When to Hospitalize for ACS: A Q&A With Dr Debabrata Mukherjee
Cardiovascular disease (CVD) is highly prevalent in the United States, affecting approximately 610,000 each year, according to the Centers for Disease Control and Prevention.1 Among the most common forms of CVD are acute coronary syndromes (ACS), such as myocardial infarction (MI)—or a heart attack.
The most common symptoms of an ACS event like a heart attack often include:
- Pressure, squeezing, fullness, or pain in the center of the chest that lasts more than a few minutes.
- Pain or discomfort in one or both arms, the neck, jaw, stomach, or back.
- Cold sweats, nausea, shortness of breath, or lightheadedness.
Chest pain is the most recognizable sign of a heart attack in both men and women, but other common symptoms can sometimes be overlooked or misconstrued, especially in women, according to Debabrata Mukherjee, MD, chairman of the department of internal medicine and chief of cardiovascular medicine at Texas Tech University.
Women are somewhat more likely than men to experience symptoms such as shortness of breath, nausea or vomiting, and back or jaw pain in addition to or instead of chest pain, Dr Mukherjee said.
In his presentation “Acute Coronary Syndromes: Nomenclature, Guidelines, and Drugs” at the American College of Physicians Internal Medicine Meeting in New Orleans, Louisiana, Dr Mukherjee shed light on recognizing these signs and symptoms of ACS, knowing when to hospitalize patients for ACS, and guideline-recommended treatment and management strategies.2
Consultant360 recently spoke with Dr Mukherjee, who answered our questions about his presentation.
Consultant360: What do the guidelines recommend for managing and treating ACS? When do they recommend hospitalization for patients with ACS?
Debabrata Mukherjee: Guidelines suggest that patients with suspected ACS should be risk stratified based on the likelihood of ACS and adverse outcomes to determine the need for hospitalization and assist in the selection of treatment options. Risk scores such as Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry of Acute Coronary Events (GRACE) should be used to assess prognosis in patients with non-ST-elevation ACS (NSTE-ACS) and can be useful in deciding management strategy.
Patients with the following attributes need to be hospitalized for chest pain:
- Positive biomarkers (troponin) with temporal change.
- Abnormal/concerning vital signs, such as:
- Tachycardia/bradycardia,
- Hypotension,
- Tachypnea, or
- Hypoxemia.
- Ischemic electrocardiographic findings, such as:
- ST elevation/ST depression,
- Left bundle branch block (LBBB; new), or
- Ischemic T wave changes.
C360: How do treatments for ACS vary based on condition severity, comorbidity, family history, etc.?
DM: Treatment for ACS should be patient-centered and based on risk assessment. All patients should be treated with guideline-directed therapies such as antiplatelet agents, statins, β-blockers, angiotensin converting enzyme inhibitors (ACE)/angiotensin-receptor blockers (ARB), and so on. The decision on when and if patients needs to go to cardiac catheterization laboratory is based on risk assessment, summarized below: 3
(Chart adapted from Amsterdam EA, Wenger NK, Mukherjee D, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;23;64(24):e139-e228.)
C360: What is the most common question you receive after giving this presentation? What are some of the unmet educational needs regarding ACS?
DM: The most common question I receive is “When can patients resume activity, including sexual activity, after a heart attack?” In addition to detailed instructions for daily exercise, patients should be given specific instruction about activities—such as lifting, climbing stairs, yard work, and household activities—that are permissible and those to avoid. Specific mention should be made for resuming driving, returning to work, and participating in sexual activity.
Patients with previous myocardial infarction (MI) who are asymptomatic or have no ischemia with stress testing or who have undergone complete coronary revascularization are at low risk for coital MI. Before the routine use of reperfusion therapy, it was recommended that sexual activity be avoided for 6 to 8 weeks after MI.
An American Heart Association scientific statement states that “Because participation of stable patients in cardiac rehabilitation exercise programs 1 week after MI has proved safe, resumption of sexual activity soon after uncomplicated MI seems reasonable in the stable patient who is asymptomatic with mild to moderate physical activity (e.g., 3-5 METS).”4
“Sexual activity is reasonable 1 or more weeks after uncomplicated MI if the patient is without cardiac symptoms during mild to moderate physical activity,” the authors of the statement wrote.4
—Christina Vogt
References:
1. Heart disease facts. Centers for Disease Control and Prevention. Last updated November 28, 2017. https://www.cdc.gov/heartdisease/facts.htm. Accessed on April 24, 2018.
2. Mukherjee D. Acute coronary syndromes: nomenclature, guidelines, and drugs. Presented at: American College of Physicians Internal Medicine Meeting; April 19-21, 2018; New Orleans, LA.
3. Amsterdam EA, Wenger NK, Mukherjee D, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;23;64(24):e139-e228. 10.1016/j.jacc.2014.09.017
4. Levine GN, Steinke EE, Bakaeen FG, et al. Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2012;125:1058-1072. https://doi.org/10.1161/CIR.0b013e3182447787
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