Outcomes for those suffering from an MI can vary greatly. Factors such as education level, patient-physician relationship, quality of care and family support all effect patient compliance in post-MI treatment. Mortality rates in the US, in the first year following an MI “average 10%. It drops to 5% the following year” (timi.org). Even more alarming 85% of deaths occur within the first 3 months after an MI, due to coronary artery disease.
The challenge then, becomes addressing and treating the common cause of MI, which is Coronary artery disease itself. Treatment during and shortly after an MI becomes imperative, to address the underlying CAD. “The American Heart Association (AHA) and College of America Cardiology (ACC) recently issued new, evidence-based guidelines regarding the management of atherosclerotic” (Bonow & Smith). Among the guidelines are recommendations for multidisciplinary approach and rehabilitation services. Many post- MI patients today do not receive such services, even if they receive the most advanced care and medication to address the CAD. Patient education to address underlying causes, such as diet and lifestyle factors, does occur often, but can vary greatly, depending on the patient-physician relationship.
Medications to treat MI patients can include beta blockers, ASA and thromblytics, as well as statins, to reduce elevated lipid levels. It is imperative that patients know why they must take specific medications, not just that they take them. Though post-MI treatment typically begins in the hospital, follow up and continuing education is extremely important. In one study of three managed care systems, informational and educational brochures were created and mailed to patients, to encourage continued use of beta blocker medication. “Mailing recipients were also 17% more likely than non-recipients to have at least 80% of days covered overall” (Masoudi 2006). While the study strongly suggests the need for continuing education and reminders, to achieve enforcement, a hybrid approach to postal services and personal correspondence may have an even greater effect. Other considerations, “such as nursing efficiency, nosocomial complications, patient education, and follow-up after discharge may be important in the equation as well” (Phend).
Again, follow up appears as a key factor in compliance. In order for the post-MI in order for patients to provide sufficient follow-up treatment at least, an appreciation of it’s importance. Follow up that occurs outside the hospital setting, relies on the patient’s ability and desire to receive continued care. One of the other factors identified by Phend, which is quality of nursing care, can play a vital role. Physicians are often the first care providers to information to patients. However, contact with other health care workers occurs most often, after initial treatment for an MI.
Nurses can and often do provide additional education, answer questions, arrange for additional services and schedule appointments in clinics, prior to patient discharge. The position of a nurse in accordance with post-MI treatment can be one of the educators and supporting means; when there is none. Even if the patient is not in permanent contact with the nurse, referral to supportive services and educational groups can be an integral part of care, prior to patient discharge. Nurses often fill roles such as case manager and community care provider.
At the moment risk reduction is generally recognized as the safest course of action in treating post-MI patients. Aside from factors such as family support, transportation and access to treatment, fragmentation of care is also an obstacle to care. Patients often leave the hospital and receive post-MI care in clinics or community centers. “Optimal delivery of care would bridge the gap between the hospital and the outpatient setting” (Houston-Miller 1997). Physicians are responsible for risk management for patients after an MI, yet they have so little time to spend with each patient, in the clinic setting. The nurse’s role becomes that of communicator, educator, compliance manager and even support person, where there is none at home. Patients often have multiple risk factors, such as smoking, atherosclerosis and CAD. The nurse can bridge the gap and address all the risk factors together, providing a much more intense follow up program post-MI.
Nurses often call or speak to patients directly on the phone. This is an important opportunity to ensure patient compliance, answer questions about lifestyle changes or medications and other aspects of post-MI care. Once damage to the heart from an MI has occurred; heart failure is often reduced with appropriate medication at appropriate levels. “Evidence suggests that general practitioners are frequently reluctant to initiate appropriate treatments and to up-titrate drug dosages even for patients with diagnosed heart failure”(Grange 2005). Post-MI programs that address appropriate patient education should therefore, also monitor and adjust medication to appropriate or optimum levels.
