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Acute coronary syndromes: early management

About

What is covered

This NICE Pathway covers the early management of acute coronary syndromes. These include STEMI, NSTEMI and unstable angina. The guidance aims to improve survival and quality of life for people who have a heart attack or unstable angina.
It does not cover management of spontaneous coronary artery dissection.
The recommendations were developed before the COVID-19 pandemic. Acute coronary syndromes are a possible sign of acute myocardial injury in patients with COVID-19. NICE has produced a COVID-19 rapid guideline on acute myocardial injury.

Updates

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 the early management of coronary syndromes in an interactive flowchart

What is covered

This NICE Pathway covers the early management of acute coronary syndromes. These include STEMI, NSTEMI and unstable angina. The guidance aims to improve survival and quality of life for people who have a heart attack or unstable angina.
It does not cover management of spontaneous coronary artery dissection.
The recommendations were developed before the COVID-19 pandemic. Acute coronary syndromes are a possible sign of acute myocardial injury in patients with COVID-19. NICE has produced a COVID-19 rapid guideline on acute myocardial injury.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Acute coronary syndromes (2020) NICE guideline NG185
Ticagrelor for the treatment of acute coronary syndromes (2011) NICE technology appraisal guidance 236
Endoscopic saphenous vein harvest for coronary artery bypass grafting (2014) NICE interventional procedures guidance 494
Bioresorbable stent implantation for treating coronary artery disease (2014) NICE interventional procedures guidance 492
Optical coherence tomography to guide percutaneous coronary intervention (2014) NICE interventional procedures guidance 481
Percutaneous laser coronary angioplasty (2011) NICE interventional procedures guidance 378
Off-pump coronary artery bypass grafting (2011) NICE interventional procedures guidance 377
Endoaortic balloon occlusion for cardiac surgery (2008) NICE interventional procedures guidance 261
Totally endoscopic robotically assisted coronary artery bypass grafting (2005) NICE interventional procedures guidance 128
Thrombin injections for pseudoaneurysms (2004) NICE interventional procedures guidance 60
MiraQ for assessing graft flow during coronary artery bypass graft surgery (2011 updated 2018) NICE medical technologies guidance 8
SeQuent Please balloon catheter for in-stent coronary restenosis (2010) NICE medical technologies guidance 1
Acute coronary syndromes in adults (2014, updated 2020) NICE quality standard 68
Coronary revascularisation: cangrelor (2015) NICE evidence summary ESNM63
DuraGraft for preserving vascular grafts (2019) NICE medtech innovation briefing 184
VEST external stent for coronary artery bypass grafts (2017) NICE medtech innovation briefing 115
Sternal Talon for sternal closure in cardiothoracic surgery (2016) NICE medtech innovation briefing 88

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

Diagnosis of acute myocardial infarction

This quality statement is taken from the acute coronary syndromes in adults quality standard. The quality standard defines clinical best practice for acute coronary syndromes in adults and should be read in full.

Quality statement

Adults with a suspected acute coronary syndrome are assessed for acute myocardial infarction using the criteria in the universal definition of myocardial infarction.

Rationale

Acute myocardial infarction can have a poor prognosis so prompt and accurate diagnosis is important to ensure that appropriate treatment and care is offered as soon as possible. Treatment for adults with suspected acute coronary syndrome is often started before a diagnosis is confirmed. Confirming the diagnosis using the criteria in the universal definition of myocardial infarction is important to ensure that any ongoing treatment is appropriate and any inappropriate treatment is stopped.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with a suspected acute coronary syndrome are assessed for the presence of acute myocardial infarction using the criteria in the universal definition of myocardial infarction.
Data source: Local data collection.
Process
Proportion of adults with a diagnosis of acute myocardial infarction who had their diagnosis made using the criteria in the universal definition of myocardial infarction.
Numerator – the number in the denominator who had their diagnosis made using the criteria in the universal definition of myocardial infarction.
Denominator – the number of adults with a diagnosis of acute myocardial infarction.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (cardiac service providers) ensure that adults with a suspected acute coronary syndrome are assessed for the presence of acute myocardial infarction using the criteria in the universal definition of myocardial infarction.
Healthcare professionals ensure that they are aware of the universal definition of myocardial infarction and assess adults with a suspected acute coronary syndrome for the presence of acute myocardial infarction using the criteria in the universal definition.
Commissioners (clinical commissioning groups) ensure that they commission services with staff with expertise in using the criteria in the universal definition of myocardial infarction to diagnose acute myocardial infarction in adults with a suspected acute coronary syndrome.
Adults with severe pain in the chest and/or in other areas (for example, the arms, back or jaw) that might be a heart attack (a suspected acute coronary syndrome) are only given a diagnosis of heart attack if their signs and symptoms meet an agreed definition.

