My medical record says 59-year-old white female with ST-elevation myocardial infarction (MI). My mind says, “No way!” My body is a different story. Thus began my odyssey into the health care system and its approach towards patients with cardiovascular disease

Kucharska-Newton, A

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Myocardial Infarction and Postacute CareDoes One Size Fit All?My medical record says 59-year-old white female withST-elevation myocardial infarction (MI). My mind says,“No way!” My body is a different story. Thus began myodyssey into the health care system and its approachtowards patients with cardiovascular disease.I am a cardiovascular epidemiologist, interested inthe risk of MI, mortality rates following MI, and cardiacrehabilitation. But as I am now also “the MI patient,” I lookat my newfound status as an opportunity to see junc-tures where evidence-based care may not fully addresspatient preferences or improve care quality.There is no question that the care I received fromemergency medical services and in the cardiac catheter-ization laboratory was superb. Its efficiency and expe-ditiousness, even on a sleepy Sunday morning, savedmy life. I was happy to be released from the hospital only2 days after the event. Yet, while this “we fixed you andyou are now fine” approach seemed appropriate atthat time, its continuation into the postacute care sur-prised me.I saw a cardiologist within the proscribed 7 days fol-lowing my discharge, but the meeting never touched onthe profound emotional shock that I had just experi-enced. We giggled about the circumstances of my MI(I was on my way to the beach), briefly discussed the re-sults of the discharge echo (surprisingly unremarkable,even after a 95% occlusion to the left anterior descend-ing artery and 3 stents), and I was told to continue tak-ing the 5 guideline-recommended medications and comeback in 3 months. In comparison with many patients, mymedical needs are relatively uncomplicated. But,3 months? What do I do between now and then? I hadjust had a life-threatening event, I was dizzy and weakfrom the new medications, I developed frighteningbruises from the most innocuous bumps, and I nowlacked confidence to even take the dog for a walk. Car-diac rehabilitation was recommended. There was no timeduring this hurried 10-minute standard appointment todiscuss the medication regimen, including the fact thatwith my resting heart rate in the low 50s, β-blockers (aprominent component of the post-MI guideline medi-cations) might be harmful. There was also no time to talkabout my paralyzing fear of another event or my inabil-ity to distinguish between garden variety stomach painsand the epigastric pain that had marked my classic pre-sentation of an MI in women. This brief visit left nochance to discuss the psychological ramifications of theevent: should I and my family reprioritize our life goals?After a detour emergency readmission and an-other catheterization, the results of which showed openarteries, I signed up for cardiac rehabilitation. Follow-ing a stress electrocardiogram test, I exercise 3 times aweek on an aerobic machine of my choice while I amhooked up to a telemetry electrocardiogram monitor.The monitoring gives me the best piece of mind thatI have had since the MI. I know that I can push myself onthat bicycle or treadmill and someone will be able to tellme if my heart cannot keep up. Cardiac rehabilitation pro-grams, for very valid reasons, emphasize physical activ-ity, but unfortunately make little room for formal psy-chological support. Group stress management exercisesare occasionally offered, but those cannot possibly ad-dress the needs of patients who, not surprisingly, oftencomplain of posttraumatic stresslike symptoms post MI.One week following discharge, I was present at thethesis defense of one of my students. The topic was,providentially, post-MI use of cardiac rehabilitationamong Medicare beneficiaries. The results are disap-pointing. Despite the fact that cardiac rehabilitation is aclass I guideline recommendation, fewer than 25% of pa-tients who have had an MI initiate it. Those data sup-port extant studies that point to a significant underuseof cardiac rehabilitation. Further, as my student’s dataand the results of several systematic reviews of random-ized clinical trials and observational studies suggest, car-diac rehabilitation is not unequivocally beneficial with re-spect to the health status of patients post MI and ratesof rehospitalization and mortality.1,2As a researcher I am surprised. As a patient, I am not.My experience with cardiac rehabilitation tells me thatafter I ride my bicycle through 36 sessions (about 3months, the usual amount that is covered by insuranceplans) I may feel more confident exercising at home orin a gym; however, without an electrocardiogram moni-tor, I may not. I was fortunate in finding a therapist whoI hope will help me take the edge off of the profoundanxiety that accompanies cardiac patients’ recovery andmay allow me to sustain a physical activity regimen, anessential component of care following an MI. Althoughthe data are not available, I expect that the patients whohave no support for their emotional needs are the oneswho are most likely to drop off the exercise regimen fol-lowing cardiac rehabilitation. How they cope with un-expected physical symptoms and attendant emotionsis anyone’s guess.One seemingly obvious source of patient support, theprimary care clinician, has hardly any formal role in inpost-MI care. Hospitals may notify the clinician and, if thehealth records are shared, some continuity and coordi-nation of the postacute care can be achieved. However,the hospital and the primary care clinician often do not“talk” to each other, which results in profound care dis-coordination. Extant research suggests that risk factormanagement and maintaining medication adherencepost MI are best achieved with collaborative primary andcardiology care.3 So far, I have seen 3 cardiologistsAnnaKucharska-Newton,PhD, MPHThe Gillings School ofGlobal Public Health,The University of NorthCarolina at Chapel Hill,Chapel Hill.CorrespondingAuthor: AnnaKucharska-Newton,PhD, MPH, The GillingsSchool of Global PublicHealth, The Universityof North Carolina atChapel Hill, 137 EFranklin St, Chapel Hill,NC 27514 (anna_newton@unc.edu).patient symptoms and preferences, especially in the realm ofconfidence and quality-of-life following postacute care, is sparse. Weare focused on decreasing unwarranted variation through guide-lines, but my experience has shown me that instead what is neededis a better understanding of how the panoply of clinicians, services,and medications corresponds to unwanted variation in patient-centered outcomes, including quality-of-life and emotionalwell-being.Published Online: September 13, 2017.doi:10.1001/jamacardio.2017.3121Conflict of Interest Disclosures: The author hascompleted and submitted the ICMJE Form forDisclosure of Potential Conflicts of Interest andnone were reported.Additional Contributions: I thank family andfriends for their support in writing this essay.1. Sumner J, Harrison A, Doherty P.The effectiveness of modern cardiac rehabilitation:a systematic review of recent observational studiesin non-attenders versus attenders. PLoS One.2017;12(5):e0177658.2. Anderson L, Thompson DR, Oldridge N, et al.Exercise-based cardiac rehabilitation for coronaryheart disease. Cochrane Database Syst Rev. 2016;(1):CD001800.3. Daugherty SL, Ho PM, Spertus JA, et al.Association of early follow-up after acutemyocardial infarction with higher rates ofmedication use. Arch Intern Med. 2008;168(5):485-491.postdischarge. None have communicated directly with my primary care clinician, nor can she easily communicate with them.It is easy to accept evidence-based care, backed by statistical results of improvements in outcomes, as a one-size fits all ap-proach. Yet, my post-MI readmission was perhaps a result of an in-appropriate, albeit fully evidence-based, medication regimen. While there has been consistent research to understand better how health systems are achieving evidence-based care, research concerning

Myocardial infarction and postacute care does one size fit all?

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Myocardial infarction and postacute care does one size fit all?

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