Non-ST Segment Elevated Myocardial Infarction: Patient Management and Education

Mr Dawkins is a 75-year-old male who had non-ST segment elevated myocardial infarction (NSTEMI) and new onset congestive cardiac failure (CCF). He has coronary artery disease (CAD) and underwent coronary artery grafting and percutaneous coronary intervention previously. However, the interventions were not very effective. Mr Dawkins had impairment of cardiac function as he had experienced breathlessness and intermittent chest tightness over the past month. The cardiac function might deteriorate as the new onset CCF after NSTEMI. (His cardiac structure could change because of hypertension, diabetes, CAD and NSTEMI. Besides that, the lung function test showed a combination of restrictive and obstructive pattern which might caused by obesity and severe obstructive sleep apnoea (OSA) respectively. they can cause respiratory impairment including O2 impairment and CO2 impairment. Type2 respiratory failure can happen when it is deteriorating. Furthermore, cardiac impairment can cause dead space resulting O2 and CO2 impairment. Finally, diabetic foot can impair sensation and cause pain and muscle weakness. Combined with the impairment of cardiac and respiratory function, activities such as long-distance walking could be limited, notwithstanding Mr Dawkins can walk around the ward without chest pain or breathlessness with medical intervention and non-invasive ventilation. As a result, participation such as community life and social relationship could be restricted. Restriction of community access can restrain him from coming to cardiac rehabilitation (CR), therefore aggravating the vicious circle of inactivity and further deterioration of cardiac and respiratory function. Moreover, isolation from society could impact Mr Dawkins’s health as a psychosocial factor. As there were no clear statements about activity and participation, clarification with the patient is needed. Besides above, he also suffers from poorly controlled diabetes, obesity and hypertension.

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Metabolic syndrome is defined as a cluster of at least three out of five clinical risk factors: abdominal obesity, hypertension, elevated serum triglycerides, low serum high-density lipoprotein and insulin resistance.[i] Mr Dawkins is likely to have metabolic syndrome. Obesity is regarded to be the primary risk factor for metabolic syndrome,[ii] as well as insulin resistance and cardiovascular disease (CVD).[iii] Mr Dawkins’ BMI is 43.4. it is essential to control his weight to minimize the detrimental impact on CVD, diabetes and OSA. Besides cardiac and respiratory impairment, obesity adds overloads on Mr Dawkins’ feet, which can deteriorate his diabetic foot condition. OSA is characterized by repeated episodes of obstructions of the upper airway during sleep, which can cause hypercapnic respiratory failure in Mr Dawkins’ case. OSA has a positive association with type2 diabetes,[iv] CAD and myocardial infarction.[v] OSA can also impair cognition including processing speed, attention and memory. This cognition impairment might impact Mr Dawkins ’s ability to participate cardiac rehabilitation. Diabetic foot can lead to ulceration, infection, delay wound healing and amputations in severe case.[vi] It also contributes to muscle weakness and gait changing. Those complications of diabetic foot combine with pain can discourage Mr Dawkins to participate exercise, therefore jeopardize cardiac rehabilitation. All the risk factors such as hypertension, diabetes, obesity and OSA can increase the risk of CVD to Mr Dawkins.

We should first of all provide Mr dawkins an education program. Education should cover medication, management of cardiovascular risk factors, diet, life style change, physical activity advice and self-efficacy. We should encourage ongoing use of continuous positive airway pressure (CPAP). A structural exercise program should be tailed to Mr Dawkins. Hydrotherapy can reduce the load of his diabetic foot. However, the patients previous exercise experience should be considered. A centra-based cardiac rehabilitation can start first because Mr Dawkins’complexity requires more supervision. However, the goal is to improve self-efficacy. Thus, Mr Dawkins can manage his exercise and condition in a lifelong fashion.