Source guidance

Definitions of terms used in this quality statement

Universal definition of myocardial infarction
A rise in cardiac biomarkers (preferably cardiac troponin) with at least 1 value above the 99th percentile of the upper reference limit and/or a fall in cardiac biomarkers, together with at least 1 of the following:
  • symptoms of ischaemia
  • new or presumed new significant ST-segment-T wave changes or new left bundle branch block
  • pathological Q wave changes in the ECG
  • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
  • identification of an intracoronary thrombus by angiography.

Equality and diversity considerations

Symptoms of acute coronary syndromes should be assessed in the same way in men and women and among people from different ethnic groups.

Risk assessment for adults with NSTEMI or unstable angina

This quality statement is taken from the acute coronary syndromes in adults quality standard. The quality standard defines clinical best practice for acute coronary syndromes in adults and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.

Rationale

Assessing and categorising risk of future adverse cardiovascular events by formal risk assessment (for example, using the GRACE scoring system) in people who have been diagnosed with NSTEMI or unstable angina is important for determining early management strategies. It also allows the benefits of treatment to be balanced against the risks of treatment related adverse events. Failure to categorise future risk can lead to people being given inappropriate treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.
Data source: Local data collection.
Process
Proportion of presentations for NSTEMI or unstable angina that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.
Numerator – the number in the denominator that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.
Denominator – the number of presentations because of NSTEMI or unstable angina.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina to be assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality. Providers should also raise awareness among healthcare professionals of the importance of risk assessment in guiding clinical management.
Healthcare professionals ensure that they assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using an established risk scoring system that predicts 6-month mortality to guide clinical management.
Commissioners (clinical commissioning groups) ensure that they commission services with staff with the expertise to assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using established risk scoring systems that predict 6-month mortality to guide clinical management.
Adults with heart conditions called NSTEMI and unstable angina have their risk of another heart attack estimated to guide their treatment.

Source guidance

Acute coronary syndromes. NICE guideline NG185 (2020), recommendations 1.2.7 and 1.2.10

Definitions of terms used in this quality statement

Assessment for risk of future adverse cardiovascular events
Individual risk of future adverse cardiovascular events should be formally assessed using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).
The formal risk assessment should include:
  • a full clinical history (including age, previous myocardial infarction and previous percutaneous coronary intervention or coronary artery bypass grafting)
  • a physical examination (including measurement of blood pressure and heart rate)
  • resting 12-lead ECG (looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia)
  • blood tests (such as troponin I or T, creatinine, glucose and haemoglobin).
[NICE’s guideline on acute coronary syndromes, recommendations 1.2.7 and 1.2.8]
Categories for risk of future adverse cardiovascular events
Table 1 Categories for the risk of future adverse cardiovascular events using 6-month mortality
Predicted 6-month mortality
Risk of future adverse cardiovascular events
1.5% or below
Lowest
>1.5% to 3.0%
Low
>3.0% to 6.0%
Intermediate
>6.0% to 9.0%
High
Over 9.0%
Highest

Coronary angiography and PCI within 72 hours for NSTEMI or unstable angina

This quality statement is taken from the acute coronary syndromes in adults quality standard. The quality standard defines clinical best practice for acute coronary syndromes in adults and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events who are having coronary angiography (with follow-on percutaneous coronary intervention [PCI] if indicated), have it within 72 hours of first admission to hospital.

Rationale

In people with an intermediate or higher risk of future adverse cardiovascular events, coronary angiography to define the extent and severity of coronary disease, done within 72 hours of admission to hospital, offers advantages over an initial conservative strategy, provided there are no contraindications to angiography (such as active bleeding or comorbidity). Services should provide coronary angiography (with follow-on PCI if indicated) as soon as it offers net clinical benefits; within 72 hours and sooner if possible.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events who are having coronary angiography (with follow-on PCI if indicated), have it within 72 hours of first admission to hospital.
Data source: Local data collection.
Process
a) Proportion of adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events who receive coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Numerator – the number of people in the denominator receiving coronary angiography (with follow-on PCI if indicated) within 72 hours of admission to hospital.
Denominator – the number of adults with NSTEMI or unstable angina with an intermediate or higher risk of future adverse cardiovascular events having coronary angiography (with follow-on PCI if indicated).
Data source: Local data collection.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events, who are having coronary angiography (with follow-on PCI if indicated) to have it within 72 hours of first admission to hospital.
Healthcare professionals ensure that adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events, who are having coronary angiography (with follow-on PCI if indicated), have it within 72 hours of first admission to hospital.
Commissioners (clinical commissioning groups) ensure that they commission services with the capacity and expertise to ensure that adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events who are having coronary angiography (with follow-on PCI if indicated), have it within 72 hours of first admission to hospital.
Adults with heart conditions called NSTEMI and unstable angina and a medium or higher risk of another heart attack who are having a test called coronary angiography (and treatment to improve blood flow to the heart if needed), have this within 72 hours of first being admitted to hospital.

