BMJ 2013;347:f6544 doi: 10.1136/bmj.f6544 (Published 13 November 2013)
Page 1 of 5
Practice
PRACTICE GUIDELINES
Secondary prevention for patients after a myocardial infarction: summary of updated NICE guidance 1
1
Katie Jones project manager , Leanne Saxon research fellow , William Cunningham retired general 2 3 practitioner , Phil Adams emeritus consultant cardiologist , on behalf of the Guideline Development Group Royal College of Physicians, National Clinical Guideline Centre, London NW1 4LE, UK; 2Hadrian Primary Care Alliance, Corbridge, UK; 3Newcastle Hospitals NHS Foundation Trust, Newcastle, UK 1
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
Acute management of people who have had a myocardial infarction (MI) has changed dramatically, with more people surviving. More effective treatment, including percutaneous coronary intervention, raises questions about the relevance of current recommendations on secondary prevention. Concerns have arisen about the need for the antiplatelet regimens mandated by coronary stent insertion in people who have an independent need for warfarin. New data are also available about how to increase attendance for cardiac rehabilitation programmes, about existing drug treatments and lifestyle advice, and new antithrombotic agents. The impact of shorter stays in hospital on the changes in acute management have emphasised the importance of primary care in secondary prevention. General practitioners and nurses are now responsible for most of this activity, specifically the promotion of cardiac rehabilitation programmes and the prescription and monitoring of ongoing drug therapy. This also requires effective communication between hospital and primary care, ensuring that clear management plans are relayed in a timely way.
These considerations have led to a revision of the 2007 guideline on secondary prevention after an MI.1 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE).2
Recommendations
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good
practice. Evidence levels for the recommendations are given in italic in square brackets.
Cardiac rehabilitation Cardiac rehabilitation should be offered to all people who have had an MI and should be provided in different settings (such as in the person’s home) and at different times of the day to ensure that people can attend and complete the programme. • Offer cardiac rehabilitation programmes designed to motivate people to attend and complete the programme. Explain the benefits of attending (which include reducing the risk of death and of having another MI, and improving quality of life). (New recommendation.) [Based upon high quality qualitative evidence and low to moderate quality randomised studies and the experience and opinion of the Guideline Development Group (GDG)] • Begin cardiac rehabilitation as soon as possible after admission and before discharge from hospital. Invite the person to a cardiac rehabilitation session starting within 10 days of their discharge from hospital. (New recommendation.) [Based upon low to high quality randomised studies, an original economic model directly applicable with potentially serious limitations, and the experience and opinion of the GDG]
Lifestyle changes after an MI Lifestyle changes after an MI should focus on smoking cessation, dietary interventions, weight management, moderation of alcohol consumption, and regular physical activity. • Advise all people who smoke to stop and offer assistance from a smoking cessation service in line with NICE public health guidance on brief interventions and referral for smoking cessation (PH1).3
Correspondence to: K Jones [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
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BMJ 2013;347:f6544 doi: 10.1136/bmj.f6544 (Published 13 November 2013)
Page 2 of 5
PRACTICE
• 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).
• After an MI, offer all patients who are overweight or obese advice and support to achieve and maintain a healthy weight in line with NICE clinical guideline on obesity (CG43).4
• Advise people who drink alcohol to keep weekly 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 (more than 3 alcoholic drinks in 1-2 hours).
• 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, stepwise manner, with the aim of increasing their exercise capacity. They should start at a level that is comfortable and increase the duration and intensity of activity as they gain fitness. • Do not recommend routinely eating oily fish for the sole purpose of preventing another MI. If people after MI choose to consume oily fish, healthcare professionals should be aware that there is no evidence of harm, and fish may form part of a Mediterranean-style diet. (New recommendation.) [Based upon low to moderate quality randomised studies and the experience and opinion of the GDG] • Do not offer or advise people to use the following to prevent another MI: - Omega 3 fatty acid capsules - Omega 3 fatty acid supplemented foods. If people choose to take omega 3 fatty acids (as capsules or supplemented foods), healthcare professionals should be aware that there is no evidence of harm. (New recommendation.) [Based upon low to moderate quality randomised studies and the experience and opinion of the GDG]
Drug therapy Box 1 summarises the drug treatment recommended to reduce the risk of another MI, with detail in the following text. For details on contraindications, please refer to the British National Formulary.5
Angiotensin converting enzyme (ACE) inhibitors • Offer people who present acutely an ACE inhibitor and continue it indefinitely.
