Patient management and care after primary percutaneous coronary intervention: reinforcing a continuum of care after primary percutaneous coronary intervention

Abstract

Primary percutaneous coronary interventions (PPCIs) improve outcomes in patients with ST-elevation myocardial infarction and facilitate the hospitalization course. In most cases, the patient can be discharged within 3 to 5 days after the PPCI, provided that careful triage is applied. Bleeding--often associated with excessive antithrombotic drug dosing--is a major concern. Transfusion has been documented to be a strong and independent predictor of mortality; for this reason, recent guidelines recommend that bleeding be managed using a conservative strategy that limits transfusions and the discontinuation of antithrombotic drugs to major bleeding events and only when local hemostatic interventions are not effective. Primary percutaneous coronary intervention is often performed without previous assessment of renal function, and the amount of contrast medium should be kept to a minimum, because contrast-induced nephropathy occurs frequently and is associated with higher early and late mortality. The risk of major arrhythmias should also be addressed correctly. The prognostic implication of ventricular arrhythmias is extremely dependent on the timing of presentation: midterm mortality is much higher among subjects experiencing a new arrhythmic event after PPCI compared with patients with existing arrhythmias at PPCI or those without arrhythmias. The Zwolle risk score is useful for identifying subjects who may be safely discharged early. Secondary prevention starts at the end of PPCI. Hospital discharge and the planning of follow-up visits are critical for therapeutic recommendations. After an ST-elevation myocardial infarction, patients are at increased risk of recurrences, even when the PPCI is timely; a rehabilitation program and all measures that increase adherence to medications should be implemented, starting at discharge.