Source guidance

Acute coronary syndromes. NICE guideline NG185 (2020), recommendation 1.2.13

Definitions of terms used in this quality statement

Intermediate or higher risk of future adverse cardiovascular events
A predicted 6-month mortality above 3.0%. [NICE's guideline on acute coronary syndromes, recommendation 1.2.13]

Coronary angiography and PCI for adults with NSTEMI or unstable angina who are clinically unstable

This quality statement is taken from the acute coronary syndromes in adults quality standard. The quality standard defines clinical best practice for acute coronary syndromes in adults and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina who are clinically unstable have coronary angiography (with follow-on percutaneous coronary intervention [PCI] if indicated) as soon as possible, but within 24 hours of becoming clinically unstable.

Rationale

Coronary angiography is important to define the extent and severity of coronary disease. The benefits of an early invasive strategy appear to be greatest in people at higher risk of future adverse cardiovascular events. In people with NSTEMI or unstable angina who are clinically unstable, coronary angiography (with follow-on PCI if indicated) should be done as soon as possible so that appropriate treatment can be given. It may reduce lengthy hospital stays and prevent further cardiovascular events in both the short and long term. The timing of coronary angiography will be different for each person, but should be within 24 hours of becoming clinically unstable.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina who are clinically unstable have coronary angiography (with follow-on PCI if indicated) as soon as possible, but within 24 hours of becoming clinically unstable.
Data source: Local data collection.
Process
a) Length of time taken for adults with NSTEMI or unstable angina who are clinically unstable (on admission or during their hospital stay) to receive coronary angiography (with follow-on PCI if indicated).
Local areas should collaborate with healthcare professionals to determine if the timeframe was appropriate for the patient.
Data source: Local data collection.
b) Proportion of adults with NSTEMI or unstable angina who are clinically unstable who receive coronary angiography (with follow-on PCI if indicated) within 24 hours of becoming clinically unstable.
Numerator – the number in the denominator receiving coronary angiography (with follow-on PCI if indicated) within 24 hours of becoming clinically unstable.
Denominator – the number of adults with NSTEMI or unstable angina who are clinically unstable.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care and cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina who are clinically unstable to be offered coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.
Healthcare professionals ensure that they offer adults with NSTEMI or unstable angina who are clinically unstable, coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.
Commissioners (clinical commissioning groups) ensure that they commission services with the capacity and expertise for adults with NSTEMI or unstable angina who are clinically unstable to be offered coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.
Adults with heart conditions called NSTEMI and unstable angina and whose condition is unstable are offered a test called coronary angiography and treatment to improve blood flow to the heart if needed, as soon as possible but within 24 hours of their condition becoming unstable.

Source guidance

Definitions of terms used in this quality statement

Clinically unstable
People who are clinically unstable are defined as those with:
  • ongoing or recurring pain despite treatment
  • haemodynamic instability (low blood pressure, shock)
  • dynamic ECG changes
  • left ventricular failure.
[Expert opinion]
As soon as possible
Local areas should collaborate with healthcare professionals to determine the appropriate timeframes for patients. [Expert opinion]

Level of consciousness and eligibility for coronary angiography and primary PCI

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults who are unconscious after cardiac arrest caused by suspected acute ST segment elevation myocardial infarction (STEMI) are not excluded from having coronary angiography (with follow–on primary percutaneous coronary intervention [PCI] if indicated).

Rationale

People who remain unconscious after cardiac arrest should not be treated differently from people who are conscious. They should be able to have the same treatments within the same timescales and should be admitted to centres capable of undertaking primary PCI. Carrying out immediate primary PCI, if successful, could stabilise the person’s heart and may reduce the risk of further complications.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography (with follow–on primary PCI if indicated) because they are unconscious.
Data source: Local data collection.
Process
Proportion of adults who were unconscious after cardiac arrest caused by suspected acute STEMI who receive coronary angiography (with follow-on primary PCI if indicated).
Numerator – the number in the denominator receiving coronary angiography (with follow-on primary PCI if indicated).
Denominator – the number of adults who were unconscious after cardiac arrest caused by suspected acute STEMI.
Data source: Local data collection.

