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BMJ. 2007 May 26; 334(7603): 1112–1113.
PMCID: PMC1877903
NICE guidelines

Secondary prevention for patients after a myocardial infarction: summary of NICE guidance

J S Skinner, consultant community cardiologist,1 A Cooper, senior health services research fellow,2 and G S Feder, professor of primary care research and development3

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.

Why read this summary?

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).

Recommendations

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

Lifestyle advice should be consistent and take account of patients' current habits; any changes should be tailored to the individual.

Advise patients:

  • • To take enough regular physical activity to increase exercise capacity (reduces total mortality), building this up to 20-30 minutes a day to the point of slight breathlessness
  • • To quit smoking. Offer support, advice, and pharmacotherapy to those wishing to quit4 5
  • • To eat a Mediterranean-style diet: more bread, fruit, vegetables, and fish; less meat; inclusion of products based on vegetable and plant oils rather than butter and cheese (reduces total mortality and the risk of myocardial infarction)
  • • To consume at least 7 g of omega 3 fatty acids (from two to four portions of oily fish) a week. If within three months of the patient's myocardial infarction they are not achieving this, consider offering at least 1 g daily of omega 3 acid ethyl esters treatment licensed for secondary prevention after myocardial infarction for up to four years. It is not recommended that omega 3 acid ethyl esters supplements are routinely prescribed to patients who have had a myocardial infarction more than three months earlier (no evidence of benefit)
  • • To keep weekly alcohol consumption within safe limits (no more than 21 units a week for men, 14 units for women) and to avoid binge drinking (more than three drinks in 1-2 hours)*
  • • To achieve and maintain a healthy weight if overweight or obese. Offer appropriate advice and support.6

Advise patients against taking:

  • • Supplements containing β carotene (may increase risk of cardiovascular death)
  • • Vitamin E or C supplements (no evidence of benefit)
  • • Folic acid supplements (no evidence of benefit).

Cardiac rehabilitation

All healthcare professionals (including senior medical staff) caring for patients after a myocardial infarction should actively promote cardiac rehabilitation.*

  • • Offer cardiac rehabilitation with an exercise component to all patients (reduces total mortality), and provide access regardless of the patient's age, sex, ethnicity, socioeconomic status, or comorbidities.
  • • Include the following components in comprehensive cardiac rehabilitation: exercise (reduces total mortality), health education, and stress management (reduces anxiety, depression and the risk of non-fatal myocardial infarction). However, complex psychological interventions, such as cognitive behavioural therapy, should not be routinely offered.
  • Comprehensive cardiac rehabilitation may be offered as a validated home based programme (for example, the Edinburgh Heart Manual7) with follow-up by a trained facilitator.
  • • Involve partners or carers, if the patient wishes.*
  • • Include advice on return to work and to activities of daily living, taking into account the patient's physical and psychological status, the nature of the activity or work proposed, and the work environment.*
  • • Reassure patients that after recovery from a heart attack, sexual activity presents no greater risk of triggering a subsequent attack than if the patient had never had one.
  • • Take into account the patient's wider health and social needs, which may involve economic needs, welfare rights, or social support issues, especially for those in more deprived situations.*

Drug treatment after acute myocardial infarction

  • • Treat all patients with the following combination:
  • 1. Angiotensin converting enzyme inhibitor (reduces mortality, the risk of myocardial infarction, and, in selected patients, the risk of developing heart failure)
  • 2. Aspirin (reduces cardiovascular mortality and morbidity)
  • 3. β blocker (reduces total mortality and cardiovascular morbidity)
  • 4. Statin (reduces total mortality and cardiovascular morbidity).
  • • After a non-ST elevation myocardial infarction , treat patients with both clopidogrel and low dose aspirin for 12 months8 (reduces cardiovascular mortality and the risk of myocardial infarction and stroke). After an ST elevation myocardial infarction , treat patients for at least four weeks if this combination has been started within the first 24 hours (reduces total mortality and the risk of myocardial infarction and stroke). Thereafter, continue standard treatment, including low dose aspirin without clopidogrel, unless there are other indications to continue both.
  • • In patients intolerant of both aspirin and clopidogrel, consider treatment with moderate intensity warfarin (aiming for an international normalised ratio of 2-3) instead (reduces the risk of myocardial infarction). In patients intolerant of clopidogrel and who have a low risk of bleeding, consider treatment with aspirin and moderate intensity warfarin combined.
  • • In patients already taking warfarin for another indication, continue warfarin; in those taking moderate intensity warfarin (international normalised ratio of 2-3) and who have a low risk of bleeding, consider adding aspirin.