• Titrate the dose upwards at short intervals in hospital (such as every 12-24 hours) and ensure complete titration within four to six weeks after discharge. (Updated recommendation.) [Based upon very low to moderate quality randomised evidence and the experience and opinion of the GDG] • Offer people after an MI who are intolerant to ACE inhibitors an angiotensin receptor blocker instead of an ACE inhibitor. (New recommendation.) [Based upon the experience and opinion of the GDG] • For patients who have had an acute MI and who have symptoms or signs of heart failure and left ventricular For personal use only: See rights and reprints http://www.bmj.com/permissions
systolic dysfunction, start treatment with an aldosterone antagonist licensed for post-MI treatment within 3-14 days of the MI, preferably after starting ACE inhibitor therapy. Box 2 includes recommendations on monitoring for people receiving ACE inhibitors and aldosterone antagonists
Antiplatelet therapy • Offer low dose aspirin to all people after an MI and continue it indefinitely. (Updated recommendation.) [Based upon low to very low quality randomised evidence and the experience and opinion of the GDG] • Where aspirin is contraindicated or not tolerated (for example, because of hypersensitivity or a history of dyspepsia): - For people with aspirin hypersensitivity, consider clopidogrel monotherapy as an alternative - For people with a history of dyspepsia, consider treatment of their dyspepsia in line with NICE clinical guideline on dyspepsia (CG17, currently being updated)10 - For people with a history of aspirin induced ulcer bleeding whose ulcers have healed and who are negative for Helicobacter pylori, consider treatment in line with NICE guideline on dyspepsia (CG17)10 • Offer clopidogrel in combination with aspirin as a treatment option for up to 12 months to people who have had - ST segment elevation MI (characterised by ST elevation or new left bundle branch block on electrocardiogram) and received a bare metal or drug eluting stent - Non-ST segment elevation MI (characterised by an absence of persistent ST elevation on electrocardiogram) regardless of treatment. (New recommendation.) [Based upon NICE technology appraisal 80,11 moderate to low quality randomised evidence, and the experience and opinion of the GDG] • Ticagrelor in combination with low dose aspirin for up to 12 months is recommended as another treatment option to adults with acute coronary syndromes: - Those with ST segment elevation MI whom cardiologists intend to treat with primary percutaneous coronary intervention - Those with Non-ST segment elevation MI. (New recommendation.) [Based upon NICE technology appraisal 23612 and the experience and opinion of the GDG] • Offer clopidogrel in combination with low dose aspirin for at least one month and consider continuing for up to 12 months for people who have had an ST segment elevation MI for which they received medical management, with or without reperfusion treatment using a fibrinolytic agent. (New recommendation.) [Based upon high to very low quality evidence and the experience and opinion of the GDG] • Offer clopidogrel instead of aspirin to people who have had an MI more than 12 months ago if they also have other clinical vascular disease or are aspirin intolerant, in line with NICE technology appraisal of clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (TA210). (Updated recommendation.) [Based upon NICE technology appraisal 21013 and the experience and opinion of the GDG] Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f6544 doi: 10.1136/bmj.f6544 (Published 13 November 2013)
Page 3 of 5
PRACTICE
Box 1: Drug therapy for people who have had an MI • Angiotensin converting enzyme (ACE) inhibitor • Dual antiplatelet therapy (low dose aspirin plus a second antiplatelet agent) • β blocker • Statin Refer to relevant NICE guidance on use of prasugrel for treating acute coronary syndromes (technology appraisal 182),6 on the acute management of MI with ST segment elevation and non-ST segment elevation (clinical guidelines 167 and 94),7 8 and on the use of statins (clinical guideline 67, to be updated in 2014)9
Box 2: Drug monitoring for people who have had an MI ACE inhibitors • Monitor renal function (serum creatinine concentration), serum electrolytes, and blood pressure before starting an ACE inhibitor • Monitor thereafter until treated with a stable dose, and then at least annually • Consider more frequent monitoring in people at risk of deteriorating renal function, of developing hyperkalaemia, or during an intercurrent illness, particularly when associated with a risk of dehydration
Aldosterone antagonists • Check renal function and serum electrolytes • Consider seeking specialist advice if concerned about an increased risk of developing serious hyperkalaemia (such as patients with reduced renal function or if baseline serum potassium is >5 mmol/L) • Routinely measure blood biochemistry after 48 hours, at 1 and 4 weeks, and at 3 months, and 3 monthly thereafter; and 1 week after a titration upwards in the dose
The figure⇓ outlines antiplatelet treatment recommendations for people who otherwise need anticoagulation.
