Guidelines on secondary prevention after an MI

Dr Rubin Minhas reviews NICE advice on secondary prevention after an MI.

Multifactorial risk factor intervention and multidisciplinary care are central to optimising recovery and reducing risk of further coronary events. This new NICE guideline was written not only by a multidisciplinary team of cardiologists, GPs, nurses and pharmacists but also by patients, who were able to provide a unique perspective.

The guideline development group used a systematic and transparent approach to developing the recommendations based on the AGREE collaboration framework.

Following on from the NSF-CHD, this guideline quite fittingly begins with a foreword from Professor Roger Boyle, the national clinical director for heart disease. He identifies the role of this guideline to promote the 'pillars that support recovery'.

Detailed advice
Smoking, diet, physical activity and obesity are key modifiable risk factors that have been recognised as priorities for implementation in this guideline.

Discussion of modifiable risk factors are often neglected in favour of drug treatments, although lifestyle factors have a significant role in aiding a full recovery.

The evidence base for addressing diet, smoking and physical activity is comprehensive, and practical advice and recommendations have been provided. This is illustrated by the dietary advice section, which includes a description of the Mediterranean diet and advice on vitamin and dietary supplementation that discriminates between those supplements that are potentially harmful and those of no proven benefit.

Advice is also given regarding the type and amount of oily fish that should be consumed. Patients are advised to eat 7g of omega-3 fatty acids, through two to four portions of fish, per week.

An accompanying table lists the quantities of beneficial fish oils found in servings of various types of fish.

Lifestyle guidance in brief
Patients should be advised to be physically active to the point of slight breathlessness for 20-30 minutes a day.

A Mediterranean-style diet is recommended and alcohol consumption should be kept within safe limits (no more than 21 units per week for men and 14 units for women).

The need to tailor lifestyle advice to individuals and the family is discussed in detail.

Treatment updates
The classic quartet of drugs (aspirin, beta-blockers, ACE inhibitors and statins) are recommended but updated advice is given for more recent agents such as clopidogrel, eplerenone and fish oil supplements for those unable to maintain an adequate dietary intake.

Advice regarding clopidogrel is provided for both patients who have had an STEMI and those with an NSTEMI.

Eplerenone has been added to the regimen of medication for post-MI patients if there is evidence of heart failure or left ventricular dysfunction. Implicit in this part of the guidance is the routine requirement for echocardiography.

For patients who have had an MI within three months and are not achieving a sufficient dietary intake of fish oils, 1g daily of licensed omega-3-acid ethyl esters should be considered for up to four years.

Both clinician and patient experience has led to further thought being given to prescribing in diverse clinical situations where polypharmacy or co-morbidities may exist.

Examples of these are the co-administration of aspirin and warfarin, and the use of beta-blockers in low risk groups such as those patients presenting with evidence of an 'old MI'.

The lack of benefit for ACE inhibitors in low risk groups was also considered, but the evidence was deemed insufficient to permit a recommendation.

Rehabilitation
All patients should be offered a cardiological assessment for consideration of revascularisation.

Detailed advice is provided regarding cardiac rehabilitation programmes and the importance of an exercise component as a key driver of benefit is emphasised.

The guideline development group recognised the value that rehabilitation programmes may have in providing a comprehensive approach to risk factor reduction at an important point in the patient journey.

Access to care
The guideline makes recommendations to those responsible for commissioning cardiac services to ensure barriers to access to care are addressed.

Factors such low socio-economic status have been identified and adjustments to cardiac rehabilitation programmes have been recommended.

Overview
This new post-MI guideline is a practical guideline: the recommendations recognise the difficulties of caring for patients with multiple co-morbidities, and additional recommendations are made for managing depression, impotence, sports or other activities.

It offers an integrated resource for all those who deliver cardiac care and seek to deliver evidence-based care. Patient versions and short summaries have also been produced and are available at the NICE website www.nice.org.uk.

  • Dr Minhas is a GP with a special interest in cardiology and CHD clinical lead for Medway PCT. He writes on behalf of the NICE Guideline Development Group for Secondary Prevention following MI
  • This article was originally published in MIMS Cardiovascular. To register to receive this journal see www.hayreg.co.uk/specials/.

KEY POINTS

  • Multifactorial risk factor intervention and multidisciplinary care are central to optimising patients' recovery after an MI.
  • The latest NICE guideline incorporates the views of patients as well as a multidisciplinary team.
  • It provides detailed, practical guidance on diet, exercise and alcohol consumption, while acknowledging the need to tailor this advice to patients and families.
  • Updated advice is given for recent treatments such as clopidogrel, epleronone and fish oil supplements, with consideration for the impact of polypharmacy and co-morbidities.
  • The value of cardiac rehabilitation programmes is highlighted and detailed advice given.
  • Recommendations are made to people commissioning cardiac services to help overcome barriers, such as poor access and deprivation.
  • The guideline offers an integrated resource for everyone involved in cardiac care. Patient and short versions are also available.

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