This model of care is very applicable to the post-MI clinic setting, where it can help to ensure patients receive better care within the critical three month post-MI period. Lipid lowering medications are often a vital part of post-MI care. “Unfortunately, in the majority of patients, lipid lowering therapy does not get initiated during outpatient follow-up”( Mitaishvili & Gagua 2007). Nurses who fill the role of case manager, can ensure that lipid lowering medication is included in post-MI care, when necessary.
Bridging the gap also increases the likelihood of compliance, “based on evidence demonstrating that immediately after hospital initiation of lipid-lowering and other cardiovascular protective medications resulted in a marked increase in treatment rates, improved long-term patient compliance and improved outcomes”(Mitaishvili & Gagua). Other forms of treatment, such as diagnostic ECG, echocardiogram and angiography are often part of post-MI treatment. Nurses who manage post-MI care can ensure patients are scheduled, understand the need for such diagnostic tests and better prepare patients for them as well.
Beyond post-MI care in the clinic setting, are barriers in accessing post-MI care, such as transportation, lack of health coverage and lack of family support. Much of a patient’s compliance with post-MI care is linked to levels of education. The more a patient understands the importance of care, the more likely the patient is to comply with treatment. However, many patients lack understanding of the situation and the importance of post-MI care. The managed care study shows how important patient education can be, even without intervention by a nurse or case manager. The role of the nurse as case manager then becomes one of educator and community support. Some physicians are very knowledgeable about free or reduced cost medication programs. Most often though, such details are left to the case manager upon discharge from the Hospital.
Brigham and Women’s Hospital and Harvard Medical School have undertaken a research to ‘evaluate the effect of cost-sharing in important cardiac medicinal products high-risk patients on clinical and economic outcomes”(Choudry, et al 2008). Prior evidence suggests that linking patients to necessary programs and providing ongoing support and education are vital to treatment compliance of post-MI patients.
Expectations that the study will show affordable cost for prescription drugs in treatment post-MI, as a key component in compliance, is not surprising. However, low cost or affordable medications is just one component of compliance. Patient education and understanding of the importance of treatment, is the other major variable. This can occur only if enough attention is given to education and communication components of the post-MI treatment regimen.
- Alexander, K. et al.(2001). Post Myocardial Infarction Risk Stratification in Elderly Patients. Am Heart J. Vol.142, No.1, 37-42
- Bonow, R. & Smith, S.(2007). Presentation. Managing Vascular Atherosclerotic Disease in the Post MI Patient. Retrieved October 24 2008 from http://my.americanheart.org/portal/professional
- Choudry, N. (2008). Rationale and Design of the Post-MI FREEE Trial: a Randomized Evaluation of First-Dollar Drug Coverage for Post-Myocardial Infarction Secondary Preventive Therapies. Am Heart J. Vol.156, No 1, 31-36.
- Fonarow, G. (2007). Identifying and Managing Post-Myocardial Infarction Patients With Left Ventricular Dysfunction. Medscape Cardiology. Retrieved October 24 2008 from http://www.medscape.com/medscapetoday/cardiology.
- Grange, J. (2005). The Role of Nurses in the Management of Heart Failure. BMJ Publishing Group & British Cardiac Society. Vol. 91, 38-42.
- Houston-Miller, N. (1997). The Role of Nurse as Case Manager. The American Journal of Managed Care. Vol. 3, 1-2.
- Masoudi, F. ( ). An Intervention to Improve Post-MI Patient Adherence to Beta-Blockers. Journal Watch Cardiology. Retrieved October 25 2008 from https://secure.jwatch.org/cardiology.
- Mitaishvili, R & Gagua, G. (2007). Guidelines for the Management of Post-MI Patients in the Outpatient Settings. Abkhazia Institute for Social and Economic Research. Retrieved October 24 2008 from http://www.abkhazia.com/index2.php?option=com_content&do_pdf=1&id=55.
- Phend, C. (2008). Post-MI Treatment Varies by Physician Experience and Specialty. Med Page Today. Retrieved October 24 2008 from www.medpagetoday.com.
- Timi.org. Optimal Management of the Post Myocardial Infarction Patient. Retrieved October 24, 2008 from http://www.cvtoolbox.com/downloads/postmi/Optimal_Management.ppt.