Levels of evidence (1-4) and grading of recommendations (A-D and GPP) are defined at the end of the "Major Recommendations" field.
Note from National Institute for Health and Clinical Excellence (NICE): The guideline updates the previous NICE guideline entitled 'Prophylaxis for patients who have experienced a myocardial infarction' 2001. The guideline has updated the previous guideline's information on drug therapy. The guideline has enlarged the information on cardiac rehabilitation and lifestyle changes provided in the previous guideline, to reflect the remit of the scope of the guideline.
Recommendations for Lifestyle
Changing Dietary Regimen Recommendations
| Patients should be advised not to take supplements containing beta carotene (Grade B), and should not be advised to take antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk (Grade A). |
| Patients should be advised to consume at least 7 g of omega-3 fatty acids per week from two to four portions of oily fish per week (see appendix H in the original guideline document for the equivalent quantity of oily fish consumption required to provide 7 g of omega-3-fatty acids per week) (Grade B). |
| For patients who have had a myocardial infarction (MI) within 3 months and who are not achieving this, consider providing at least 1 g daily of omega-3-acid ethyl esters treatment licensed for secondary prevention post MI for up to 4 years (Grade B). |
| Initiation of omega-3-acid ethyl esters supplement treatment is not routinely recommended in patients that have had an MI more than 3 months earlier (GPP). |
| Patients should be advised 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) (Grade A). |
Delivery of Dietary Advice Recommendations
| Patients should be given consistent dietary advice, tailored to their needs (GPP). |
| Patients should be offered an individual consultation to discuss diet, including their current eating habits, and advice on improving their diet (Grade B). |
| Patients should be given healthy eating advice that can be extended to the whole family (GPP). |
Alcohol Consumption Recommendations
| Patients who drink alcohol should be advised 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) (GPP). |
Regular Physical Activity Recommendations
| Patients should be advised to undertake regular physical activity sufficient to increase exercise capacity (Grade B). |
| Patients should be advised to be physically active for 20–30 minutes a day to the point of slight breathlessness. Patients who are not achieving this should be advised 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 (GPP). |
| Advice on physical activity should involve a discussion about current and past activity levels and preferences. The benefit of exercise may be enhanced by tailored advice from a suitably qualified professional (GPP). |
Smoking Cessation Recommendations
Weight Management Recommendations
Recommendations for Cardiac Rehabilitation
Comprehensive Cardiac Rehabilitation Recommendations
| All patients (regardless of their age) should be given advice about and offered a cardiac rehabilitation programme with an exercise component (Grade A). |
| 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 (GPP). |
| 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 (GPP). |
| Patients with left ventricular dysfunction who are stable can safely be offered the exercise component of cardiac rehabilitation (Grade B). |
Patient Engagement Recommendations
| Cardiac rehabilitation should be equally accessible and relevant to all patients 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 and people with mental and physical health comorbidities (GPP). |
| Healthcare professionals should take into account patients' wider health and social needs, which may involve identifying and addressing economic, welfare rights, housing or social support issues. This may be a particular issue for patients in more deprived circumstances, and rehabilitation services should assess the likely scale of these needs when planning how their services meet the needs of the local population (GPP). |
| Cardiac rehabilitation programmes should be culturally sensitive. Employing bilingual peer educators or cardiac rehabilitation assistants who reflect the diversity of the local population should be considered (GPP). |
| Cardiac rehabilitation programmes should include an exercise component designed to meet the needs of older patients or patients with significant comorbidity. Any transport problems should be addressed (GPP). |
| Healthcare professionals should ask patients whether they would prefer single-sex classes or mixed classes (GPP). |
| Healthcare professionals should establish patients' health beliefs and level of health literacy before offering appropriate lifestyle advice (GPP). |
| Healthcare professionals, including senior medical staff involved in providing care for patients after an MI, should actively promote cardiac rehabilitation (GPP). |
Reminders such as:
- Telephone calls
- Telephone calls in combination with direct contact from a healthcare professional
- Motivational letters
should be used to improve uptake of cardiac rehabilitation (Grade A).
