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2013+NICE172指南:心肌梗塞的二级预防指南

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2013+NICE172指南:心肌梗塞的二级预防指南 © NICE 2013 NICE has accredited the process used by the Centre for Clinical Practice at NICE to produce guidelines. Accreditation is valid for 5 years from September 2009 and applies to guidelines produced since April 2007 using the processes described...
2013+NICE172指南:心肌梗塞的二级预防指南
© NICE 2013 NICE has accredited the process used by the Centre for Clinical Practice at NICE to produce guidelines. Accreditation is valid for 5 years from September 2009 and applies to guidelines produced since April 2007 using the processes described in NICE's 'The guidelines manual' (2007, updated 2009). More information on accreditation can be viewed at www.nice.org.uk/accreditation 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 guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 2 of 35 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 guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 3 of 35 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 guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 4 of 35 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. guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 5 of 35 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. guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 6 of 35 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] guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 7 of 35  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] guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 8 of 35 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] guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 9 of 35 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 guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 10 of 35  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] guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 11 of 35 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] guide.medlive.cn © NICE 2013. All rights reserved. Last modified November 2013 MI – secondary prevention NICE clinical guideline 172 Page 12 of 35 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
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