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Myocardial infarction: secondary prevention

About

What is covered

This interactive flowchart covers the secondary prevention of MI in primary and secondary care.
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 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:
  • STEMI, which is generally caused by complete and persisting blockage of the artery
  • 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 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.

Updates

Updates to this interactive flowchart

13 December 2016 Ticagrelor for preventing atherothrombotic events after myocardial infarction (NICE technology appraisal guidance 420) added to antiplatelets.
3 September 2015 Secondary prevention after a myocardial infarction quality standard added to this pathway.
24 March 2015 Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome (NICE technology appraisal guidance 335) added to antiplatelets and anticoagulants.
22 July 2014 Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes (review of technology appraisal guidance 182) (NICE technology appraisal guidance 317) added to antiplatelets and anticoagulants.
24 June 2014 Implantable cardioverter defibrillators and cardiac resynchronisation therapy for arrhythmias and heart failure (review of TA95 and TA120) (NICE technology appraisal guidance 314) added to left ventricular systolic dysfunction and heart failure.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on secondary prevention of myocardial infarction in primary and secondary care in an interactive flowchart

What is covered

This interactive flowchart covers the secondary prevention of MI in primary and secondary care.
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 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:
  • STEMI, which is generally caused by complete and persisting blockage of the artery
  • 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 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.

Updates

Updates to this interactive flowchart

13 December 2016 Ticagrelor for preventing atherothrombotic events after myocardial infarction (NICE technology appraisal guidance 420) added to antiplatelets.
3 September 2015 Secondary prevention after a myocardial infarction quality standard added to this pathway.
24 March 2015 Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome (NICE technology appraisal guidance 335) added to antiplatelets and anticoagulants.
22 July 2014 Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes (review of technology appraisal guidance 182) (NICE technology appraisal guidance 317) added to antiplatelets and anticoagulants.
24 June 2014 Implantable cardioverter defibrillators and cardiac resynchronisation therapy for arrhythmias and heart failure (review of TA95 and TA120) (NICE technology appraisal guidance 314) added to left ventricular systolic dysfunction and heart failure.

Quality standards

Secondary prevention after a myocardial infarction

These quality statements are taken from the secondary prevention after a myocardial infarction quality standard. The quality standard defines clinical best practice in secondary prevention after a myocardial infarction and should be read in full.

Quality statements

Assessment of left ventricular function

This quality statement is taken from the secondary prevention after a myocardial infarction quality standard. The quality standard defines clinical best practice in secondary prevention after a myocardial infarction and should be read in full.

Quality statement

Adults admitted to hospital with a myocardial infarction (MI) have an assessment of left ventricular function before discharge.

Rationale

After an MI, some people have heart failure because of damage to heart muscle and impaired contraction of the left ventricle. This is known as left ventricular systolic dysfunction (LVSD). The effectiveness of drug treatment with angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, aldosterone antagonists and beta-blockers depends on left ventricular function. The assessment of left ventricular function after an MI informs the type, titration and duration of drug treatment and the type of cardiac rehabilitation that is appropriate. To improve the clinical effectiveness of treatment and to ensure patient safety, this assessment should be done before discharge from hospital.

Quality measures

Structure
Evidence of local arrangements to ensure that adults admitted to hospital with an MI have an assessment of left ventricular function before discharge.
Data source: Local data collection.
Process
Proportion of discharges from hospital after an MI where the patient had an assessment of left ventricular function while in hospital.
Numerator – the number in the denominator where the patient had an assessment of left ventricular function while in hospital.
Denominator – the number of discharges from hospital after an MI.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary and tertiary care services) ensure that adults admitted to hospital with an MI have an assessment of left ventricular function before discharge.
Healthcare professionals assess the left ventricular function of adults admitted to hospital with an MI before discharge.
Commissioners (clinical commissioning groups) commission services that have the capacity and expertise to assess left ventricular function before discharge in adults admitted to hospital with an MI.

What the quality statement means for patients, service users and carers

Adults who are admitted to hospital with a heart attack have a scan to see how well the blood is being pumped through their heart. This helps with decisions about the type and dose of drug treatment and the recovery programme that is appropriate for them. The scan should be done before a person leaves hospital.

Source guidance

Definitions of terms used in this quality statement

Assessment of left ventricular function
Left ventricular function can be assessed using a variety of methods, including echocardiography, cardiac magnetic resonance imaging (MRI), angiography and nuclear imaging. [Expert opinion]

Referral for cardiac rehabilitation

This quality statement is taken from the secondary prevention after a myocardial infarction quality standard. The quality standard defines clinical best practice in secondary prevention after a myocardial infarction and should be read in full.

Quality statement

Adults admitted to hospital with a myocardial infarction (MI) are referred for cardiac rehabilitation before discharge.

