The natural history of unstable angina is typically characterized by either progression to nonfatal MI or death on the one hand, or resumption of the more quiescent clinical course of chronic stable angina on the other. The acute phase of unstable angina is usually over within 8 weeks. The need for continued hospitalization of the unstable angina patient is determined by whether the inpatient objectives of that hospital admission have been achieved.
Patients who have undergone successful revascularization will usually have the remainder of their hospitalization defined by the standard protocol for the given procedure (e.g., 1 to 2 days for PTCA, 5 to 7 days for CABG surgery). Patients electing medical treatment after a cardiac catheterization or functional study include both a low-risk group that can be rapidly discharged (e.g., 1 to 2 days after testing) and a high-risk group unsuitable for or unwilling to have coronary revascularization. These latter patients may require a prolonged hospitalization to ensure adequate (or as adequate as possible) symptom control and that risk of cardiac events in the next 4 to 6 weeks has fallen to an acceptably low level.
Management of all these patient groups prior to hospital discharge is described in the preceding chapters. Details and objectives of care from the time of hospital discharge until the final clinic visit for the unstable angina episode are described in this chapter (Figure 13).
The goal during the hospital discharge phase is to prepare the patient for normal activities to the extent possible. The goal of postdischarge outpatient care is to make adjustments in the discharge regimen that appear most appropriate after an initial period away from direct patient care. The long-term management of the unstable angina event ends as the patient reenters the stable phase of CAD.
The use of and rationale for different medical agents have been described earlier in this guideline. In most cases, the inpatient medical regimen used in the nonintensive phase will be continued postdischarge. The need for continued medical therapy after discharge relates to potential prognostic benefits (primarily shown for ASA and beta blockers), control of symptoms (nitrates and calcium antagonists), and treatment of major risk factors, such as hypertension, hyperlipidemia, and diabetes mellitus. Thus, selection of a medical regimen will be individualized to the specific needs of each patient and the events that have occurred in hospital.
Discharge of a patient from the hospital often requires a team effort from the medical staff (physicians, nurses, dietitians, pharmacists, rehabilitation specialists, physical and occupational therapists). Use of instruction sheets can help to document and reinforce the instructions given but should not be used in lieu of in-person instruction.
Clinical information available at discharge has been shown by Cox analysis to predict death within 1 year in 515 survivors of hospitalization for non-Q-wave MI, including persistent ST-segment depression, CHF, advanced age, and ST-segment elevation ( Schechtman, Capone, Kleiger et al., 1989). Patients with all high-risk markers present had a 14-fold increase in mortality compared with patients with all markers absent. Patients recognized to be at high risk for a cardiac event after discharge deserve earlier and more frequent followup than low-risk patients.
Recommendation: Patients with recurrent unstable angina should be managed as specified in an earlier chapter of this guideline corresponding to the clinical situation (strength of evidence = B, evidence cited in Chapter 6). Recommendation: Patients who have stable or no anginal symptoms at this followup visit should be managed further for stable CAD (strength of evidence = C).It is presently unclear whether patients who come through an episode of unstable angina without complications are at increased risk for future episodes of unstable angina, but their overall risk for death or MI is similar to that of other CAD patients with their characteristics who have not had unstable angina. The last element in the management of unstable angina, therefore, is a followup clinic visit at the point when the patient's disease activity has returned to the baseline level.
Either formal or informal telephone followup can serve to reinforce in-hospital learning, provide reassurance, and answer the patient's questions. Beckie (1989) found that bypass patients in a telephone followup program telephoned their physicians less frequently and had fewer readmissions, lower anxiety, and higher CAD knowledge scores compared with the control group.
Where personnel and budget resources allow, the health care team may consider establishing such a followup system in which nurses telephone patients approximately once a week for the first 4 weeks after discharge. This structured program would gauge the progress of the patient's recovery, reinforce the CAD education taught in hospital, address patient questions and concerns, and monitor progress in meeting risk behavior modification goals.
Recommendation: Recurrent symptoms lasting more than 1 to 2 minutes should prompt the patient to stop his or her activities, sit down, and place an NTG tablet under the tongue. This may be repeated twice at 5-minute intervals for two additional tablets. If symptoms persist after three NTG tablets, the patient should promptly seek medical attention (strength of evidence = C). Recommendation: If symptoms change in pattern (e.g., asymptomatic to symptomatic, more frequent or more severe symptoms), the patient should contact his or her primary care physician and discuss whether changes in the management plan are warranted. However, if the patient cannot reach a physician and chest pain persists for more than 20 minutes or despite three NTG tablets, he or she should seek transportation to the nearest hospital ED either by ambulance or the fastest available alternative (strength of evidence = C).The health care team should work with patients and their families to set specific goals for risk-factor reduction. In some cases, the family may be able and willing to support the patient further by also making changes in risk behaviors (e.g., cooking low-fat meals for the entire family, exercising together).
Particular attention should be paid to smoking cessation. Daly, Mulcahy, Graham, and colleagues (1983) measured the long-term effects of smoking on patients with unstable angina. For men under 60 years of age, those who continued to smoke had a risk of death from all causes 5.4 times that of men who stopped smoking (p <0.05).
More specific recommendations on risk-factor modification and cardiac rehabilitation are beyond the scope of this guideline.
Recommendation: Health care providers should initiate a conversation with the patient to discuss the safety and timing of the resumption of sexual activity (e.g. 2 weeks for low-risk patients to 4 weeks for post-CABG surgery patients) (strength of evidence = C).Very often patients will not ask their physicians or other health care providers about resuming sexual activity after their hospitalization. When appropriate, patients need to be reassured that sexual activity is still possible, and it is not likely to result in death or recurrent symptoms.
Recommendation: Beyond the instructions for daily exercise, patients require specific instruction on activities that are permissible and those that should be avoided (e.g., heavy lifting, climbing stairs, yard work, household activities). Specific mention should be made of resumption of driving and return to work (strength of evidence = C).The patient's medical record from the time of hospital discharge should indicate the discharge medical regimen, the major instructions about postdischarge activities and rehabilitation, and the patient's understanding and plan for adherence to the recommendations. The medical record of the final outpatient visit after full resolution of the episode of unstable angina should summarize cardiac events, current symptoms, medication changes since hospital discharge or last outpatient visit, and document the plan for future care as a patient with stable CAD.
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