At the time of discharge, the patient was counselled on lifestyle and risk factor modification. He was advised to stop smoking, follow a prudent low-fat diet, and continue discharge drug therapy. He was enrolled in a cardiac rehabilitation program and encouraged to continue exercising on a long term basis.
Discharge drug Rx
Our patient was discharged on aspirin, a beta blocker, a statin, and an angiotensin converting enzyme inhibitor. Clopidogrel was prescribed for one year to reduce ischemic events. These medications have been shown to improve survival. In addition, he was instructed in the appropriate use of sublingual nitroglycerin for chest pain.
Follow-up evaluation
The patient returned for follow-up evaluation as scheduled. He had done very well in his outpatient cardiac rehabilitation program and denied anginal symptoms while walking rapidly each day. He had stopped smoking, and generally felt well. His cardiovascular physical examination was entirely normal, with a resting heart rate of 60 beats per minute and a blood pressure of 110/70 mmHg. A follow-up lipid profile was normal.
Upon further questioning, he did admit to some vague atypical chest pain, unrelated to exercise. A radionuclide stress test was carried out to rule out any ischemia.
Radionuclide stress test
During the stress test the patient exercised for 12 minutes, achieving 90% of his predicted maximum heart rate. He experienced no symptoms or arrhythmias and heart rate recovery, the rate at which the heart rate returns to normal post exercise, was normal at 20 beats per minute. His electrocardiographic tracings showed no ST segment abnormalities. His physical examinations pre and post exercise were normal. His baseline blood pressure was 110/70 mmHg with a normal response to exercise.
Our patient's test
This is the radionuclide myocardial perfusion scan carried out during stress testing of our patient. The black and white images on the left show normal homogeneous distribution of the isotope in all segments of the myocardium. The image on the right converts the gray scale to colors that represent normal distribution of coronary flow.
Another patient's test
This is a stress radionuclide myocardial perfusion scan from another patient. The image on the left obtained during peak stress demonstrates severely decreased blood flow to the inferior wall. This is illustrated by a light blue region as compared to the normally perfused regions shown in yellow and red. The image on the right obtained with the patient at rest doesn’t show any definite abnormality of perfusion of the inferior wall, as indicated by the yellow and/or red regions. The difference between exercise and rest indicates reversible stress induced inferior wall ischemia.
Normal study
The normal study in our patient is consistent with normal myocardial perfusion. It shows that thrombolysis was effective in salvageing his myocardium and limiting infarct size. No further invasive studies are indicated at this time. He was advised to continue his current medications and health maintenance program and return in several months for interval evaluation.