β blockers • Offer a β blocker as soon as possible after an MI, when the person is haemodynamically stable. (New recommendation.) [Based upon very low to moderate quality evidence and the experience and opinion of the GDG] • Make arrangements (for example, in the discharge summary) to recommend that titration of β blockers occurs up to the maximum tolerated or target dose. (New recommendation.) [Based upon the experience and opinion of the GDG] • Continue a β blocker for at least 12 months after an MI in people without left ventricular systolic dysfunction or heart failure. (New recommendation.) [Based upon very low to moderate quality evidence and the experience and opinion of the GDG] • Continue a β blocker indefinitely in people with left ventricular systolic dysfunction. (New recommendation.) [Based upon very low to moderate quality evidence and the experience and opinion of the GDG]
Communication of diagnosis and advice • Offer a copy of the discharge summary for all people who have had an 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.
(Updated recommendation.) [Based upon the experience and opinion of the GDG and the content of other recommendations in the guideline]
Overcoming barriers Implementation of these recommendations will be challenging throughout the healthcare system. Cardiac rehabilitation services need to ensure that people who have had an MI are offered their first cardiac rehabilitation session within 10 days of hospital discharge, and make arrangements to offer further appointments to non-attenders. Hospital services need to review drug policies—particularly around antiplatelet agents, prescribing for people with an independent indication for anticoagulation, and drug titration. Clear and timely communication of management plans, optimising use of discharge summaries, is critical. Primary care teams are largely responsible for the secondary prevention of MI. General practices need to use their in-house systems to identify those who have had a recent MI based on hospital discharge letters and to follow up these patients at an early stage, reviewing management plans, attendance at cardiac rehabilitation, and drug prescription, and providing appropriate lifestyle advice. The members of the Guideline Development Group were Philip Adams (chair), Ivan Bennet, Kathryn Carver, William Cunningham, Jennifer Jones, Caroline Levie, Joseph Mills, Jerry Murphy, Sanjay Ramdany, Linda Speck, John Walsh, Maria Wray, Paul Wright, and Robert Wright. Jo Farrington was appointed as a co-opted member of the GDG. The technical team at the National Clinical Guideline Centre included Joanna Ashe, Elizabeth Avital, Daria Bilan, Elisabetta Fenu, Jennifer Hill, Katie Jones, Kate Lovibond, Julie Neilson, Juan Carlos Rejon, and Leanne Saxon. Contributors: KJ wrote the first draft. All authors reviewed the draft, were involved in writing further drafts, and reviewed and approved the final version for publication. PA acts as guarantor. Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; not externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
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BMJ 2013;347:f6544 doi: 10.1136/bmj.f6544 (Published 13 November 2013)
Page 4 of 5
PRACTICE
Further information on the guidance Update of the existing guideline was necessary as a result of changes in acute management after an MI, potentially affecting the efficacy of existing secondary prevention treatments. The evidence base in people who have undergone modern acute treatments such as primary percutaneous coronary intervention was limited. However, the guideline reviews the available evidence and attempted to interpret it in light of the changes in acute management. Several new recommendations aim to promote uptake of and adherence to cardiac rehabilitation programmes. Lifestyle recommendations focusing on diet, smoking cessation, exercise, alcohol consumption, and weight loss remain unchanged, but the consumption of omega 3 acid ethyl esters and oily fish is no longer recommended for the sole purpose of preventing another MI, as recent studies in populations receiving modern secondary prevention strategies after an MI failed to show a benefit. The guideline also provides new and updated recommendations on antiplatelet agents for people who have had an ST segment elevation or non-ST segment elevation MI in light of newly available drugs (prasugrel and ticagrelor) and includes recommendations on the duration of treatment. For people who have a pre-existing indication for anticoagulation, the guideline recommends treatment with warfarin plus either aspirin or clopidogrel (depending on the treatment given acutely), based on new evidence (see box 1). Recommendations on other drug treatments—including ACE inhibitors, β blockers, calcium channel blockers, potassium channel antagonists, and aldosterone antagonists—after an MI remain largely unchanged. However, new recommendations on the titration of ACE inhibitors and β blockers have been included to reflect reductions in duration of hospital stay with the increased use of interventional therapy and percutaneous coronary intervention for people with MI. Hospital and general practice services may wish to audit the improvement of drug titrations and prescribing of antiplatelet agents. The Quality and Outcomes Framework (an incentive scheme for UK general practices rewarding high quality care for patients) for 2013-14 will monitor the prescribing of recommended drugs.14 As the NICE guideline has also updated recommendations on what to include in discharge summaries, general practices should monitor the timeliness and quality of discharge summaries and provide feedback to secondary care.
