The 2012 ESC guidelines for the management of acute myocardial infarction [1] defines current prehospital and in-hospital management and reperfusion strategies within 24 h of first medical contact. These guidelines result to primary PCI within a time window preferably <90 min after first medical contact (Fig. 7.2).

Following these guidelines for patients with the clinical presentation of STEMI within 24 h after symptom onset and with persistent ST-segment elevation or new or presumed new left bundle branch block, PCI should be performed as early as possible, but within 90 min after first medical contact (Fig. 7.2).

Primary PCI is defined as angioplasty and/or stenting without prior or concomitant fibrinolytic therapy and is the preferred therapeutic option when performed by experienced team. Primary PCI is effective in securing and maintaining coronary artery patency and avoids some of the bleeding risks of fibrinolysis. Randomized clinical trials comparing timely performed primary PCI with in-hospital fibrinolytic therapy in high-volume, experienced centres have shown more effective restoration of patency, less reocclusion, improved residual left ventricular function and better clinical outcome with primary PCI [2]. Routine coronary stent implantation in patients with STEMI decreases the need for target vessel revascularization but is not associated with significant reductions in death or re-infarction rates.

After successful percutaneous coronary intervention (Fig. 7.3), the patient was transferred to the coronary care unit of the PCI centre and was further monitored for 24 h. Then he was sent back to the community hospital, where he experienced the rest of his hospital stay without any complications.

Primary PCI during the early hours of myocardial infarction has become the preferred therapeutic option, if it can be performed within 90 min after the first medical contact. In contrast to fibrinolytic therapy followed by delayed PCI practised in former times, after primary PCI and stenting, in uncomplicated cases, phase I cardiac rehabilitation can start the next day, and such patients can be walking around the flat and walking upstairs within a few days. Patients with larger myocardial damage and heart failure, shock or serious arrhythmias should be kept bedridden, and their physical activity increased slowly, dependent upon their symptoms and the extent of myocardial damage. After primary PCI, patients who experience an uncomplicated course of the event can be discharged after a hospital stay of 2–3 days. Exercise-based rehabilitation is recommended in all patients after acute myocardial infarction (Class I; Evidence Level A) [1, 3].

At day of discharge an interview was performed to detect patient’s risk factors. Except an occupational distress during many years, no acquired cardiovascular risk factors could be detected (Table 7.1). Nevertheless cardiac rehabilitation was strongly recommended to the patient because of the current cardiovascular event. After financial agreement of his health insurance 2 weeks after hospital discharge, the patient could be admitted to an outpatient rehabilitation centre.

Patients without significant LV damage can sit out of bed late on the first day, be allowed to use a commode and undertake self-care and self-feeding. Ambulation can start the next day, and such patients can be walking up to 200 m on the flat and walking upstairs within a few days. Those who have experienced heart failure, shock or serious arrhythmias should be kept in bed longer, and their physical activity increased slowly, dependent upon their symptoms and the extent of myocardial damage.

Following routine clinical practice of the hospital, where this patient was clinically managed after primary PCI, he was discharged with prescription of aspirin, prasugrel, nebivolol, candesartan and atorvastatin.

The ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation recommend in its 2012 version [1].

After acute myocardial infarction, risk assessment is important to identify patients at high risk of further events. When primary PCI has been performed successfully in the acute phase, early risk assessment is less important since it can be assumed that the infarct-related coronary lesion has been treated and stabilized. After hospital discharge, phase II cardiac rehabilitation should start as early as possible. The aim is to restore the patient to as full a life as possible, including return to work. Dependent upon local facilities, in-hospital cardiac rehabilitation for 4 weeks can be useful in patients with severe left ventricular dysfunction or relevant co-morbidity. All other patients can start with outpatient cardiac rehabilitation immediately after hospital discharge and should be continued the succeeding weeks and months but at least reach rehabilitation targets. Outpatient stress testing within 2 weeks in combination with ECG or imaging techniques would be appropriate in these patients.

A bicycle stress test was performed before starting phase II cardiac rehabilitation. Patient could perform only 75 W of 150 W expected by age and gender. He was not limited by symptoms of angina or dyspnoea. He only reported fatigue as he also felt during the weeks before his event.

Acute coronary syndrome (unstable angina or acute myocardial infarction) represents an acute phase in the life cycle of the patient with chronic coronary disease. Thus, the role and timing of exercise testing in ACS relates to this acute and convalescent period. Only limited evidence available supports the use of exercise testing in patients with STEMI with appropriate indications as soon as the patient has stabilized clinically. Only three studies investigated a symptom-limited pre-discharge (3–7 days) exercise test in patients with unstable angina or non-Q-wave infarction. The major independent predictors of 1-year infarction-free survival in multivariable regression analysis were the number of leads with ischemic ST-segment depression and peak exercise workload achieved [5]. Because of the extraordinary fatigue and mood disturbance of the patient presented without clinical meaningful test results, psychological aspects were focused in the initial phase of cardiac rehabilitation.

Anxiety is almost inevitable, in both patients and their associates, so that reassurance and explanation of the nature of the illness are of great importance and must be handled sensitively. It is also necessary to warn of the frequent occurrence of depression and irritability that more frequently occurs after returning home. It must also be recognized that denial is common; while this may have a protective effect in the acute stage, it may make subsequent acceptance of the diagnosis more difficult. Large studies suggest a role for psychosocial factors as prognostic factors in cardiovascular disease with the strongest evidence for depression as a negative factor in post-infarction patients [6]. However, whether depression is an independent risk (after adjustment for conventional risk factors) is still unclear, and there is, so far, little evidence that any intervention targeting these factors improves prognosis.