Rehabilitation after acute coronary syndrome and myocardial infarction in older adults
THE CONTEXT
Recovery involves graded return to activity and psychological support. Older patients may present atypically and have greater mortality and treatment hazards.
Return to activity after uncomplicated illness
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When there are no complications, patients can mobilise on the second day and return home in 2–3 days.
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Activity should increase gradually, with the aim of returning to work in 4 weeks.
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Most patients may resume driving after 1–4 weeks. In most countries, drivers of heavy goods and public service vehicles require special assessment before returning to work.
Psychological support and formal rehabilitation
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Denial, anxiety and depression are common and require attention. Psychological effects can cause severe or permanent incapacity.
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Patients benefit from explanation, counselling and reassurance. A mistaken belief that stress caused the heart attack may lead to inappropriate restriction of activity.
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The patient's spouse or partner also needs emotional support, information and counselling.
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Formal rehabilitation combines graded exercise protocols with individual and group counselling. These programmes are often successful and have sometimes improved quality of life and long-term outcome.
Myocardial infarction in older adults
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Presentation is often atypical, with anorexia, fatigue, weakness, delirium or falls rather than chest pain.
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Hospital mortality exceeds 25% in patients older than 75 years, approximately five times that in patients younger than 55 years.
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Age does not influence the survival benefit of treatment; the absolute benefit of evidence-based treatment may therefore be greatest in older people.
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Treatment hazards increase with age, partly because of greater comorbidity. Intracerebral bleeding after thrombolysis is one example.
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Older patients, especially those with significant comorbidity, were under-represented in many treatment trials. The balance of benefit and risk for treatments such as thrombolysis and primary percutaneous intervention remains uncertain in frail older people.