Methods The Guideline Development Group followed the standard NICE methods in the development of this guideline (www.nice.org.uk/aboutnice/ howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp). The GDG comprised an emeritus consultant cardiologist, a general practitioner with a special interest in cardiology, a general practitioner, a cardiac rehabilitation lead nurse, a physiotherapist, a cardiac rehabilitation practitioner with a special interest in cardiology, a professor of cardiovascular medicine, a community matron with a special interest in coronary heart disease, a consultant clinical health psychologist, a cardiac pharmacist, a consultant cardiologist, and two patient members. The GDG also co-opted a dietitian. The group developed clinical questions; collected and appraised clinical evidence; and evaluated the cost effectiveness of proposed interventions through systematic literature review and original economic modelling. The draft guideline went through a rigorous reviewing process, in which stakeholder organisations were invited to comment. The GDG took all comments into consideration when producing the final version of the guideline. Quality ratings of the evidence were based on GRADE methodology (www.gradeworkinggroup.org). These relate to the quality of the available evidence for assessed outcomes rather than the quality of the clinical study. Further updates of the guideline will be produced as part of NICE’s guideline development programme.
Future research The GDG identified the following areas for further research: • What characteristics are associated with uptake and adherence to cardiac rehabilitation after an acute MI when rehabilitation is started early? • In patients who are not revascularised after an MI, does clopidogrel plus placebo have a better outcome than clopidogrel plus aspirin? • In people who have had an MI, have an indication for oral anticoagulation, and are treated medically by primary percutaneous intervention or by coronary artery bypass surgery, is treatment with an oral anticoagulant, aspirin, and clopidogrel preferable to treatment with an oral anticoagulant and clopidogrel? • In patients who have had an ST segment elevation MI, who undergo primary percutaneous coronary intervention with a bare metal stent, and who have had four weeks’ treatment with aspirin and clopidogrel, is there an additional benefit to continuing clopidogrel for a further 11 months? • In people who have had an MI and who have normal left ventricular systolic function, does continuing β blocker treatment beyond one year improve outcomes? 1 2 3 4 5 6 7
National Institute for Health and Care Excellence. Secondary prevention in primary and secondary care for patients following a myocardial infarction. (Clinical guideline 48.) 2007. www.nice.org.uk/CG48. National Institute for Health and Care Excellence. Secondary prevention in primary and secondary care for patients following a myocardial infarction. (Clinical guideline 172.) 2013. www.nice.org.uk/CG172. National Institute for Health and Care Excellence. Brief interventions and referral for smoking cessation in primary care and other settings. (Public health guidance 1.) 2006. www.nice.org.uk/PH1. National Institute for Health and Care Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. (Clinical guideline 43.) 2006. www.nice.org.uk/CG43. British Medical Association, Royal Pharmaceutical Society of Great Britain. British national formulary . BMA, RPS, 2013. (No 66.) National Institute for Health and Care Excellence. Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention. (Technology appraisal 182.) 2009. www.nice.org.uk/TA182. National Institute for Health and Care Excellence. Myocardial infarction with ST-segment elevation: the acute management of myocardial infarction with ST-segment elevation. (Clinical guideline 167.) 2013. www.nice.org.uk/CG167.
8 9 10 11 12 13 14
National Institute for Health and Care Excellence. Unstable angina and NSTEMI: the early management of unstable angina and non-ST-segment-elevation myocardial infarction. (Clinical guideline 94.) 2010. www.nice.org.uk/CG94. National Institute for Health and Care Excellence. Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. (Clinical guideline 67.) 2008. www.nice.org.uk/CG67. National Institute for Health and Care Excellence. Dyspepsia: Managing dyspepsia in adults in primary care. (Clinical guideline 17.) 2004. www.nice.org.uk/CG17. National Institute for Health and Care Excellence. Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome. (Technology appraisal 80.) 2004. www.nice.org.uk/TA80. National Institute for Health and Care Excellence. Ticagrelor for the treatment of acute coronary syndromes (ACS). (Technology appraisal 236.) 2011. www.nice.org.uk/TA236. National Insitute for Health and Care Excellence. Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (review of technology appraisal guidance 90). (Technology appraisal 210.) 2010. www.nice.org.uk/TA210. National Institute for Health and Care Excellence. Quality and Outcomes Framework: NICE menu of indicators. www.nice.org.uk/aboutnice/qof/indicators.jsp.