Rationale

Cardiac rehabilitation aims to address the underlying causes of cardiovascular disease and improve physical and mental health after a heart attack. Cardiac rehabilitation encourages a healthy lifestyle which slows the progression of heart disease. It also reduces the risk of dying prematurely, especially as a result of a heart attack or stroke. People who are referred to rehabilitation programmes before they are discharged from hospital have better rates of uptake and adherence and improved clinical outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults admitted to hospital with an MI are referred for cardiac rehabilitation before discharge.
Data source: Local data collection.
Process
Proportion of discharges from hospital after an MI where the patient was referred for cardiac rehabilitation while in hospital.
Numerator – the number in the denominator where the patient was referred for cardiac rehabilitation while in hospital.
Denominator – the number of discharges from hospital after an MI.
Data source: Local data collection.
Outcome
Uptake rates of cardiac rehabilitation programmes.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from National Audit of Cardiac Rehabilitation (NACR).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary and tertiary care services) ensure that adults admitted to hospital with an MI are referred for cardiac rehabilitation while they are in hospital.
Healthcare professionals refer adults admitted to hospital with an MI for cardiac rehabilitation while they are in hospital.
Commissioners (clinical commissioning groups) commission services that have the capacity and expertise to refer adults admitted to hospital with an MI for cardiac rehabilitation while they are in hospital.

What the quality statement means for patients, service users and carers

Adults who are admitted to hospital with a heart attack are referred to a cardiac rehabilitation programme while they are in hospital. A cardiac rehabilitation programme includes exercise sessions, information about health and lifestyle changes and how to cope with stress. This helps to slow down or stop heart disease and to reduce the risk of a heart attack or stroke in the future.

Source guidance

Definitions of terms used in this quality statement

Cardiac rehabilitation
Cardiac rehabilitation is a coordinated and structured programme designed to remove or reduce the underlying causes of cardiovascular disease. It provides the best possible physical, mental and social conditions so that people can, by their own efforts, continue to play a full part in their community. A healthier lifestyle and slowed or reversed progression of cardiovascular disease can also be achieved. [MI – secondary prevention (NICE guideline CG172): full guideline]
Cardiac rehabilitation programmes should include a range of interventions with health education, lifestyle advice, stress management and physical exercise components. [MI – secondary prevention (NICE guideline CG172): recommendations 1.1.1 and 1.1.19]

Communication with primary care

This quality statement is taken from the secondary prevention after a myocardial infarction quality standard. The quality standard defines clinical best practice in secondary prevention after a myocardial infarction and should be read in full.

Quality statement

Adults admitted to hospital with a myocardial infarction (MI) have the results of investigations and a plan for future treatment and monitoring shared with their GP.

Rationale

People with an MI have cardiac investigations in hospital – clear communication of these results to primary care in a discharge summary ensures that people receive the right treatment after they leave hospital. Other key information to be shared with the GP includes future treatment, including incomplete drug titrations, plans for further revascularisation procedures and plans for antiplatelet and anticoagulant treatment. A clear plan for monitoring blood pressure and renal function ensures that people are on the correct drug dose after they leave hospital. Finally, it is also important for GPs to know that people have been referred for cardiac rehabilitation to encourage them to attend.
Ensuring that this information is included in a discharge summary will improve clinical outcomes, patient experience and continuity of care between primary and secondary or tertiary care services. This is especially important for people who have had hospital treatment for an MI outside of their local area.

Quality measures

Structure
Evidence of local arrangements to ensure that adults admitted to hospital with an MI have the results of investigations and a plan for future treatment and monitoring shared with their GP.
Data source: Local data collection.
Process
a) Proportion of discharges from hospital after an MI where the patient had the results of investigations shared with their GP.
Numerator – the number in the denominator where the patient had the results of investigations shared with their GP.
Denominator – the number of discharges from hospital after an MI.
Data source: Local data collection.
b) Proportion of discharges from hospital after an MI where the patient had plans for future treatment and monitoring shared with their GP.
Numerator – the number in the denominator where the patient had plans for future treatment and monitoring shared with their GP.
Denominator – the number of discharges from hospital after an MI.
Data source: Local data collection.
Outcome
a) Readmission rates.
b) Rates of uptake and adherence to cardiac rehabilitation.
c) Patient experience of GP services.
Data source: National data on emergency readmissions within 30 days of discharge from hospital are available from the Health and Social Care Information Centre.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary and tertiary care services) ensure that adults discharged from hospital after an MI have the results of investigations and a plan for future treatment and monitoring shared with their GP.
Healthcare professionals include the results of investigations and a plan for future treatment and monitoring in the GP discharge summary for adults discharged from hospital after an MI.
Commissioners (clinical commissioning groups) commission services that provide GP discharge summaries for adults discharged from hospital after an MI. The GP discharge summaries should include the results of investigations and a plan for future treatment and monitoring.

