© NICE 2013
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MI – secondary prevention
Secondary prevention in primary and secondary care for
patients following a myocardial infarction
Issued: November 2013
NICE clinical guideline 172
guidance.nice.org.uk/cg172
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Contents
Introduction .................................................................................................................................. 3
Patient-centred care ..................................................................................................................... 5
Key priorities for implementation .................................................................................................. 6
1 Recommendations ............................................................................................................... 8
1.1 Cardiac rehabilitation after an acute myocardial infarction (MI).................................. 8
1.2 Lifestyle changes after an MI ................................................................................... 12
1.3 Drug therapy ............................................................................................................ 14
1.4 Coronary revascularisation after an MI .................................................................... 21
1.5 Selected patient subgroups ...................................................................................... 21
1.6 Communication of diagnosis and advice .................................................................. 21
2 Research recommendations ............................................................................................... 22
3 Other information ................................................................................................................ 25
4 The Guideline Development Group, National Collaborating Centre and NICE project team
2013 ........................................................................................................................................... 28
About this guideline .................................................................................................................... 31
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Introduction
This guideline updates and replaces 'MI – secondary prevention' (NICE clinical guideline 48)
and updates and replaces a recommendation from NICE technology appraisal guidance 80.
The recommendations are labelled according to when they were originally published (see
About this guideline for details).
Myocardial infarction (MI) is one of the most dramatic presentations of coronary artery disease.
It is usually caused by blockage of a coronary artery producing tissue death and consequently
the typical features of a heart attack: severe chest pain, changes on the electrocardiogram
(ECG), and raised concentrations of proteins released from the dying heart tissue into the
blood. MIs are divided into 2 types according to the changes they produce on the ECG:
ST-segment elevation myocardial infarction (STEMI), which is generally caused by
complete and persisting blockage of the artery
non-ST-segment elevation myocardial infarction (NSTEMI), reflecting partial or intermittent
blockage of the artery.
In England and Wales in 2011/12 more than 79,000 hospital admissions were caused by MI
according to the Myocardial Ischaemia National Audit Project (MINAP). Of these, 41% were
STEMIs and 59% were NSTEMIs. Twice as many men had MIs as women.
People who have had a STEMI or an NSTEMI benefit from treatment to reduce the risk of
further MI or other manifestations of vascular disease. This is known as secondary prevention.
Since the late 1990s MINAP has documented the reductions in mortality resulting from changes
in acute treatment of MI and the application of secondary prevention measures. Although 30-
day mortality was almost 13% for STEMI in 2003/04, it fell to 8% in 2011/12, with similar falls for
NSTEMI.
The NICE guideline on the secondary prevention of MI (NICE clinical guideline 48) was
published in 2007, offering comprehensive advice to prevent further MI and progression of
vascular disease in those who had already had an MI, either recently or in the past (more than
12 months ago). Since 2007, there has been a major change in the management of acute MI,
both STEMI and NSTEMI, although more dramatically the former. Primary percutaneous
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coronary intervention (PCI) has replaced thrombolysis in most cases of STEMI. This
improvement in acute treatment may have an impact on the efficacy of secondary prevention,
which is one of the reasons this update is needed.
Uptake of cardiac rehabilitation is still low, with only 44% of people starting an outpatient cardiac
rehabilitation programme in England, Northern Ireland and Wales after an MI. People also wait
an average of 53 days to start an outpatient rehabilitation programme. Interventions that may
enhance uptake and adherence to cardiac rehabilitation programmes have been included in this
2013 update.
Drug therapy for secondary prevention is effectively applied nationally, but new findings on
antithrombotic therapy, omega-3 fatty acid supplementation, angiotensin-converting enzyme
(ACE) inhibitors and beta-blockers have also contributed to a need for this guideline to be
updated.
Drug recommendations
The guideline will assume that prescribers will use a drug's summary of product characteristics
to inform decisions made with individual patients.
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Patient-centred care
This guideline offers best practice advice on the care of adults who have had a myocardial
infarction.
Patients and healthcare professionals have rights and responsibilities as set out in the NHS
Constitution for England – all NICE guidance is written to reflect these. Treatment and care
should take into account individual needs and preferences. Patients should have the opportunity
to make informed decisions about their care and treatment, in partnership with their healthcare
professionals. Healthcare professionals should follow the Department of Health's advice on
consent (or, in Wales, advice on consent from the Welsh Government). If someone does not
have capacity to make decisions, healthcare professionals should follow the code of practice
that accompanies the Mental Capacity Act and the supplementary code of practice on
deprivation of liberty safeguards.