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BMJ 2013;347:f6544 doi: 10.1136/bmj.f6544 (Published 13 November 2013)
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PRACTICE
Figure
Antiplatelet therapy in people who have had an MI and who otherwise need anticoagulation (such as people who have atrial fibrillation or a mechanical heart valve replacement)
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Page 1 of 5
Practice
PRACTICE GUIDELINES
Secondary prevention for patients after a myocardial infarction: summary of updated NICE guidance 1
1
Katie Jones project manager , Leanne Saxon research fellow , William Cunningham retired general 2 3 practitioner , Phil Adams emeritus consultant cardiologist , on behalf of the Guideline Development Group Royal College of Physicians, National Clinical Guideline Centre, London NW1 4LE, UK; 2Hadrian Primary Care Alliance, Corbridge, UK; 3Newcastle Hospitals NHS Foundation Trust, Newcastle, UK 1
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
Acute management of people who have had a myocardial infarction (MI) has changed dramatically, with more people surviving. More effective treatment, including percutaneous coronary intervention, raises questions about the relevance of current recommendations on secondary prevention. Concerns have arisen about the need for the antiplatelet regimens mandated by coronary stent insertion in people who have an independent need for warfarin. New data are also available about how to increase attendance for cardiac rehabilitation programmes, about existing drug treatments and lifestyle advice, and new antithrombotic agents. The impact of shorter stays in hospital on the changes in acute management have emphasised the importance of primary care in secondary prevention. General practitioners and nurses are now responsible for most of this activity, specifically the promotion of cardiac rehabilitation programmes and the prescription and monitoring of ongoing drug therapy. This also requires effective communication between hospital and primary care, ensuring that clear management plans are relayed in a timely way.
These considerations have led to a revision of the 2007 guideline on secondary prevention after an MI.1 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE).2
Recommendations
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good
practice. Evidence levels for the recommendations are given in italic in square brackets.
Cardiac rehabilitation Cardiac rehabilitation should be offered to all people who have had an MI and should be provided in different settings (such as in the person’s home) and at different times of the day to ensure that people can attend and complete the programme. • Offer cardiac rehabilitation programmes designed to motivate people to attend and complete the programme. Explain the benefits of attending (which include reducing the risk of death and of having another MI, and improving quality of life). (New recommendation.) [Based upon high quality qualitative evidence and low to moderate quality randomised studies and the experience and opinion of the Guideline Development Group (GDG)] • Begin cardiac rehabilitation as soon as possible after admission and before discharge from hospital. Invite the person to a cardiac rehabilitation session starting within 10 days of their discharge from hospital. (New recommendation.) [Based upon low to high quality randomised studies, an original economic model directly applicable with potentially serious limitations, and the experience and opinion of the GDG]
Lifestyle changes after an MI Lifestyle changes after an MI should focus on smoking cessation, dietary interventions, weight management, moderation of alcohol consumption, and regular physical activity. • Advise all people who smoke to stop and offer assistance from a smoking cessation service in line with NICE public health guidance on brief interventions and referral for smoking cessation (PH1).3
Correspondence to: K Jones [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f6544 doi: 10.1136/bmj.f6544 (Published 13 November 2013)
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PRACTICE
• 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).
• After an MI, offer all patients who are overweight or obese advice and support to achieve and maintain a healthy weight in line with NICE clinical guideline on obesity (CG43).4
• Advise people who drink alcohol to keep weekly 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 (more than 3 alcoholic drinks in 1-2 hours).
• 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, stepwise manner, with the aim of increasing their exercise capacity. They should start at a level that is comfortable and increase the duration and intensity of activity as they gain fitness. • Do not recommend routinely eating oily fish for the sole purpose of preventing another MI. If people after MI choose to consume oily fish, healthcare professionals should be aware that there is no evidence of harm, and fish may form part of a Mediterranean-style diet. (New recommendation.) [Based upon low to moderate quality randomised studies and the experience and opinion of the GDG] • Do not offer or advise people to use the following to prevent another MI: - Omega 3 fatty acid capsules - Omega 3 fatty acid supplemented foods. If people choose to take omega 3 fatty acids (as capsules or supplemented foods), healthcare professionals should be aware that there is no evidence of harm. (New recommendation.) [Based upon low to moderate quality randomised studies and the experience and opinion of the GDG]
Drug therapy Box 1 summarises the drug treatment recommended to reduce the risk of another MI, with detail in the following text. For details on contraindications, please refer to the British National Formulary.5
Angiotensin converting enzyme (ACE) inhibitors • Offer people who present acutely an ACE inhibitor and continue it indefinitely.