CR can reduce cardiovascular mortality, hospital admissions and improve quality of life for patients with CAD.[vii] In addition, CR could benefit adults with heart failure,[viii] stable angina pectoris[ix] and myocardial infarction (MI).[x] Aerobic exercise may improve oxidative metabolites in patients with cardiovascular disease, and as a result, improve exercise capacity.[xi] By increasing exercise capacity, Mr Dawkins can access the community more easily and maintain his social relationships. Aerobic exercise also helps to reduce weight. Mr Dawkins should start with low intensity and progress gradually. Warm up and cool down is required as a gradual process for the heart to adapt to increased intensity, especially for MR Dawkins with the presence of CCF. Exercise intensity can be guided by Borg Rating of Perceived Exertion scale and heart rate.[xii] A progression of ECG monitoring over a number of sessions is suggested.[xiii] If Mr Dawkins is experiencing chest pain, closer ECG monitoring or medical referral is required. Patients with CCF normally have poor heat tolerance. Reduction in intensity and hydration should be considered on hot days. Progressive resistance training can reduce muscle atrophy which is common in patients with CCF and CAD. However, exercise design should avoid the Valsalva manoeuvre and isometric techniques in Mr Dawkins. The Valsalva manoeuvre during isometric exercise can change the hemodynamic function and significantly increase blood pressure (BP).[xiv] Because Mr Dawkins has poorly controlled hypertension, BP, angina, dizziness, headache and dyspnoea should be monitored peri-exercise. Furthermore, monitoring BP over the course of therapy can help to adjust antihypertensive medication does if necessary. Structured exercise training that includes aerobic exercise, resistance training, or combination of both showed improvement of diabetes [xv] However, vigorous exercise should be avoided in Mr Dawkins ’s case until metabolic control is improved. In addition, postprandial exercise might be more effective to reduce glucose level.[xvi] Hydration should be guaranteed peri-exercise due to his diabetes. Blood glucose level (BGL) monitoring is important as Mr Dawkins ’s diabetes is poorly controlled. If BGL<5mmol/l, carbohydrate supply is needed. Mr Dawkins has diabetic foot. Exercise has been shown to be safe and demonstrate the improvement in foot muscle strength and function.[xvii] Avoiding overloads to feet could minimize the risk of tissue damage to Mr Dawkins. Exercises such hydrotherapy and cycling are good options for him due to his diabetic foot. The water temperature should be controlled between 33-34 degree because of the hemodynamic impact.[xviii] Water level should be not over the level of xiphoid, so significant increase of central venous pressure can be avoided.[xix] 

Education on diabetic foot is essential to Mr Dawkins. He should clean and inspect his feet daily, always wears socks and shoes and gets checked by qualified health professionals regularly. Physiotherapists should choose appropriate timing If Mr Dawkins takes pain medication for his feet.

When the exercise is designed, Mr Dawkins ’s preference and perspective should be taken in account. We should investigate Mr Dawkin’s exercise history[xx]  to consider whether he needs additional facilitators to support him. Such as support and motivation from relatives and friends, goals for weight control or to increase fitness, and to select stimulating and fun exercises he can complete. If Mr Dawkins has experienced previous angina pectoris precipitated by exertion, he may have a fear of exercise, so this fear will need to be addressed. Ambition and attitude are also key components of CR. Mr Dawkins lives 88kilmeteres outside of Dubbo, it could be a barrier for him to participate centre-based cardiac rehabilitation. As home-based cardiac rehabilitation has similar outcomes of quality of life as centra-based rehabilitation.[xxi] After initial learning through a supervised rehabilitation, we will need to determine if Mr Dawkins believes he could manage his own progress

Interventions for severe OSA include weight control and CPAP.  CPAP can provide pressure support during inspiration and positive end expiratory pressure during expiration, thus, improving O2 and CO2. Although CPAP has only demonstrated a reduction of cardiovascular events in patients with CAD and OSA in observational studies, Mr Dawkins should continue with CPAP because it makes him feel less sleepy and more awake and energetic, which can facilitate CR. CPAP has been shown to be effective in reducing OSA severity, improving sleepiness, improving sleep-related quality of life and reducing BP in patients with hypertension.[xxii] The pressure from mask can cause skin damage. Regular check is important, especially Mr Dawkins has diabetes.

Strategies such as concise instruction and written information should be considered because Mr Dawkins might have cognition impairment as explained before. Tai Chi exercise is also a consideration for patients with HF and CAD.[xxiii] If Mr Dawkins shows depression or anxiety, a referral for psychological counselling is necessary.

[i] Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. (2001). Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA: The Journal Of The American Medical Association, 285(19), 2486-2497. doi: 10.1001/jama.285.19.2486

[ii] Park, Y., Zhu, S., Palaniappan, L., Heshka, S., Carnethon, M., & Heymsfield, S. (2003). The Metabolic Syndrome. Archives Of Internal Medicine, 163(4), 427. doi: 10.1001/archinte.163.4.427

[iii] Pedersen, B., & Saltin, B. (2015). Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian Journal Of Medicine & Science In Sports, 25, 1-72. doi: 10.1111/sms.12581

[iv] Muraki, I., Wada, H., & Tanigawa, T. (2018). Sleep apnea and type 2 diabetes. Journal of Diabetes Investigation, 9(5), 991–997. doi: 10.1111/jdi.12823

[v] Porto, F., Sakamoto, Y., & Salles, C. (2017). Association between Obstructive Sleep Apnea and Myocardial Infarction: A Systematic Review. Arquivos Brasileiros De Cardiologia. doi: 10.5935/abc.20170031