NICE has produced guidance on the components of good patient experience in adult NHS
services. All healthcare professionals should follow the recommendations in Patient experience
in adult NHS services.
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Key priorities for implementation
The following recommendations have been identified as priorities for implementation. The full
list of recommendations is in section 1.
Cardiac rehabilitation after an acute myocardial infarction (MI)
Offer cardiac rehabilitation programmes designed to motivate people to attend and
complete the programme. Explain the benefits of attending. [new 2013]
Begin cardiac rehabilitation as soon as possible after admission and before discharge from
hospital. Invite the person to a cardiac rehabilitation session which should start within
10 days of their discharge from hospital. [new 2013]
Lifestyle changes after an MI
Advise people to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish;
less meat; and replace butter and cheese with products based on plant oils). [2007]
Advise people to be physically active for 20–30 minutes a day to the point of slight
breathlessness. Advise people who are not active to this level to increase their activity in a
gradual, step-by-step way, aiming to increase their exercise capacity. They should start at
a level that is comfortable, and increase the duration and intensity of activity as they gain
fitness. [2007]
Advise all people who smoke to stop and offer assistance from a smoking cessation
service in line with Brief interventions and referral for smoking cessation (NICE public
health guidance 1). [2007]
Drug therapy
Offer all people who have had an acute MI treatment with the following drugs:
ACE (angiotensin-converting enzyme) inhibitor
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
beta-blocker
statin. [2007, amended 2013]
Offer an assessment of left ventricular function to all people who have had an MI. [2013]
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Titrate the ACE inhibitor dose upwards at short intervals (for example, every 12–24 hours)
before the person leaves hospital until the maximum tolerated or target dose is reached. If
it is not possible to complete the titration during this time, it should be completed within 4–
6 weeks of hospital discharge. [new 2013]
Communicate plans for titrating beta-blockers up to the maximum tolerated or target dose
– for example, in the discharge summary. [new 2013]
Communication of diagnosis and advice
After an acute MI, ensure that the following are part of every discharge summary:
confirmation of the diagnosis of acute MI
results of investigations
incomplete drug titrations
future management plans
advice on secondary prevention. [2007, amended 2013]
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1 Recommendations
The following guidance is based on the best available evidence. The full guideline gives details
of the methods and the evidence used to develop the guidance.
The wording used in the recommendations in this guideline (for example words such as 'offer'
and 'consider') denotes the certainty with which the recommendation is made (the strength of
the recommendation). See About this guideline for details.
1.1 Cardiac rehabilitation after an acute myocardial infarction (MI)
Comprehensive cardiac rehabilitation
1.1.1 All patients (regardless of their age) should be given advice about and offered a
cardiac rehabilitation programme with an exercise component. [2007]
1.1.2 Cardiac rehabilitation programmes should provide a range of options, and patients
should be encouraged to attend all those appropriate to their clinical needs. Patients
should not be excluded from the entire programme if they choose not to attend
certain components. [2007]
1.1.3 If a patient has cardiac or other clinical conditions that may worsen during exercise,
these should be treated if possible before the patient is offered the exercise
component of cardiac rehabilitation. For some patients, the exercise component may
be adapted by an appropriately qualified healthcare professional. [2007]
1.1.4 Patients with left ventricular dysfunction who are stable can safely be offered the
exercise component of cardiac rehabilitation. [2007]
Encouraging people to attend
1.1.5 Deliver cardiac rehabilitation in a non-judgemental, respectful and culturally sensitive
manner. Consider employing bilingual peer educators or cardiac rehabilitation
assistants who reflect the diversity of the local population. [new 2013]
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1.1.6 Establish people's health beliefs and their specific illness perceptions before offering
appropriate lifestyle advice and to encourage attendance to a cardiac rehabilitation
programme. [new 2013]
1.1.7 Offer cardiac rehabilitation programmes designed to motivate people to attend and
complete the programme. Explain the benefits of attending. [new 2013]
1.1.8 Discuss with the person any factors that might stop them attending a cardiac
rehabilitation programme, such as transport difficulties. [new 2013]
1.1.9 Offer cardiac rehabilitation programmes in a choice of venues (including at the
person's home, in hospital and in the community) and at a choice of times of day, for
example, sessions outside of working hours. Explain the options available. [new
2013]
1.1.10 Provide a range of different types of exercise, as part of the cardiac rehabilitation
programme, to meet the needs of people of all ages, or those with significant
comorbidity. Do not exclude people from the whole programme if they choose not to
attend specific components. [new 2013]
1.1.11 Offer single-sex cardiac rehabilitation programme classes if there is sufficient
demand. [new 2013]
1.1.12 Enrol people who have had an MI in a system of structured care, ensuring that there
are clear lines of responsibility for arranging the early initiation of cardiac
rehabilitation. [new 2013]
1.1.13 Begin cardiac rehabilitation as soon as possible after admission and before
discharge from hospital. Invite the person to a cardiac rehabilitation session which
should start within 10 days of their discharge from hospital. [new 2013]
1.1.14 Contact people who do not start or do not continue to attend the cardiac rehabilitation
programme with a further reminder, such as:
a motivational letter
a prearranged visit from a member of the cardiac rehabilitation team
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a telephone call
a combination of the above. [new 2013]
1.1.15 Seek feedback from cardiac rehabilitation programme users and aim to use this
feedback to increase the number of people starting and attending the programme.