|
Health Education and Information Needs Recommendations
| Comprehensive cardiac rehabilitation programmes should include health education and stress management components (Grade A). |
| A home based programme validated for patients who have had an MI (such as 'The Edinburgh heart manual'; see http://www.theheartmanual.com) that incorporates education, exercise and stress management components with follow-ups by a trained facilitator may be used to provide comprehensive cardiac rehabilitation (Grade A). |
| Most patients who have had an MI can return to work. Any advice should take into account the physical and psychological status of the patient, the nature of the work and the work environment (GPP). |
| Healthcare professionals should be up to date with the latest Driver and Vehicle Licensing Agency guidelines. Regular updates are published on the website (http://www.dvla.gov.uk) (GPP). |
| After an MI without complications, patients can usually travel by air within 2–3 weeks. Patients who have had a complicated MI need expert individual advice (GPP). |
| Patients who hold a pilot's licence should seek advice from the Civil Aviation Authority (GPP). |
| Most patients can return to normal activities of daily living. Any advice about the timing of this should take into account the patient's physical and psychological status, as well as the type of activity planned (GPP). |
| 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 http://www.cdc.gov/nccdphp/dnpa/physical/measuring/met.htm). Patients should also be advised how to use a perceived exertion scale to help monitor physiological demand. Patients who have had a complicated MI may need expert advice (GPP). |
| 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 (GPP). |
Psychological and Social Support Recommendations
| Stress management should be offered in the context of comprehensive cardiac rehabilitation (Grade A). |
| Complex psychological interventions such as cognitive behavioural therapy should not be offered routinely (GPP). |
| There should be provision to involve partners or carers in the cardiac rehabilitation programme if the patient wishes (GPP). |
| For recommendations on the management of patients with clinical anxiety and/or depression, refer to 'Anxiety. NICE clinical guideline 22' and 'Depression. NICE clinical guideline 23' (Grade A). |
Sexual Activity Recommendations
| Patients should be reassured 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 (Grade C). |
| Patients who have made an uncomplicated recovery after their MI can resume sexual activity when they feel comfortable to do so, usually after about 4 weeks (GPP). |
| The subject of sexual activity should be raised with patients within the context of cardiac rehabilitation and aftercare (GPP). |
| When treating erectile dysfunction, treatment with a PDE5 (phosphodiesterase type 5) inhibitor may be considered in patients who had an MI more than 6 months earlier and who are now stable (Grade A). |
| PDE5 inhibitors must be avoided in patients treated with nitrates and/or nicorandil because this can lead to dangerously low blood pressure (GPP). |
Recommendations for Drug Therapy
Overall Drug Therapy Recommendation
All patients who have had an acute MI should be offered treatment with a combination of the following drugs (Grade A):
- ACE (angiotensin-converting enzyme) inhibitor
- Aspirin
- Beta-blocker
- Statin
|
ACE Inhibitors Recommendations
| Early after presenting with an acute MI, all patients should be offered an ACE inhibitor (Grade A) |
| ACE inhibitor therapy should be initiated at the appropriate dose, and titrated upwards at short intervals (for example every 1 to 2 weeks) until the maximum tolerated or target dose is reached (GPP). |
| Assessment of left ventricular function is recommended in all patients who have had an MI (GPP). |
| After an MI, all patients with preserved left ventricular function or with left ventricular systolic dysfunction should continue treatment with an ACE inhibitor indefinitely, whether or not they have symptoms of heart failure (Grade A). |
| Routine prescription of angiotensin receptor blockers (ARBs) after an acute MI is not recommended (GPP). |
| For patients after an acute MI who have had to discontinue an ACE inhibitor because of intolerance (for example because of cough) or allergy, an ARB should be substituted (Grade A). |
| Combined treatment with an ACE inhibitor and an ARB is not recommended for routine use in patients early after an acute MI with heart failure and/or left ventricular systolic dysfunction (Grade A). |
| In patients with a proven MI in the past (more than 1 year ago) and with heart failure and left ventricular systolic dysfunction, ACE inhibitor and ARB treatment should be in line with 'Chronic heart failure. NICE clinical guideline 5' (Grade A). |
