Monitoring
Follow-up is focused on the patient's individual profile and level of
risk. Low- and intermediate-risk medically treated patients and revascularized
patients may have a follow-up appointment in 2 to 6 weeks, while high- and very
high-risk patients may follow up in 1 to 2 weeks. Further
stratification utilizing the TIMI risk score for secondary prevention should be
undertaken to guide the intensity of therapy and treatment targets, the need
for additional treatment (such as anticoagulation for atrial fibrillation), and
the discussion of long-term prognosis with the patient and their family.
Secondary prevention should include:
- Achieving treatment goals through optimization of risk factor control
- Emphasizing lifestyle modification, including smoking and vaping cessation, abstinence from alcohol, regular exercise, dietary changes, and weight maintenance
- Checking and managing adverse reactions from treatment and monitoring treatment adherence
- Reinforcing compliance to treatment, regular follow-up and the importance of continuing secondary preventive measures
- Educating the patient about the disease
Outpatient evaluation of low-risk NSTE-ACS patients may include echocardiography for assessment of LV function, stress echocardiography (treadmill or pharmacological stress), treadmill stress test, cardiac MRI (stress MRI for ischemia and perfusion MRI for viability), and nuclear perfusion study. Patients with significant demonstrable ischemia should be referred for coronary angiography for potential revascularization. A fasting lipid profile is recommended 4 to 8 weeks after starting or modifying the dose of the lipid-lowering therapy. Referral to cardiac rehabilitation is considered to improve functional status and quality of life.
Complications
Post-ACS Complications
Patients should be assessed for significant
complications after ACS, particularly arrhythmias and heart failure. Heart
failure after ACS may result from extensive myocardial damage or mechanical
complications. The chest pain after ACS is evaluated for the following possible
causes: Reinfarction/recurrent ACS, post-infarct angina or pericarditis. If LV
thrombus is identified after ACS, anticoagulation is recommended for at least 3
months or until thrombus resolution. After the resolution of the LV thrombus, periodic
follow-up imaging should still be performed, at least annually. Lastly, indefinite
anticoagulation may be considered if bleeding risk is low in patients with LV
aneurysm, large dyskinetic LV segments and/or prior thromboembolic events.