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This is one of a series of BMJ summaries of new NICE guidelines, which are based on the best available evidence; they will highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
Although premature mortality from coronary heart disease in the United Kingdom has fallen since the 1970s, it remains higher than in most other Western countries. After an acute myocardial infarction, many eligible patients are prescribed aspirin, β blockers, angiotensin converting enzyme inhibitors, and statins. Not everyone, however, is offered the most effective secondary prevention1 2—that is, all four of these drugs or other effective drugs—nor does everyone receive lifestyle advice and cardiac rehabilitation. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on effective secondary prevention in patients after myocardial infarction.3 The detailed consideration of the evidence is available in the full guideline (www.nice.org.uk/CG048).
NICE recommendations are based on systematic reviews of best available evidence. For the guidance on secondary prevention for patients after a myocardial infarction, in cases where minimal evidence was available, the guideline development group developed the recommendations on the basis of their own opinions and those of leading specialists; such recommendations are indicated with an asterisk (*).
Every discharge summary after a myocardial infarction should confirm this diagnosis and include results of investigations, future management plans, and advice on secondary prevention.*
Lifestyle advice should be consistent and take account of patients' current habits; any changes should be tailored to the individual.
Advise patients against taking:
All healthcare professionals (including senior medical staff) caring for patients after a myocardial infarction should actively promote cardiac rehabilitation.*
Effective implementation of these recommendations depends on planning between specialist and generalist services. Thus, as secondary prevention measures are generally started before discharge, timely discharge summaries with recommendations for ongoing care are crucial.
Appropriate review and patient education in both primary and secondary care improves concordance with drug treatment. Some drugs will need further monitoring and doses increased for optimal efficacy.
Standard models of care should include advice about lifestyle for all patients. Existing cardiac rehabilitation programmes should evaluate their current provision in relation to the recommendations and ensure continuity of care before and after discharge. The costing tool being developed by NICE can be used to estimate additional costs (www.nice.org.uk/page.aspx?o=tools).
As the NICE guidance includes recommendations for all patients who have had a previous myocardial infarction, general practitioners should review their disease registers and ensure that all eligible patients are being appropriately managed.
About 838000 men and 394000 women in the United Kingdom have had a myocardial infarction at some point in their lives. Considerable progress has been made since publication of England's national service framework for coronary heart disease,w1 with increased prescribing of secondary prevention drugs such as aspirin and statins. However, on discharge after acute myocardial infarction, not all patients are treated with all four drugs required for effective secondary prevention (aspirin, β blockers, angiotensin converting enzyme inhibitors, and statins), and other effective drugs may not be consistently prescribed. Limited advice and support may be offered for lifestyle changes. A postal survey in 2000 estimated that only 14%-23% of patients were enrolled into a cardiac rehabilitation programme after their heart attack.2 While such services are developing, provision still varies across geographical areas, and services may not be tailored to the needs of different patient groups.
This new guidance updates the 2001 NICE guideline.w2 The previously limited recommendations on lifestyle (physical activity, diet, smoking habit) and cardiac rehabilitation have been expanded, with greater emphasis on their importance. Drug treatment remains crucial for secondary prevention, and recommendations for aspirin, β blockers, statins, and angiotensin converting enzyme inhibitors have been updated. New recommendations are made for combined treatment with aspirin and clopidogrel (especially regarding its duration), early treatment with an aldosterone antagonist in patients with heart failure and left ventricular dysfunction, and use of other drugs, such as vitamin K antagonists. We also recommend that patients have a cardiological assessment so that patients suitable for other interventions such as coronary revascularisation can be identified.
The new NICE guidance was developed by the National Coordinating Centre-Primary Care, whose members worked alongside a guideline development group that included primary and secondary care nurses and doctors, patients, a pharmacist, and a consultant in public health medicine.
The scope was agreed in advance after consultation with stakeholders, and it formed the basis for developing key clinical questions. The review team refined these questions into specific evidence based questions, specifying interventions and outcomes to be searched for. A systematic reviewer appraised and synthesised all the clinical evidence for presentation to the development group. A health economist appraised and analysed the health economic evidence and did additional economic analyses required by the development group. Literature searches were updated in June 2006 to identify recent evidence. Comments on the draft guidelines were invited from registered stakeholders and from an independent Guideline Review Panel established by NICE. The comments were considered systematically by the development group and informed the final versions of the guideline. Future updates of the guideline will be produced as part of the NICE guideline development programme.w3
Competing interests: All authors were members of the Guideline Development Group for the NICE guideline (JSS was the clinical adviser, AC was the lead systematic reviewer, and GSF chaired the development group). During the past five years JSS has received travel grants to attend educational meetings from Novartis, Pfizer, and Sanofi Synthelabo/Bristol Myers Squibb Pharmaceuticals, with none during the past two years.
Funding: The National Collaborating Centre for Primary Care was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.