What the quality statement means for patients, service users and carers

Adults who are admitted to hospital with a heart attack have a letter sent to their GP, which includes the results of any tests and a plan for treatment and monitoring in the future. This helps to make sure that people get the right treatment after they leave hospital and start a programme to improve their long-term health (cardiac rehabilitation) as soon as possible.

Source guidance

  • MI – secondary prevention (2013) NICE guideline CG172, recommendations 1.3.2, 1.3.31 (key priority for implementation) and 1.6.1 (key priority for implementation)

Definitions of terms used in this quality statement

Results of investigations
People admitted to hospital with an MI may have several investigations of cardiac function while in hospital. These may include coronary angiography and should include assessment of left ventricular function. [Expert opinion]
Plan for future treatment and monitoring
A plan for future treatment and monitoring after an MI should include details of:
  • any further revascularisation procedures
  • any drug titrations that need to be completed by the GP
  • duration of antiplatelet treatment
  • duration of any anticoagulant treatment
  • blood pressure and renal function monitoring
  • referral for cardiac rehabilitation. [Expert opinion]  

Cardiac rehabilitation – assessment appointment

This quality statement is taken from the secondary prevention after a myocardial infarction quality standard. The quality standard defines clinical best practice in secondary prevention after a myocardial infarction and should be read in full.

Quality statement

Adults referred to a cardiac rehabilitation programme after a myocardial infarction (MI) have an assessment appointment within 10 days of discharge from hospital.

Rationale

Starting cardiac rehabilitation as soon as possible after a heart attack significantly improves ongoing attendance at cardiac rehabilitation programmes. Cardiac rehabilitation improves clinical outcomes and is cost saving through a reduction in unplanned re-admissions for cardiac problems. An assessment appointment within 10 days of discharge ensures that people have contact with a member of the cardiac rehabilitation team as soon as possible. Because some people may not be able to drive or may not be ready for physical assessment within 10 days of discharge, this appointment can be an outpatient appointment, a home visit or a telephone interview.

Quality measures

Structure
Evidence of local arrangements to ensure that adults referred to a cardiac rehabilitation programme after an MI have an assessment appointment within 10 days of discharge from hospital.
Data source: Local data collection.
Process
a) Proportion of referrals to a cardiac rehabilitation programme from hospital where the patient attends an assessment appointment within 10 days of discharge after an MI.
Numerator – the number in the denominator where the patient attends an assessment appointment within 10 days of discharge.
Denominator – the number of referrals to a cardiac rehabilitation programme from hospital after admission for an MI.
Data source: Local data collection. National data on adherence to cardiac rehabilitation are available from National Audit of Cardiac Rehabilitation (NACR).
Outcome
Uptake rates of cardiac rehabilitation programmes.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from the National Audit of Cardiac Rehabilitation (NACR).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary and tertiary care services) ensure that adults referred to a cardiac rehabilitation programme after an MI can have an assessment appointment within 10 days of discharge.
Healthcare professionals ensure that adults referred to a cardiac rehabilitation programme after an MI have an assessment appointment within 10 days of discharge.
Commissioners (clinical commissioning groups) commission services that have the capacity to give adults referred to a cardiac rehabilitation programme after an MI an assessment appointment within 10 days of discharge.

What the quality statement means for patients, service users and carers

Adults referred to a cardiac rehabilitation programme after a heart attack have an appointment for an assessment within 10 days of leaving hospital. Starting cardiac rehabilitation as soon as possible encourages people to take part in the programme and makes it more likely that they will carry on.

Source guidance

Definitions of terms used in this quality statement

Assessment appointment
An assessment appointment is the first session of a cardiac rehabilitation programme. The session includes advice on lifestyle and risk factors and an assessment of the person’s cardiac function and suitability for different components of the programme. The assessment appointment can be an outpatient appointment, a home visit or a telephone interview.
Cardiac rehabilitation
Cardiac rehabilitation is defined as a coordinated and structured programme designed to remove or reduce the underlying causes of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that people can, by their own efforts, continue to play a full part in their community. A healthier lifestyle and slowed or reversed progression of cardiovascular disease can also be achieved. [MI – secondary prevention (NICE guideline CG172): full guideline]
Cardiac rehabilitation programmes should include a range of interventions with health education, lifestyle advice, stress management and physical exercise components. [MI – secondary prevention (NICE guideline CG172): recommendations 1.1.1 and 1.1.19]

Options for cardiac rehabilitation: developmental

This quality statement is taken from the secondary prevention after a myocardial infarction quality standard. The quality standard defines clinical best practice in secondary prevention after a myocardial infarction and should be read in full.

