Going home

The first few weeks after a heart attack

Early discharge after myocardial infarction avoids the dangers of prolonged immobilisation, but it often leaves the patient bewildered, depressed, and anxious.1 Many survivors and their partners will say that the period immediately after discharge was the most difficult after their heart attack.2 3 Sudden death is a substantial possibility in the first few weeks at home,4 yet commonly this stage in the recovery receives little attention from health professionals. and most patients receive no medical help during their first few weeks at home (unpublished data).

If general practitioners visit soon after discharge they can do a great deal to help. They can confirm the diagnosis and discuss the nature of the disease. Much of this will have been done in hospital, but the patient may not have understood or remembered all that he or she has been told.5 A booklet in language suitable for the individual patient should help.6 The general practitioner should check that the patient understands the importance of modifying risk factors to avoid future coronary problems. The patient should also be told to expect and ignore niggling left sided chest pain, light headedness, and occasional “missed” beats. Questions should also be asked about less common but potentially serious symptoms which warrant urgent referral to hospital. These are angina on minor exertion, breathlessness with light exercise or in bed, and rapid palpitations, particularly if accompanied by faintness.

The next step is to review the drugs currently being taken, including the dose, duration, purpose, and possible side effects. Nearly all patients should be taking aspirin,7 and many will be taking β blockers and experiencing some of their common side effects. An increasing number will be taking an angiotensin converting enzyme inhibitor8 and will need their blood pressure and renal function monitored while the dose is gradually increased to the optimum level. Patients given glyceryl trinitrate tablets or a spray should have written instructions on their appropriate use.

Patients are often anxious about physical activity and how rapidly to increase it. Here the advice must be tailored to the individual: what is right for a 35 year old man who has just recovered from a small infarct will be very different from that for a man aged 80 already disabled by other diseases to which has been added substantial cardiac damage. If the local district hospital offers an exercise based rehabilitation programme the general practitioner should strongly encourage the patient to join.9 In the absence of such a programme many general practitioners may find the Heart Manual useful.10 11

Advice will also be needed on specific topics including sexual intercourse, driving, and flying on commercial airlines. Sex within a week or two of arriving home is unlikely to cause any problems unless it is with an unfamiliar partner.12 The Driving Vehicle Licence Authority recommends that people should not drive for four weeks after an infarct, but it does not need to be informed of the attack unless the patient has heart failure, dangerous arrhythmias, or angina precipitated by driving13. Patients should inform their insurance company. Air travel is best delayed for six weeks after the attack, or longer in patients who have heart failure or severe angina.

Most hospitals arrange to see patients who have had infarcts at least once after discharge—usually at about four to six weeks. Typically, patients will have an exercise test at this stage, and those whose result is negative are usually discharged without a follow up appointment. Abnormal results on exercise testing will require further assessment and may lead to coronary angiography and perhaps to revascularisation. Patients who have made an uncomplicated recovery and have sedentary jobs are fit to be back at work within six weeks, but those with manual jobs are commonly advised to stay away for 8-12 weeks.

The aftercare of patients with infarcts also puts an onus on the hospital. A discharge summary sent out at the time that the patient goes home should include the degree of risk so that patients at high risk can be monitored especially carefully. Three factors increase risk. These are extensive left ventricular damage4 14 15 such patients should usually be discharged taking an angiotensin converting enzyme inhibitor10; residual reversible ischaemia as evidenced by angina14; and frequent ventricular ectopic beats.15

The care of and outlook for patients recovering from infarcts could be improved. Cardiologists in district hospitals could coordinate their aftercare; general practitioners could visit patients soon after discharge; and follow up in outpatients could be with a doctor of at least registrar status, with encouragement to attend the rehabilitation programme. Finally, general practitioners could organise a follow up programme that would check on and treat risk factors, review drug treatment, and monitor new symptoms. Too few patients receive treatment of this quality.