**16. Prognosis**

bypass on the ischemic myocardium, on the other hand, CABG may more frequently offer complete revascularization in advanced multivessel CAD. The decision to perform PCI or CABG was left to the discretion of the investigator. A post hoc analysis of NSTE-ACS patients with multivessel CAD included in the ACUITY trial showed that 78% underwent PCI while the remaining patients were treated surgically [176]. There were no differences in mortality at 1 month and 1 year between the two modalities. PCI treated patients experienced lower rates of stroke, MI, major bleeds and renal injury, but had significantly higher rates of unplanned revascularization than CABG during the periprocedural period and at 1 year [177–179].

While the majority of patients with single-vessel CAD should undergo ad hoc PCI of the culprit lesion, the revascularization strategy in an individual NSTE-ACS patient with multivessel CAD should be discussed in the context of a Heart Team and be based on the clinical status as well as the severity and distribution of the CAD and the lesion characteristics. The SYNTAX score was found to be useful in the prediction of death, MI and revascularization among NSTE-ACS patients undergoing PCI and may help guide the choice between revascularization strategies [180].

Cardiac rehabilitation is a structured program that provides heart attack survivors with the tools, motivation, and support needed to change behavior and increase chance of survival. Typically, cardiac rehabilitation programs use group therapy to supervise and promote beneficial exercise, as well as to provide emotional support. The aims of cardiac rehabilitation are to:

• Restore and maintain optimal physical, psychological, emotional, social, and vocational

Cardiac rehabilitation should be started on discharge and after clearance by an outpatient physician. The basic prescription should include aerobic and weight-bearing exercise 4–5

• Aspirin should be continued indefinitely at a low dose if the patient is tolerant and not

**14. Long-term management post-stabilization**

• Increase functional capacity

• Modify lipids and lipoproteins

• Decrease body weight and fat stores

• Improve psychosocial well-being

• Prevent progression and promote plaque stability

**15. Pharmacologic strategies include the following**

• Stop cigarette smoking

• Reduce BP

80 Myocardial Infarction

functioning.

times per week for >30 min.

contraindicated.

Patients who have experienced NSTEMI have a high risk of morbidity and death from a future event. The rate of sudden death in patients who have had an MI is 4–6 times the rate in the general population [189]. Life-threatening ventricular arrhythmias (sustained VT or VF) occurring after 48 h from the index acute coronary syndrome portend a poor prognosis, and are most frequently associated with left ventricular dysfunction. The benefit of implantable cardioverter-defibrillators, for both primary and secondary prevention, in patients with significant left ventricular dysfunction has been well demonstrated [190, 191]. Implantation for primary prevention should be considered at a minimum of 40 days following hospital discharge based on current recommendations [192].

Data from the era prior to medical therapy and revascularization suggest that the risk of cardiovascular death following an MI in the absence of treatment is approximately 5% per year, with a death rate after hospital discharge in the first year of about 10%. Pharmacotherapy, lifestyle changes, and cardiac rehabilitation are well demonstrated to be beneficial and together are additive in reducing mortality [193].