Heart failure after myocardial infarction

  • • Treat patients with heart failure and left ventricular systolic dysfunction with an aldosterone antagonist licensed for this indication, preferably after treatment with an angiotensin converting enzyme inhibitor, within three to 14 days of the acute myocardial infarction (reduces total mortality and the risk of hospital admission for cardiovascular events, including heart failure).

Cardiological assessment

  • • Offer cardiological assessment, taking account of comorbidity, to all patients so that those who will benefit from coronary revascularisation for secondary prevention (reduces the risk of myocardial infarction and total mortality in appropriately selected patients) or from other cardiological interventions9 can be identified.

Overcoming barriers

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.

Further information on the guidance

Background

About 838 000 men and 394 000 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.

What's new?

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.

Methods

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

Unanswered research questions

  • • How long should patients with ST elevation myocardial infarction who have been treated with thrombolysis take aspirin plus clopidogrel, compared with aspirin alone?
  • • How effective is long term continuation of drugs for secondary prevention after a myocardial infarction? For example, do all patients with normal left ventricular function benefit from long term treatment with β blockers and angiotensin converting enzyme inhibitors?
  • • How effective is spironolactone compared with eplerenone in patients with heart failure and left ventricular dysfunction early after myocardial infarction?
  • • What strategies are effective in improving uptake of and adherence to comprehensive cardiac rehabilitation programmes, particularly in groups under-represented in those programmes?
  • • What is the added value of the non-exercise components of comprehensive cardiac rehabilitation programmes?
  • • How effective are omega 3 acid ethyl esters in all patients after myocardial infarction?
  • • What measures encourage the maintenance of regular exercise and a Mediterranean style diet beyond the period of comprehensive cardiac rehabilitation?

References

  • w1 Department of Health. Coronary heart disease: national service framework for coronary heart disease. London: DoH, 2000.
  • w2 National Institute for Clinical Excellence. Prophylaxis for patients who have experienced a myocardial infarction: drug treatments, rehabilitation and dietary manipulation. London: NICE, 2001. http://guidance.nice.org.uk/CGA/guidance/pdf/English
  • w3 National Institute for Health and Clinical Excellence. Updating guidelines and correcting errors. In: The guidelines manual. (Ch 15.) www.nice.org.uk/page.aspx?o=423088

Notes

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.

References

1. Royal College of Physicians. Myocardial infarction national audit project (MINAP) www.rcplondon.ac.uk/college/ceeu/ceeu_ami_home.htm.
2. Bethell HJ, Turner SC, Evans JA, Rose L. Cardiac rehabilitation in the United Kingdom: how complete is the provision? J Cardiopulm Rehabil 2001;21:111-5. [PubMed]
3. National Institute for Health and Clinical Excellence. Clinical guideline 48: MI: secondary prevention in primary and secondary care for patients following a myocardial infarction. London: NICE, 2007. www.nice.org.uk/CG48
4. National Institute for Clinical Excellence. TA039: smoking cessation—bupropion and nicotine replacement therapy. London: NICE, 2002. www.nice.org.uk/TA39
5. National Institute for Health and Clinical Excellence. PHI001: smoking cessation—brief interventions and referral for smoking cessation in primary care and other settings London: NICE, 2006. http://guidance.nice.org.uk/PHI1
6. National Institute for Health and Clinical Excellence. Clinical guideline 43: obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children London: NICE, 2006. www.nice.org.uk/CG43
7. University of York. Cardiac rehabilitation. BHF Cardiac Cardiac Care and Education Research Group. www.cardiacrehabilitation.org.uk/heart_manual/heartmanual.htm
8. National Institute for Clinical Excellence. TA080: acute coronary syndromes—clopidogrel. London: NICE, 2004. www.nice.org.uk/TA80
9. National Institute for Health and Clinical Excellence. TA095: arrhythmia—implantable cardioverter defibrillators (ICDs) (review) London: NICE, 2006. www.nice.org.uk/TA95

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