• Titrate the dose upwards at short intervals in hospital (such as every 12-24 hours) and ensure complete titration within four to six weeks after discharge. (Updated recommendation.) [Based upon very low to moderate quality randomised evidence and the experience and opinion of the GDG] • Offer people after an MI who are intolerant to ACE inhibitors an angiotensin receptor blocker instead of an ACE inhibitor. (New recommendation.) [Based upon the experience and opinion of the GDG] • For patients who have had an acute MI and who have symptoms or signs of heart failure and left ventricular For personal use only: See rights and reprints http://www.bmj.com/permissions
systolic dysfunction, start treatment with an aldosterone antagonist licensed for post-MI treatment within 3-14 days of the MI, preferably after starting ACE inhibitor therapy. Box 2 includes recommendations on monitoring for people receiving ACE inhibitors and aldosterone antagonists
Antiplatelet therapy • Offer low dose aspirin to all people after an MI and continue it indefinitely. (Updated recommendation.) [Based upon low to very low quality randomised evidence and the experience and opinion of the GDG] • Where aspirin is contraindicated or not tolerated (for example, because of hypersensitivity or a history of dyspepsia): - For people with aspirin hypersensitivity, consider clopidogrel monotherapy as an alternative - For people with a history of dyspepsia, consider treatment of their dyspepsia in line with NICE clinical guideline on dyspepsia (CG17, currently being updated)10 - For people with a history of aspirin induced ulcer bleeding whose ulcers have healed and who are negative for Helicobacter pylori, consider treatment in line with NICE guideline on dyspepsia (CG17)10 • Offer clopidogrel in combination with aspirin as a treatment option for up to 12 months to people who have had - ST segment elevation MI (characterised by ST elevation or new left bundle branch block on electrocardiogram) and received a bare metal or drug eluting stent - Non-ST segment elevation MI (characterised by an absence of persistent ST elevation on electrocardiogram) regardless of treatment. (New recommendation.) [Based upon NICE technology appraisal 80,11 moderate to low quality randomised evidence, and the experience and opinion of the GDG] • Ticagrelor in combination with low dose aspirin for up to 12 months is recommended as another treatment option to adults with acute coronary syndromes: - Those with ST segment elevation MI whom cardiologists intend to treat with primary percutaneous coronary intervention - Those with Non-ST segment elevation MI. (New recommendation.) [Based upon NICE technology appraisal 23612 and the experience and opinion of the GDG] • Offer clopidogrel in combination with low dose aspirin for at least one month and consider continuing for up to 12 months for people who have had an ST segment elevation MI for which they received medical management, with or without reperfusion treatment using a fibrinolytic agent. (New recommendation.) [Based upon high to very low quality evidence and the experience and opinion of the GDG] • Offer clopidogrel instead of aspirin to people who have had an MI more than 12 months ago if they also have other clinical vascular disease or are aspirin intolerant, in line with NICE technology appraisal of clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (TA210). (Updated recommendation.) [Based upon NICE technology appraisal 21013 and the experience and opinion of the GDG] Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f6544 doi: 10.1136/bmj.f6544 (Published 13 November 2013)
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PRACTICE
Box 1: Drug therapy for people who have had an MI • Angiotensin converting enzyme (ACE) inhibitor • Dual antiplatelet therapy (low dose aspirin plus a second antiplatelet agent) • β blocker • Statin Refer to relevant NICE guidance on use of prasugrel for treating acute coronary syndromes (technology appraisal 182),6 on the acute management of MI with ST segment elevation and non-ST segment elevation (clinical guidelines 167 and 94),7 8 and on the use of statins (clinical guideline 67, to be updated in 2014)9
Box 2: Drug monitoring for people who have had an MI ACE inhibitors • Monitor renal function (serum creatinine concentration), serum electrolytes, and blood pressure before starting an ACE inhibitor • Monitor thereafter until treated with a stable dose, and then at least annually • Consider more frequent monitoring in people at risk of deteriorating renal function, of developing hyperkalaemia, or during an intercurrent illness, particularly when associated with a risk of dehydration
Aldosterone antagonists • Check renal function and serum electrolytes • Consider seeking specialist advice if concerned about an increased risk of developing serious hyperkalaemia (such as patients with reduced renal function or if baseline serum potassium is >5 mmol/L) • Routinely measure blood biochemistry after 48 hours, at 1 and 4 weeks, and at 3 months, and 3 monthly thereafter; and 1 week after a titration upwards in the dose
The figure⇓ outlines antiplatelet treatment recommendations for people who otherwise need anticoagulation.