| In patients with a proven MI in the past and with left ventricular systolic dysfunction, who are asymptomatic, ACE inhibitor treatment should be offered and the dose titrated upwards, as tolerated, to the effective clinical dose for patients with heart failure and left ventricular systolic dysfunction (Grade A). |
| In patients with a proven MI in the past without heart failure and with preserved left ventricular function, ACE inhibitor treatment should be offered and the dose titrated upwards, as tolerated, to the effective clinical dose (Grade A). |
| In patients with a proven MI in the past with left ventricular systolic dysfunction, who are asymptomatic and who have had to discontinue an ACE inhibitor because of intolerance (for example because of cough) or allergy, an ARB should be substituted (Grade A). |
| Renal function, serum electrolytes and blood pressure should be measured before starting an ACE inhibitor or ARB and again within 1 or 2 weeks of starting treatment. Patients should be monitored as appropriate as the dose is titrated upwards, until the maximum tolerated or target dose is reached, and then at least annually. More frequent monitoring may be needed in patients who are at increased risk of deterioration in renal function. Patients with chronic heart failure should be monitored in line with 'Chronic heart failure. NICE clinical guideline 5' (GPP). |
Anti-Platelet Recommendations
| Aspirin should be offered to all patients after an MI, and should be continued indefinitely (Grade A). |
| Clopidogrel should not be offered as first-line monotherapy after an MI (Grade A). |
| Clopidogrel, in combination with low-dose aspirin, is recommended for use in the management of non-ST-segment-elevation acute coronary syndrome in people who are at moderate to high risk of MI or death (Grade A).
(This recommendation is from NICE technology appraisal 80 [see the NGC summary of this guideline, Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome for details], and has been incorporated into this guideline in line with NICE procedures for developing clinical guidelines)
|
People at moderate to high risk of MI or death, presenting with non-ST-segment-elevation acute coronary syndrome can be determined by clinical signs and symptoms, accompanied by one or both of the following:
- The results of clinical investigations, such as new ECG changes (other than persistent ST segment elevation) indicating ongoing myocardial ischaemia, particularly dynamic or unstable patterns
- The presence of raised blood levels of markers of cardiac cell damage such as troponin (Grade A).
(This recommendation is from NICE technology appraisal 80 Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome and has been incorporated into this guideline in line with NICE procedures for developing clinical guidelines).
|
| Treatment with clopidogrel in combination with low-dose aspirin should be continued for 12 months after the most recent acute episode of non-ST- segment-elevation acute coronary syndrome. Thereafter, standard care, including treatment with low-dose aspirin alone, is recommended unless there are other indications to continue dual antiplatelet therapy (Grade A).
(This recommendation is from NICE technology appraisal 80 Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome and has been incorporated into this guideline in line with NICE procedures for developing clinical guidelines.)
|
| After an ST-segment-elevation MI, patients treated with a combination of aspirin and clopidogrel during the first 24 hours after the MI should continue this treatment for at least 4 weeks. Thereafter, standard treatment including low-dose aspirin should be given, unless there are other indications to continue dual antiplatelet therapy (Grade A). |
| If the patient has not been treated with a combination of aspirin and clopidogrel during the acute phase of an MI, this combination should not routinely be initiated (GPP). |
| The combination of aspirin and clopidogrel is not recommended for routine use for any longer than 12 months after the acute phase of MI, unless there are other indications to continue dual anti-platelet therapy, and the combination is usually recommended for a shorter duration after an ST-elevation MI (Grade A). |
| For patients with aspirin hypersensitivity, clopidogrel monotherapy should be considered as an alternative treatment (Grade B). |
| In patients with a history of dyspepsia, treatment with a proton pump inhibitor and low-dose aspirin should be considered in line 'Dyspepsia. NICE clinical guideline No. 17' (Grade A). |
| After appropriate treatment, patients with a history of aspirin-induced ulcer bleeding whose ulcers have healed and who are negative for Helicobacter pylori should be considered for treatment with a full-dose proton pump inhibitor and low-dose aspirin. Refer to 'Dyspepsia. NICE clinical guideline No. 17' (Grade A). |
Beta-Blockers Recommendations
