Post-hospitalization management of high-risk coronary patients

The major cause of morbidity and mortality associated with coronary atheros clerosis is plaque rupture, which often results in one of the acute coronar y syndromes: unstable angina, non-Q-wave myocardial infarction (MI), or Q-w ave MI. Plaque rupture may be attributable to the thickness of the overlyin g fibrous cap; thinner plaques are more likely to rupture. It appears that the presence of inflammation is a significant contributor to rupture. Acute -phase treatments are highly efficacious, but secondary prevention, often o verlooked, also is lifesaving. Diet, exercise, and medications are the inte rventions available for secondary prevention. Four classes of medications-a spirin, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, and 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (stati ns)-are also used in this setting with a high degree of success in reducing mortality and morbidity. Numerous studies have demonstrated a 30-50% reduc tion in mortality with aspirin. The reduction in mortality achieved with be ta blockers in studies of patients after myocardial infarction are 15-50%. ACE inhibitors significantly reduce the risk of death from myocardial infar ction in patients with coronary artery disease with or without myocardial i nfarction. Statins are beneficial even in patients whose cholesterol level is low to normal. Patients who were discharged on a statin showed a 50% red uction in mortality over those who did not receive statin therapy independe nt of lipid level. C-reactive protein, a marker of inflammation, is predict ive of mortality, as are age and ejection fraction. Statins may be antiinfl ammatory in addition to their lipid-lowering effect. Secondary-prevention s trategies such as case management, electronic discharge prompting, better c ommunication between referring physicians and cardiologists, and patient ed ucation may also have positive effects on after-discharge morbidity and mor tality. (C)2000 by Excerpta Medica, Inc.