β blockers • Offer a β blocker as soon as possible after an MI, when the person is haemodynamically stable. (New recommendation.) [Based upon very low to moderate quality evidence and the experience and opinion of the GDG] • Make arrangements (for example, in the discharge summary) to recommend that titration of β blockers occurs up to the maximum tolerated or target dose. (New recommendation.) [Based upon the experience and opinion of the GDG] • Continue a β blocker for at least 12 months after an MI in people without left ventricular systolic dysfunction or heart failure. (New recommendation.) [Based upon very low to moderate quality evidence and the experience and opinion of the GDG] • Continue a β blocker indefinitely in people with left ventricular systolic dysfunction. (New recommendation.) [Based upon very low to moderate quality evidence and the experience and opinion of the GDG]
Communication of diagnosis and advice • Offer a copy of the discharge summary for all people who have had an 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.
(Updated recommendation.) [Based upon the experience and opinion of the GDG and the content of other recommendations in the guideline]
Overcoming barriers Implementation of these recommendations will be challenging throughout the healthcare system. Cardiac rehabilitation services need to ensure that people who have had an MI are offered their first cardiac rehabilitation session within 10 days of hospital discharge, and make arrangements to offer further appointments to non-attenders. Hospital services need to review drug policies—particularly around antiplatelet agents, prescribing for people with an independent indication for anticoagulation, and drug titration. Clear and timely communication of management plans, optimising use of discharge summaries, is critical. Primary care teams are largely responsible for the secondary prevention of MI. General practices need to use their in-house systems to identify those who have had a recent MI based on hospital discharge letters and to follow up these patients at an early stage, reviewing management plans, attendance at cardiac rehabilitation, and drug prescription, and providing appropriate lifestyle advice. The members of the Guideline Development Group were Philip Adams (chair), Ivan Bennet, Kathryn Carver, William Cunningham, Jennifer Jones, Caroline Levie, Joseph Mills, Jerry Murphy, Sanjay Ramdany, Linda Speck, John Walsh, Maria Wray, Paul Wright, and Robert Wright. Jo Farrington was appointed as a co-opted member of the GDG. The technical team at the National Clinical Guideline Centre included Joanna Ashe, Elizabeth Avital, Daria Bilan, Elisabetta Fenu, Jennifer Hill, Katie Jones, Kate Lovibond, Julie Neilson, Juan Carlos Rejon, and Leanne Saxon. Contributors: KJ wrote the first draft. All authors reviewed the draft, were involved in writing further drafts, and reviewed and approved the final version for publication. PA acts as guarantor. Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; not externally peer reviewed.
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BMJ 2013;347:f6544 doi: 10.1136/bmj.f6544 (Published 13 November 2013)
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Further information on the guidance Update of the existing guideline was necessary as a result of changes in acute management after an MI, potentially affecting the efficacy of existing secondary prevention treatments. The evidence base in people who have undergone modern acute treatments such as primary percutaneous coronary intervention was limited. However, the guideline reviews the available evidence and attempted to interpret it in light of the changes in acute management. Several new recommendations aim to promote uptake of and adherence to cardiac rehabilitation programmes. Lifestyle recommendations focusing on diet, smoking cessation, exercise, alcohol consumption, and weight loss remain unchanged, but the consumption of omega 3 acid ethyl esters and oily fish is no longer recommended for the sole purpose of preventing another MI, as recent studies in populations receiving modern secondary prevention strategies after an MI failed to show a benefit. The guideline also provides new and updated recommendations on antiplatelet agents for people who have had an ST segment elevation or non-ST segment elevation MI in light of newly available drugs (prasugrel and ticagrelor) and includes recommendations on the duration of treatment. For people who have a pre-existing indication for anticoagulation, the guideline recommends treatment with warfarin plus either aspirin or clopidogrel (depending on the treatment given acutely), based on new evidence (see box 1). Recommendations on other drug treatments—including ACE inhibitors, β blockers, calcium channel blockers, potassium channel antagonists, and aldosterone antagonists—after an MI remain largely unchanged. However, new recommendations on the titration of ACE inhibitors and β blockers have been included to reflect reductions in duration of hospital stay with the increased use of interventional therapy and percutaneous coronary intervention for people with MI. Hospital and general practice services may wish to audit the improvement of drug titrations and prescribing of antiplatelet agents. The Quality and Outcomes Framework (an incentive scheme for UK general practices rewarding high quality care for patients) for 2013-14 will monitor the prescribing of recommended drugs.14 As the NICE guideline has also updated recommendations on what to include in discharge summaries, general practices should monitor the timeliness and quality of discharge summaries and provide feedback to secondary care.
