Lead ECG on follow-up 7 months later with normal ST segments and the absence of Q wavesFrom the personal collection of Dr Mahi Ashwath; used with permission [Citation ends].

Initiating risk-factor modification and aggressive medical management prior to discharge has been associated with increased patient adherence. All patients should continue the optimal medical regimen indefinitely. This includes aspirin, P2Y₁₂ inhibitor (up to 1 year), beta-blockers, statins, and ACE inhibitors (especially in patients with decreased ejection fraction).

Ejection fraction is assessed by echocardiography 3 months after the acute episode and then periodically thereafter, depending on left ventricular (LV) function and symptoms.[79]Edvardsen T, Asch FM, Davidson B, et al. Non-invasive imaging in coronary syndromes: recommendations of the European Association of Cardiovascular Imaging and the American Society of Echocardiography, in collaboration with the American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. Eur Heart J Cardiovasc Imaging. 2022 Jan 24;23(2):e6-33. https://academic.oup.com/ehjcimaging/article/23/2/e6/6423983 http://www.ncbi.nlm.nih.gov/pubmed/34751391?tool=bestpractice.com ​ 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.

Patients with a history of myocardial infarction are at increased risk for recurrent infarction. They should be evaluated by stress testing or cardiac catheterization if symptoms develop. Routine periodic ischemic evaluations with stress echocardiography or myocardial perfusion studies are controversial.