| Early after an acute MI, all patients without left ventricular systolic dysfunction or with left ventricular systolic dysfunction (symptomatic or asymptomatic) should be offered treatment with a beta blocker (Grade A). |
| For patients after an MI with left ventricular systolic dysfunction, who are being offered treatment with a beta blocker, clinicians may prefer to consider treatment with a beta blocker licensed for use in heart failure (Grade B). |
| Beta blockers should be continued indefinitely after an acute MI (GPP). |
| After a proven MI in the past, all patients with left ventricular systolic dysfunction should be offered treatment with a beta blocker whether or not they have symptoms, and those with heart failure plus left ventricular systolic dysfunction should be managed in line with 'Chronic heart failure. NICE clinical guideline 5 (Grade A). |
| After a proven MI in the past, patients with preserved left ventricular function who are asymptomatic should not be routinely offered treatment with a beta blocker, unless they are identified to be at increased risk of further cardiovascular disease (CVD) events, or there are other compelling indications for beta blocker treatment (GPP). |
| Beta blockers should be initiated as soon as possible when the patient is clinically stable and titrated upwards to the maximum tolerated dose (GPP). |
Vitamin K Antagonists Recommendations
| For patients who have had an MI, high-intensity warfarin (INR >3) should not be considered as an alternative to aspirin in first-line treatment (Grade A). |
| For patients who have had an MI and are unable to tolerate either aspirin or clopidogrel, treatment with moderate-intensity warfarin (INR 2–3) should be considered for up to 4 years, and possibly longer (Grade A). |
| For patients who have had an acute MI, are intolerant to clopidogrel and have a low risk of bleeding, treatment with aspirin and moderate-intensity warfarin (INR 2–3) combined should be considered (GPP). |
| For patients already being treated for another indication (mechanical valve, recurrent deep vein thrombosis, atrial fibrillation, left ventricular thrombus), warfarin should be continued. For patients treated with moderate-intensity warfarin (INR 2–3) and who are at low risk of bleeding, the addition of aspirin should be considered (Grade B). |
| The combination of warfarin and clopidogrel is not routinely recommended (GPP). |
Calcium Channel Blockers Recommendations
| Calcium channel blockers should not routinely be used to reduce cardiovascular risk after an MI (Grade A). |
| If beta-blockers are contraindicated or need to be discontinued, diltiazem or verapamil may be considered for secondary prevention in patients without pulmonary congestion or left ventricular systolic dysfunction (Grade B). (These drugs do not have UK marketing authorisation for this indication at the time of publication [March 2007] and specialist advice should be sought. Prescribers should check each drug's Summary of product characteristics for current licensed indications). |
| For patients who are stable after an MI, calcium channel blockers may be used to treat hypertension and/or angina. For patients with heart failure, amlodipine should be used, and verapamil, diltiazem and short-acting dihydropyridine agents should be avoided in line with 'Chronic heart failure. NICE clinical guideline 5' (Grade A). |
Potassium Channel Activators Recommendations
| Nicorandil is not recommended to reduce cardiovascular risk in patients after an MI (Grade A). |
Aldosterone Antagonists in Patients with Heart Failure and Left Ventricular (LV) Dysfunction Recommendations
| For patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction treatment with an aldosterone antagonist licensed for post-MI treatment should be initiated within 3–14 days of the MI preferably after ACE inhibitor therapy (Grade B). |
| Patients who have recently had an acute MI and have clinical heart failure and left ventricular systolic dysfunction but who are already being treated with an aldosterone antagonist for a concomitant condition (for example chronic heart failure) should continue with the aldosterone antagonist or an alternative, licensed for early post-MI treatment (GPP). |
| For patients who have had a proven MI in the past and heart failure due to left ventricular systolic dysfunction, treatment with an aldosterone antagonist should be in line with 'Chronic heart failure. NICE clinical guideline 5' (GPP). |
| Renal function and serum potassium should be monitored before and during treatment with an aldosterone antagonist. If hyperkalaemia is a problem the dose of the aldosterone antagonist should be halved or the drug stopped (GPP). |
Statins and Other Lipid Lowering Agents Recommendations
| Statin therapy is recommended for adults with clinical evidence of cardiovascular disease in line with the NICE technology appraisal guidance No. 94 (see the NGC summary of this guideline: Statins for the prevention of cardiovascular events).