Methods The Guideline Development Group followed the standard NICE methods in the development of this guideline (www.nice.org.uk/aboutnice/ howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp). The GDG comprised an emeritus consultant cardiologist, a general practitioner with a special interest in cardiology, a general practitioner, a cardiac rehabilitation lead nurse, a physiotherapist, a cardiac rehabilitation practitioner with a special interest in cardiology, a professor of cardiovascular medicine, a community matron with a special interest in coronary heart disease, a consultant clinical health psychologist, a cardiac pharmacist, a consultant cardiologist, and two patient members. The GDG also co-opted a dietitian. The group developed clinical questions; collected and appraised clinical evidence; and evaluated the cost effectiveness of proposed interventions through systematic literature review and original economic modelling. The draft guideline went through a rigorous reviewing process, in which stakeholder organisations were invited to comment. The GDG took all comments into consideration when producing the final version of the guideline. Quality ratings of the evidence were based on GRADE methodology (www.gradeworkinggroup.org). These relate to the quality of the available evidence for assessed outcomes rather than the quality of the clinical study. Further updates of the guideline will be produced as part of NICE’s guideline development programme.
Future research The GDG identified the following areas for further research: • What characteristics are associated with uptake and adherence to cardiac rehabilitation after an acute MI when rehabilitation is started early? • In patients who are not revascularised after an MI, does clopidogrel plus placebo have a better outcome than clopidogrel plus aspirin? • In people who have had an MI, have an indication for oral anticoagulation, and are treated medically by primary percutaneous intervention or by coronary artery bypass surgery, is treatment with an oral anticoagulant, aspirin, and clopidogrel preferable to treatment with an oral anticoagulant and clopidogrel? • In patients who have had an ST segment elevation MI, who undergo primary percutaneous coronary intervention with a bare metal stent, and who have had four weeks’ treatment with aspirin and clopidogrel, is there an additional benefit to continuing clopidogrel for a further 11 months? • In people who have had an MI and who have normal left ventricular systolic function, does continuing β blocker treatment beyond one year improve outcomes? 1 2 3 4 5 6 7
National Institute for Health and Care Excellence. Secondary prevention in primary and secondary care for patients following a myocardial infarction. (Clinical guideline 48.) 2007. www.nice.org.uk/CG48. National Institute for Health and Care Excellence. Secondary prevention in primary and secondary care for patients following a myocardial infarction. (Clinical guideline 172.) 2013. www.nice.org.uk/CG172. National Institute for Health and Care Excellence. Brief interventions and referral for smoking cessation in primary care and other settings. (Public health guidance 1.) 2006. www.nice.org.uk/PH1. National Institute for Health and Care Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. (Clinical guideline 43.) 2006. www.nice.org.uk/CG43. British Medical Association, Royal Pharmaceutical Society of Great Britain. British national formulary . BMA, RPS, 2013. (No 66.) National Institute for Health and Care Excellence. Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention. (Technology appraisal 182.) 2009. www.nice.org.uk/TA182. National Institute for Health and Care Excellence. Myocardial infarction with ST-segment elevation: the acute management of myocardial infarction with ST-segment elevation. (Clinical guideline 167.) 2013. www.nice.org.uk/CG167.
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National Institute for Health and Care Excellence. Unstable angina and NSTEMI: the early management of unstable angina and non-ST-segment-elevation myocardial infarction. (Clinical guideline 94.) 2010. www.nice.org.uk/CG94. National Institute for Health and Care Excellence. Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. (Clinical guideline 67.) 2008. www.nice.org.uk/CG67. National Institute for Health and Care Excellence. Dyspepsia: Managing dyspepsia in adults in primary care. (Clinical guideline 17.) 2004. www.nice.org.uk/CG17. National Institute for Health and Care Excellence. Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome. (Technology appraisal 80.) 2004. www.nice.org.uk/TA80. National Institute for Health and Care Excellence. Ticagrelor for the treatment of acute coronary syndromes (ACS). (Technology appraisal 236.) 2011. www.nice.org.uk/TA236. National Insitute for Health and Care Excellence. Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (review of technology appraisal guidance 90). (Technology appraisal 210.) 2010. www.nice.org.uk/TA210. National Institute for Health and Care Excellence. Quality and Outcomes Framework: NICE menu of indicators. www.nice.org.uk/aboutnice/qof/indicators.jsp.
Cite this as: BMJ 2013;347:f6544 © BMJ Publishing Group Ltd 2013
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BMJ 2013;347:f6544 doi: 10.1136/bmj.f6544 (Published 13 November 2013)
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Figure
Antiplatelet therapy in people who have had an MI and who otherwise need anticoagulation (such as people who have atrial fibrillation or a mechanical heart valve replacement)
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