[new 2013]
1.1.16 Be aware of the wider health and social care needs of a person who has had an MI.
Offer information and sources of help on:
economic issues
welfare rights
housing and social support issues. [new 2013]
1.1.17 Make cardiac rehabilitation equally accessible and relevant to all people after an MI,
particularly people from groups that are less likely to access this service. These
include people from black and minority ethnic groups, older people, people from
lower socioeconomic groups, women, people from rural communities, people with a
learning disability and people with mental and physical health conditions. [2007,
amended 2013]
1.1.18 Encourage all staff, including senior medical staff, involved in providing care for
people after an MI, to actively promote cardiac rehabilitation. [2013]
Health education and information needs
1.1.19 Comprehensive cardiac rehabilitation programmes should include health education
and stress management components. [2007]
1.1.20 A home-based programme validated for patients who have had an MI (such as The
heart manual) that incorporates education, exercise and stress management
components with follow-ups by a trained facilitator may be used to provide
comprehensive cardiac rehabilitation. [2007]
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1.1.21 Take into account the physical and psychological status of the patient, the nature of
their work and their work environment when giving advice on returning to work.
[2007]
1.1.22 Be up to date with the latest Driver and Vehicle Licensing Agency (DVLA) guidelines.
Regular updates are published on the DVLA website. [2007]
1.1.23 After an MI without complications, people who wish to travel by air should seek
advice from the Civil Aviation Authority. People who have had a complicated MI need
expert individual advice. [2007, amended 2013]
1.1.24 People who have had an MI who hold a pilot's licence should seek advice from the
Civil Aviation Authority. [2007]
1.1.25 Take into account the patient's physical and psychological status, as well as the type
of activity planned when offering advice about the timing of returning to normal
activities. [2007]
1.1.26 An estimate of the physical demand of a particular activity, and a comparison
between activities, can be made using tables of metabolic equivalents (METS) of
different activities (for further information please refer to the Centers for Disease
Control and Prevention website). Advise patients how to use a perceived exertion
scale to help monitor physiological demand. Patients who have had a complicated MI
may need expert advice. [2007]
1.1.27 Advice on competitive sport may need expert assessment of function and risk, and is
dependent on what sport is being discussed and the level of competitiveness. [2007]
Psychological and social support
1.1.28 Offer stress management in the context of comprehensive cardiac rehabilitation.
[2007]
1.1.29 Do not routinely offer complex psychological interventions such as cognitive
behavioural therapy. [2007]
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1.1.30 Involve partners or carers in the cardiac rehabilitation programme if the patient
wishes. [2007]
1.1.31 For recommendations on the management of patients with clinical anxiety or
depression, refer to Anxiety (NICE clinical guideline 113), Depression in adults (NICE
clinical guideline 90) and Depression in adults with a chronic physical health problem
(NICE clinical guideline 91). [2007]
Sexual activity
1.1.32 Reassure patients that after recovery from an MI, sexual activity presents no greater
risk of triggering a subsequent MI than if they had never had an MI. [2007]
1.1.33 Advise patients who have made an uncomplicated recovery after their MI that they
can resume sexual activity when they feel comfortable to do so, usually after about
4 weeks. [2007]
1.1.34 Raise the subject of sexual activity with patients within the context of cardiac
rehabilitation and aftercare. [2007]
1.1.35 When treating erectile dysfunction, treatment with a PDE5 (phosphodiesterase
type 5) inhibitor may be considered in men who have had an MI more than 6 months
earlier and who are now stable. [2007]
1.1.36 PDE5 inhibitors must be avoided in patients treated with nitrates or nicorandil
because this can lead to dangerously low blood pressure. [2007]
1.2 Lifestyle changes after an MI
Changing diet
1.2.1 Advise people to eat a Mediterranean-style diet (more bread, fruit, vegetables and
fish; less meat; and replace butter and cheese with products based on plant oils).
[2007]
1.2.2 Do n