(The NICE clinical guideline 'Cardiovascular risk assessment: the modification of blood lipids for the primary and secondary prevention of cardiovascular disease' is in development and is expected to be published in January 2008.)
|
| After an MI, all patients should be offered treatment with a statin as soon as possible (GPP). |
| The decision whether to initiate statin therapy should be made after an informed discussion between the healthcare professional and the individual about the risks and benefits of statin treatment, and taking into account additional factors such as comorbidities and life expectancy (GPP). |
| Baseline liver enzymes should be measured before initiation of a statin (GPP). |
| Patients who have raised liver enzymes should not routinely be excluded from statin therapy (GPP). |
| When the decision has been made to prescribe a statin, it is recommended that therapy should usually be initiated with a drug with a low acquisition cost (taking into account required daily dose and product price per dose) (Grade A). |
| Patients who are intolerant of statins should be considered for other lipid lowering agents (GPP). |
| Routine monitoring of creatine kinase in asymptomatic patients who are being treated with a statin after an MI is not recommended (Grade A). |
| Patients who are being treated with a statin and who develop muscle symptoms (pain, tenderness or weakness) should be advised to seek medical advice so that creatine kinase can be measured (Grade A). |
| The dose of any statin may need to be reduced or stopped if there are issues surrounding the metabolic pathway, food and/or drug interactions and/or concomitant illness (GPP). |
| Statins should be discontinued in patients who develop peripheral neuropathy that may be attributable to the statin treatment, and further advice from a specialist should be sought (Grade A). |
Coronary Revascularisation Recommendations
| All patients should be offered a cardiological assessment to consider whether coronary revascularisation is appropriate. This should take into account comorbidity (Grade A). |
Selected Patient Subgroups
Recommendations for Patients with Hypertension
| Hypertension should be treated to the currently recommended target of 140/90 mmHg or lower given in 'Hypertension. NICE clinical guideline No. 34.' Patients with relevant comorbidities, for example diabetes or renal disease, should be treated to a lower blood pressure target (Grade A). |
Recommendations for Patients With Left Ventricular Dysfunction
| Patients who have left ventricular systolic dysfunction should be considered for an implantable cardioverter defibrillator in line with the NICE technology appraisal guidance No. 95 (see the NGC summary of this guideline: Implantable cardioverter defibrillators for arrhythmias) (Grade A). |
Communication of Diagnosis and Advice Recommendations
| After an acute MI, confirmation of the diagnosis of acute MI and results of investigations, future management plans and advice on secondary prevention should be part of every discharge summary (GPP). |
| A copy of the discharge summary should be offered to the patient (GPP). |
Definitions:
Levels of Evidence
| Level of Evidence |
Type of Evidence |
| 1++ |
High-quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias |
| 1+ |
Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias |
| 1- |
Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias |
| 2++ |
High-quality systematic reviews of case–control or cohort studies
High-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
|
| 2+ |
Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal |
| 2- |
Case–control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal |
| 3 |
Non-analytical studies (for example, case reports, case series) |
| 4 |
Expert opinion, formal consensus |
Recommendation Grades
| Recommendation Grade |
Evidence |
| A |
At least one meta analysis, systematic review, or randomised controlled trial (RCT) that is rated as 1++, and is directly applicable to the target population, or
A systematic review of RCTs or a body of evidence that consists principally of studies rated as 1+, is directly applicable to the target population and demonstrates overall consistency of results, or
Evidence drawn from a National Institute for Health and Clinical Excellence (NICE) technology appraisal
|
| B |
A body of evidence that includes studies rated as 2++, is directly applicable to the target population and demonstrates overall consistency of results, or
Extrapolated evidence from studies rated as 1++ or 1+
|
| C |
A body of evidence that includes studies rated as 2+, is directly applicable to the target population and demonstrates overall consistency of results, or
Extrapolated evidence from studies rated as 2++
|
| D |
Evidence level 3 or 4, or
Extrapolated evidence from studies rated as 2+, or
Formal consensus
|
| D(GPP) |
A good practice point D(GPP) is a recommendation for best practice based on the experience of the Guideline Development Group |
