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Secondary Prevention in Primary and Secondary Care for Patients Following a Myocardial Infarction (MI)

Scope of the guidance

This item reflects the best available evidence to improve outcomes for people after they have had a myocardial infarction (MI).  It updates the previous NICE guideline ‘Prophylaxis for patients who have experienced a myocardial infarction’ published in 2001. The guidance differentiates between treatment for people after an MI in the last twelve months; and after a proven MI in the past (more than 12 months ago).

What’s new?    The drug therapy section has been revised in this latest version, and information on cardiac rehabilitation and lifestyle changes has been expanded.

Secondary prevention is ‘the long term treatment to prevent recurrent cardiac mortality in people who either had a prior acute myocardial infarction (MI) or are at high risk due to severe coronary artery stenoses, angina, or prior coronary surgical procedures.’  (Gami A – see Further Reading).

Source

Cooper A, Skinner J, Nherera L et al. Clinical Guidelines and Evidence Review for Post Myocardial Infarction: Secondary prevention in primary and secondary care for patients following a myocardial infarction. London: National Collaborating Centre for Primary Care and RCGP; 2007.

www.nice.org.uk/nicemedia/pdf/CG48FullGuideline.pdf

Key points

1. Lifestyle

• Advise patients to be physically active for 20-30 minutes a day to the point of slight breathlessness. Encourage those patients not up to this to increase their activity in a gradual step-by-step fashion, to boost their exercise capacity. They should start at a level that is comfortable and increase the duration and intensity of activity as they become fitter.
• Advise all patients who smoke to quit and offer them help with smoking cessation in line with ‘brief interventions and referral for smoking cessation in primary care and other settings’ (NICE 2006 – see Further Reading).
• Advise patients to keep their weekly alcohol consumption within safe limits (no more than 21 units of alcohol per week for men or 14 units per week for women) and to avoid binge drinking.
• Advise patients to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils).
• Offer overweight and obese patients advice and support to achieve and maintain a healthy weight this makes sense even if there is limited evidence of the effectiveness of primary care interventions in obesity.

2. Cardiac rehabilitation

• Advise all patients who have had an acute MI about local cardiac rehabilitation programmes, and offer them a programme with an exercise component. If a patient has a clinical condition that may worsen during exercise (a cardiac or non-cardiac type), treat this if possible before the patient is offered the exercise component of cardiac rehabilitation.

3. Drug therapy – after an MI in the last 12 months

• Treat all patients who have had an acute MI with the following drugs:

             o      ACE (angiotensin-converting enzyme) inhibitor

             o      aspirin

             o      beta blocker

             o      statin

• Treat patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction with an aldosterone antagonist licensed for post-MI treatment.  Initiate within 3–14 days of the MI, preferably after starting ACE inhibitor therapy.
• Treat patients with non-ST-segment-elevation acute coronary syndrome, with clopidogrel in combination with low-dose aspirin for 12 months. After 12 months, continue standard care including with low-dose aspirin, unless there are other indications to continue dual antiplatelet therapy.
• Treat patients with an ST-segment-elevation MI with a combination of aspirin and clopidogrel in the first 24 hours after the MI; they should continue taking dual platelet therapy for at least 4 weeks. After this, give standard treatment including low-dose aspirin, unless there are other indications to continue dual antiplatelet therapy.
• The evidence is different for patients who have had an MI longer than a year ago. For example, beta-blockers should not be started in asymptomatic patients with proven MI in the past who have preserved left ventricular function, unless they are at increased risk of other cardiovascular events or have other compelling indications for beta-blocker treatment.
• There is a debate as to which sort of statin to use (see http://www3.interscience.wiley.com/cgi-bin/fulltext/114802538/PDFSTART for instance). Lower cost and less intensive statins such as simvastatin and pravastatin achieve smaller reductions in cholesterol levels than intensive statins post MI.

4. Coronary revascularisation

• All patients should be offered a cardiological assessment to consider whether coronary revascularisation is appropriate. This should take into account any comorbidity.

5. Patients with hypertension

• Treat hypertension to achieve the currently recommended target of 140/90 mmHg or lower. The blood pressure target will be lower though for patients with other comorbidities such as diabetes or renal disease.

Practical tips for the busy GP >>

EGP 1. May 2008