[vi] Galiano. (2008). A review of becaplermin gel in the treatment of diabetic neuropathic foot ulcers. Biologics: Targets & Therapy, 1. doi: 10.2147/btt.s1338

[vii] Anderson, L., Thompson, D., Oldridge, N., Zwisler, A., Rees, K., Martin, N., & Taylor, R. (2016). Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Of Systematic Reviews. doi: 10.1002/14651858.cd001800.pub3

[viii] Gruenebaum, D. (2019). What are the effects of exercise-based cardiac rehabilitation for adults with heart failure?. Cochrane Clinical Answers. doi: 10.1002/cca.2436

[ix] Oldridge, N. (2012). Exercise-based cardiac rehabilitation in patients with coronary heart disease: meta-analysis outcomes revisited. Future Cardiology, 8(5), 729-751. doi: 10.2217/fca.12.34

[x] Anderson, L., Thompson, D., Oldridge, N., Zwisler, A., Rees, K., Martin, N., & Taylor, R. (2016). Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Of Systematic Reviews. doi: 10.1002/14651858.cd001800.pub3

[xi] Fukuda, T., Kurano, M., Fukumura, K., Yasuda, T., Iida, H., & Morita, T. et al. (2013). Cardiac Rehabilitation Increases Exercise Capacity with a Reduction of Oxidative Stress. Korean Circulation Journal, 43(7), 481. doi: 10.4070/kcj.2013.43.7.481

[xii] Heath, E. (1998). Borg's Perceived Exertion and Pain Scales. Medicine& Science In Sports & Exercise, 30(9), 1461. doi: 10.1097/00005768-199809000-00018

[xiii] (2013). Guidelines for cardiac rehabilitation and secondary prevention programs. Champaign, IL: Human Kinetics.

[xiv] Figueroa, A., & Vicil, F. (2010). Post-exercise aortic hemodynamic responses to low-intensity resistance exercise with and without vascular occlusion. Scandinavian Journal Of Medicine & Science In Sports, 21(3), 431-436. doi: 10.1111/j.1600-0838.2009.01061.x

[xv] Umpierre, D. (2011). Physical Activity Advice Only or Structured Exercise Training and Association With HbA1cLevels in Type 2 Diabetes. JAMA, 305(17), 1790. doi: 10.1001/jama.2011.576

[xvi] Borror, A., Zieff, G., Battaglini, C., & Stoner, L. (2018). The Effects of Postprandial Exercise on Glucose Control in Individuals with Type 2 Diabetes: A Systematic Review. Sports Medicine, 48(6), 1479-1491. doi: 10.1007/s40279-018-0864-x

[xvii] Francia, P., Gulisano, M., Anichini, R., & Seghieri, G. (2014). Diabetic Foot and Exercise Therapy: Step by Step The Role of Rigid Posture and Biomechanics Treatment. Current Diabetes Reviews, 10(2), 86-99. doi: 10.2174/1573399810666140507112536

[xviii] Arborelius, M., Ballidin, U., Lilja, B., Lundgren, C., (1972). Haemodynamic Changes in Man During Immersion with the Head Above Water. Aerosp Med. 43, 592-598

[xix] Cider, A., Svealv, B., Tang, M., Schaufelberger, M., Andersson, B., (2006). Immersion in Warm Water Induces Improvement in Cardiac Function in patients with Chronic Heart Failure. Eur J Heart Failure. 8(3), 308-313.

[xx] Bäck, M., Öberg, B., & Krevers, B. (2017). Important aspects in relation to patients’ attendance at exercise-based cardiac rehabilitation – facilitators, barriers and physiotherapist’s role: a qualitative study. BMC Cardiovascular Disorders, 17(1). doi: 10.1186/s12872-017-0512-7

[xxi] Anderson, L., Sharp, G. A., Norton, R. J., Dalal, H., Dean, S. G., Jolly, K., … Taylor, R. S. (2017). Home-based versus centre-based cardiac rehabilitation. Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.cd007130.pub4

[xxii] Patil, S., Ayappa, I., Caples, S., Kimoff, R., Patel, S., & Harrod, C. (2019). Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment. Journal Of Clinical Sleep Medicine, 15(02), 301-334. doi: 10.5664/jcsm.7638

[xxiii] Yang, Y., Wang, Y., Wang, S., Shi, P., & Wang, C. (2018). The Effect of Tai Chi on Cardiorespiratory Fitness for Coronary Disease Rehabilitation: A Systematic Review and Meta-Analysis. Frontiers In Physiology, 8. doi: 10.3389/fphys.2017.01091