Quality statement

Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

Adults referred to a cardiac rehabilitation programme after a myocardial infarction (MI) are offered sessions during and outside working hours and the choice of undertaking the programme at home, in the community or in a hospital setting.

Rationale

Cardiac rehabilitation programmes improve clinical outcomes for people who have had an MI. Offering cardiac rehabilitation programmes at different times of day and at different venues is likely to increase both uptake and adherence and to improve patient experience. It is important that programmes are provided outside normal working hours, so that they are accessible to people who work and to those with other commitments during the day.

Quality measures

Structure
Evidence of local arrangements to provide cardiac rehabilitation programmes during and outside working hours and the choice of undertaking programmes at home, in the community or in a hospital setting.
Data source: Local data collection.
Process
Proportion of people referred to a cardiac rehabilitation programme who are offered sessions during and outside working hours and the choice of undertaking the programme at home, in the community or in a hospital setting.
Numerator – the number in the denominator offered sessions during and outside working hours and the choice of undertaking the programme at home, in the community or in a hospital setting.
Denominator – the number of people referred to a cardiac rehabilitation programme after an MI.
Outcome
a) Rates of uptake of and adherence to cardiac rehabilitation programmes.
b) Patient experience of cardiac rehabilitation programmes.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from the National Audit of Cardiac Rehabilitation (NACR).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary and tertiary care services) offer cardiac rehabilitation programmes during and outside working hours and the choice of undertaking the programme at home, in the community or in a hospital setting.
Healthcare professionals offer adults referred to cardiac rehabilitation programmes a choice of programmes during and outside working hours, and a choice of undertaking the programme at home, in the community or in a hospital setting.
Commissioners (clinical commissioning groups) commission cardiac rehabilitation services that have the capacity and expertise to provide programmes during and outside working hours and the choice of undertaking the programme at home, in the community or in a hospital setting.

What the quality statement means for patients, service users and carers

Adults referred to a cardiac rehabilitation programme can choose a programme in the daytime or outside working hours, at a hospital, in the local area or at home. Having a choice of time and place means that they are more likely to be able to take part in a programme.

Source guidance

Definitions of terms used in this quality statement

Cardiac rehabilitation
Cardiac rehabilitation is defined as a coordinated and structured programme designed to remove or reduce the underlying causes of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that people can, by their own efforts, continue to play a full part in their community. A healthier lifestyle and slowed or reversed progression of cardiovascular disease can also be achieved. [MI – secondary prevention (NICE guideline CG172): full guideline]
Cardiac rehabilitation programmes should include a range of interventions with health education, lifestyle advice, stress management and physical exercise components. [MI – secondary prevention (NICE guideline CG172): recommendations 1.1.1 and 1.1.19]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

For patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, initiate treatment with an aldosterone antagonist licensed for post-MI treatment within 3–14 days of the MI, preferably after ACE inhibitor therapy.
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.
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 monitoring and review in the NICE pathway on chronic heart failure.
The following recommendations are from NICE technology appraisal guidance on clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events.
This guidance does not apply to people who have had, or are at risk of, a stroke associated with atrial fibrillation, or who need treatment to prevent occlusive events after coronary revascularisation or carotid artery procedures.
Clopidogrel is recommended as an option to prevent occlusive vascular events:
  • for people who have had a myocardial infarction only if aspirin is contraindicated or not tolerated.
Treatment with clopidogrel to prevent occlusive vascular events should be started with the least costly licensed preparation.
People currently receiving clopidogrel either with or without aspirin outside the criteria above should have the option to continue treatment until they and their clinicians consider it appropriate to stop.
NICE has written information for the public explaining its guidance on clopidogrel and modified-release dipyridamole.
Continue a beta-blocker indefinitely in people with left ventricular systolic dysfunction.
Offer an assessment of left ventricular function to all people who have had an MI.

Statins and other lipid lowering agents

Statin therapy is recommended for adults with clinical evidence of CVD in line with the NICE pathway on cardiovascular disease prevention.

Potassium channel activators

Do not offer nicorandil to reduce cardiovascular risk in patients after an MI.

Calcium channel blockers

Do not routinely offer calcium channel blockers to reduce cardiovascular risk after an MI.
Do not offer combined treatment with an ACE inhibitor and an ARB to people after an MI, unless there are other reasons to use this combination.

Glossary

angiotensin-converting enzyme
angiotensin II receptor blocker
coronary artery bypass graft
cardiovascular disease
electrocardiogram
myocardial infarction
Myocardial Ischaemia National Audit Project
non-ST-segment elevation myocardial infarction
phosphodiesterase type 5
ST-segment elevation myocardial infarction

Paths in this pathway

Pathway created: November 2013 Last updated: May 2017

© NICE 2017

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