(March 4, 2009 - Insidermedicine) Watch Dr. Neica Goldberg, author of "Dr. Nieca Goldberg’s Complete Guide to Women’s Health," discuss what she would do if she had a non-STEMI heart attack and had been discharged from the hospital. Dr. Goldberg is Clinical Associate Professor of Medicine at the NYU School of Medicine and the Medical Director of NYU's Women Heart Center.
At the American Heart Association Scientific Sessions in New Orleans, we spoke Dr. Neica Goldberg, Clinical Associate professor of medicine at the NYU School of Medicine, and the medical director of NYU Women’s Heart Centre. Dr. Goldberg is a cardiologist and author of “Dr Neica Goldberg’s Complete Guide to Women’s Health”.
What is a Non-STEMI heart attack?
Dr. Goldberg: A non-STEMI heart attack is a non-ST segment Elevation heart-attack (Myocardial Infarction) which really refers to an abnormality on the electrocardiogram. So if you have a non-STEMI, you’re most likely to have had a normal electrocardiogram, abnormal blood tests telling us that you did have a heart attack and that you also had symptoms that were consistent with a heart attack, you’ve had a small amount of heart muscle damage, and when you are hospitalised you may or may not have had a coronary angiogram which is a test that uses a catheter in the ground that is advanced to the heart and we inject contrast that allows us to visualise the arteries, and an x-ray picture. Sometimes, the doctors find a blockage that needs a stent (a little wire mesh that keeps the artery open after the doctor has opened it up with a balloon).
What can I expect after discharge?
Dr. Goldberg: When you’re discharged from the hospital, what you have to know is that you did have a heart attack, and the first thing you should do before leaving the hospital is to look at those discharge instructions. The nurse will often sit down and discuss the various discharge instructions with you. The first one is what kind of activity you can have after you leave the hospital; usually we tell people that they can take some walks after their heart attack, but not to do any vigorous activities until after the first doctor’s visit.
What can I expect in terms of medication?
Dr. Goldberg: The other thing is that you would be given a series of prescriptions. Pay close attention. Most likely you should be given a prescription for a cholesterol-lowering medication known as a statin. Even though your cholesterol may have been seen to be normal, when you’ve had a heart attack, we put you on a statin because we want your bad cholesterol to get down to levels as low as 70 mg/dL. So if you don’t have a prescription for a statin, find out why.
If you have high blood pressure, or have had a heart attack, a common medicine we use is an ace-inhibitor, also known as an angiotensin-converting enzyme inhibitor, helps to improve the flexibility or your arteries not only lowering your blood pressure but also making them more resistant to plaque. Everyone who's had a heart attack should be going home on a beta-blocker unless they are allergic to them or cannot tolerate them. We know from studies that have been going on for a long time more than 20 years, almost 30 years that beta-blockers help to reduce the risk of a recurrent heart attack. In addition you won't be getting a prescription for aspirin but you will be recommended to take an aspirin. The reason that you are not given a prescription is you can buy it over the counter. What you should check is the dose of aspirin that you should be on with your doctor. We give a range of doses that are anywhere from 81 - 325 mg depending upon what your doctor feels is right for you.
When should I have my return visit?
Dr. Goldberg: Usually in 7 to 14 days after your discharge. If you are stable then that’s when you will see your doctor. But of course if you have any recurrent symptoms of chest discomfort, shortness of breath, light-headedness, or fainting, you should call your doctor and schedule an earlier appointment. Or they may give you direction to go back to the hospital. But the most important thing your doctor should talk to you about during this visit is when you are going to go to cardiac rehab. Cardiac rehab is an organized program of exercise, nutritional counseling, and stress management. It's covered by most insurance plans and the unfortunate thing is most people don’t get referred. So if your doctor doesn't bring it up, you should ask.
What is Secondary Prevention?
Dr. Goldberg: Well, secondary prevention of heart disease, which means that you are already diagnosed with heart disease because you have had a heart attack, the object is to prevent another one. And that is why we give aspirin, to prevent a second heart attack; it lowers the risk of a second heart attack by 25%. An ACE inhibitor has been shown in people who many have serious heart muscle damage to prevent heart failure, and also lower blood pressure.
How will I know how much I can exercise?
Dr. Goldberg: Before you go into a rehab program it's no mystery, you get a stress test before they prescribe exercise. And your exercise prescription, the intensity of your exercise is based on the results of the stress test.
After rehabilitation, what diagnostic tests might be ordered?
Dr. Goldberg: After rehab they do a follow up stress test to see how you've improved in your fitness. They also recommend repeat blood testing for cholesterol. And one of the diagnostic, so called test, but it's really a survey, is to be tested for depression. That is a requirement for cardiac rehab certification. Programs must tests people for depression because of the strong association with increased mortality in people who have depression after their heart attack.
If I had a non-STEMI heart attack...
Dr. Goldberg: If I had a non-STEMI heart attack and I was being discharged from the hospital, I would want to know what I needed to do when I went home to prevent a second heart attack. I would make sure that my prescriptions were for an ACE inhibitor, a beta-blocker, and aspirin, because these three things have been shown to reduce risk of recurrent heart attacks. In addition I would make sure I had a date for a follow-up visit with my doctor and instructions about what kind of activity I can do, when I am discharged from the hospital and before my next office visit. I would also go to that office visit prepared to have my questions answered about any symptoms I'm concerned about. As well as whether or not I can start cardiac rehabilitation. And to ask my doctor to find a program that is close to my house.