Rehabilitation of patients after myocardial infarction (recovery)

Myocardial infarction belongs to the so-called catastrophic episodes. Thanks to timely diagnosis and effective treatment methods, the incidence of fatalities has decreased, but patients who have suffered it need long-term rehabilitation. The chances to resume an active life in full directly depend on how correctly it is provided.

Goals and objectives of medical rehabilitation in the post-MI period

The coronary arteries are responsible for the blood supply to the heart muscle. If it is interrupted, the heart starves of oxygen and, as a consequence, a heart attack occurs.

The body has to adapt to new conditions.

The lifespan and quality of life of such patients directly depend on compensatory mechanisms. Therefore, the rehabilitation treatment of myocardial infarction has the following goals:

• Prevention of late complications, in particular, aneurysm, rhythm disturbance, pulmonary oedema, myocarditis, cardiogenic shock;
• Restoration of activity, professional activity;
• Psychological rehabilitation, adaptation of thinking to new conditions and capabilities;
• Prevention of recurrent acute conditions.

Rehabilitation may take several months or several years, depending on the damage volume and the person’s general health.

Special features of post-MI recovery

The acute period of the disease lasts up to a week from the onset, with the first six hours considered as the acute period. The scar on the muscle is formed within 28 days.

Rehab methods

The main recovery means in patients with a myocardial infarction history are:

• therapeutic physical training to ensure the necessary physical activity;
• medical control, allowing the timely prevention of late complications and relapses;
• patient psychological support and adaptation to new capabilities;
• drug therapy aimed at normalizing the blood circulation.

Physical therapy 

To draw up an exercise plan, the physiotherapist must first assess the overall health condition. The following tests are used for this purpose:

• bicycle ergometry with customized workload;
• a treadmill test;
• six-minute walking without switching to running.

According to the results of the study, the patient's condition is determined:

• In normal condition, moderate fatigue is detected, without shortness of breath or pain behind the sternum; the blood pressure remains within the normal range for a particular person, there are no changes on ECG.
• In the intermediate period, fatigue lasts less than five minutes, there is slight dyspnea, pain in the heart area, which goes away on its own, the pressure gets normal within five minutes. On the ECG, single extrasystoles can appear, as well as ST displacement of less than 1 mm.
• In serious disorders, fatigue persists for a long time, dyspnea is pronounced, the heart pain is controlled only by Nitroglycerin, the blood pressure takes 10 minutes or more to return to normal. ECG shows rhythm disturbances, the His bundle branch block, as well as ST segment displacement of more than 2 mm.

Based on the patient's condition, a plan of physical therapy is drawn up. In the first days exercises are performed in the supine position and may include:

• flexion of fingers and toes 6 times each;
• 3 times abduction of arms bent at the elbows;
• bending the legs at the knees without taking the feet off the bed 4 times;
• pulling up with the palms of the hands to the knees with tense torso muscles 2-3 times;
• leg abduction 4 times.

Between exercises there should be 20-30-second breaks for recovery. From day 4, one can proceed with a more complex routine in a sitting position:

• Put your hands on your knees; then, during inspiration, shift the hands to the shoulders, simultaneously spreading the elbows. During expiration, return to the initial position. Repeat 8 times.
• During inspiration, get your hands forward and further upwards, finishing the exercise during expiration. Repeat 5 times.
• Keeping your feet on the floor, imitate walking 15 times with each leg.
• During inspiration, spread straight arms to the sides, during expiration, bring them back together.
• Turn your head 10 times to each side.

From day 12, the routine should be increased, taking into consideration the patient's condition.

Psychological support during rehabilitation

Infarction is especially often associated with death, so providing patients with psychological support is of key importance. Restriction of activity after discharge from a cardiology facility also has a negative effect.

In addition to the involvement of a psychologist or psychotherapist, support from the loved ones is also important. It can reduce the risk of developing depression, which negatively affects the person’s adaptive potential.

Support with drugs

Drug therapy should be aimed at normalizing blood pressure, lipid metabolism and blood coagulation, preventing angina pectoris and treating heart failure. During the recovery period, the following drugs are most often prescribed:

• Antiarrhythmics. Their aim is to manage the heart rhythm.
• Antiaggregants are used to prevent the formation of blood clots.
• Beta-adrenoblockers are necessary to reduce the heart muscle need of oxygen.
• Hypotensive agents are administered to normalize blood pressure.
• Statins help to prevent the formation of cholesterol plaque.

Drug therapy is carried out until the patient condition returns to normal; some drugs are taken for life.

Stages and timing of medical recovery after myocardial infarction

Rehabilitation is carried out in several stages:

• Inpatient: up to 2 weeks (3-4 days in an intensive care unit).
• Combined in- and outpatient: up to 28 days.
• Outpatient: continues for the whole life, starting from check out from a cardiology facility.

Each stage has its own specific features.

Inpatient treatment

Rehabilitation should begin right upon admission. The patient should be constantly monitored. No physical activity is allowed for the first 24 hours. From the second day, rehabilitation is supplemented with simple exercises in the supine position with mandatory 30-second breaks.

From the 4th day onwards, exercises in the sitting position are added. They are also performed with breaks for rest. At this particular stage, a psychologist joins in.

In- and outpatient rehabilitation after myocardial infarction

By discharge time, the patient’s condition has stabilized and their motor activity has increased. But rehabilitation should not be stopped. It is advisable to go to a health resort. There the patient can attend psychotherapy sessions and take and group physical therapy courses, as well as get drug and physiotherapy treatment. Such a combination has a particularly pronounced effect at the stage of recovery.

As soon as the patient’s condition is completely stabilized, the supportive stage begins. The doctor provides recommendations regarding the diet, physical activity, work and rest. The patient should continue to visit the cardiologist regularly, and take the necessary tests.

Measures to prevent a relapse

Infarction is insidious in that even if you strictly follow all doctor instructions, disease recurrence cannot be eliminated. The probability of a recurrent episode is 30-40%. And each new attack will cause more severe consequences. Therefore, prevention of relapses should be given particular importance.

First of all, smoking should be given up. An active lifestyle with moderate exercise and control of pulse rate is a must. Also, one should stick to a diet, avoiding coffee and strong tea. You should keep away from stressful situations as much as possible.

The patient should walk more often, this will not only strengthen the heart muscle, but also relieve unnecessary stress. The involvement of relatives is important, especially in the early rehabilitation period.

References:

1. Cardiac rehabilitation after STEMI, Stefano Urbinati, 2018 г. 
2. Cardiac rehabilitation following myocardial infarction, Ryszard Piotrowicz, 2008 г. 
3. Myocardial Infarction and Exercise Training: Evidence from Basic Science, Ivana C Moraes-Silva, 2017 г. 
4. Early rehabilitation after acute myocardial infarction: A nationwide inpatient database study, Kensuke Nakamura, 2021 г.