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

Service providers (ambulance services and cardiac service providers) ensure that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography (with follow–on primary PCI if indicated). Providers should also raise awareness among healthcare professionals of the importance of not using level of consciousness to exclude adults from having coronary angiography (with follow–on primary PCI if indicated).
Healthcare professionals ensure that they do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to exclude adults from having coronary angiography (with follow–on primary PCI if indicated).
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that can carry out coronary angiography (with follow–on primary PCI if indicated) in adults who are unconscious after cardiac arrest caused by suspected acute STEMI.

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

Adults who are unconscious after a type of heart attack called STEMI can have a test called coronary angiography, and treatment to improve blood flow to the heart if needed, even though they are unconscious.

Source guidance

Primary PCI for acute STEMI

This quality statement is taken from the acute coronary syndromes in adults quality standard. The quality standard defines clinical best practice for acute coronary syndromes in adults and should be read in full.

Quality statement

Adults with acute ST-segment-elevation myocardial infarction (STEMI) who present within 12 hours of onset of symptoms have primary percutaneous coronary intervention (PCI), as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of the time when fibrinolysis could have been given.

Rationale

Primary PCI is a form of reperfusion therapy which should be done as soon as possible. This is because heart muscle starts to be lost once a coronary artery is blocked and the sooner reperfusion therapy is delivered the better the outcome for the patient. If too much time elapses the benefits of primary PCI may be lost. Because of the difficulty in timely delivery, in some areas primary PCI is no longer the preferred coronary reperfusion strategy over fibrinolysis. However, when performed early, primary PCI is more effective. To ensure the best outcomes for adults with STEMI, the ambulance service and hospitals delivering primary PCI should work together to minimise delays in treatment.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults with acute STEMI who present within 12 hours of onset of symptoms have primary PCI, as the preferred coronary reperfusion strategy, within 120 minutes of the time when fibrinolysis could have been given.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that adults with acute STEMI have access to primary PCI 24 hours a day.
Data source: Local data collection.
c) Evidence that commissioners with their services providers have developed a single care pathway for coronary reperfusion.
Data source: Local data collection.
Process
a) Proportion of adults with acute STEMI who present within 12 hours of onset of symptoms who receive primary PCI within 120 minutes of when fibrinolysis could have been given.
Numerator – the number in the denominator receiving primary PCI within 120 minutes of when fibrinolysis could have been given.
Denominator – the number of adults with acute STEMI who present within 12 hours of onset of symptoms.
b) Proportion of adults with acute STEMI who present within 12 hours of onset of symptoms who receive primary PCI within 150 minutes of the call for professional help.
Numerator – the number of people in the denominator receiving primary PCI within 150 minutes of the call for professional help.
Denominator – the number of adults with acute STEMI who present within 12 hours of onset of symptoms.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (ambulance services, accident and emergency service provider and cardiac service providers) ensure that local pathways and transfer protocols are in place for adults with acute STEMI who present within 12 hours of the onset of symptoms to be offered primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given.
Healthcare professionals ensure that they offer primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given to adults with acute STEMI who present within 12 hours of the onset of symptoms.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have the capacity and expertise to provide primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given (and at any time of the day or night, including weekends) to adults with acute STEMI who present within 12 hours of onset of symptoms. Commissioners should work with their service providers to develop a single care pathway for coronary reperfusion.
Adults with a type of heart attack called STEMI whose symptoms started no more than 12 hours before first contacting a healthcare professional are offered a procedure to improve blood flow to the heart (called percutaneous coronary intervention or PCI). They should be able to have this as soon as possible, but within 120 minutes of when they could have received fibrinolysis (a ‘clot-busting’ drug).

Source guidance

Acute coronary syndromes. NICE guideline NG185 (2020), recommendations 1.1.3 and 1.1.6

Definitions of terms used in this quality statement

As soon as possible
Local areas should collaborate with healthcare professionals to determine the appropriate timeframes for patients. [Expert opinion]

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 different audiences

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.
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

Acute coronary syndromes. NICE guideline NG185 (2020), recommendations 1.1.27 and 1.2.26

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 different audiences

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.
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

Acute coronary syndromes. NICE guideline NG185 (2020), recommendations 1.8.1 and 1.8.13

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. [NICE’s full guideline on acute coronary syndromes]
Cardiac rehabilitation programmes should include a range of interventions with health education, lifestyle advice, stress management and physical exercise components. [NICE’s guideline on acute coronary syndromes, recommendations 1.8.1 and 1.8.19]

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.
Data source: Local data collection.
c) Patient experience of GP services.
Data source: Local data collection.

What the quality statement means for different audiences

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.
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

Acute coronary syndromes. NICE guideline NG185 (2020), recommendations 1.4.2, 1.4.25 and 1.7.1

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 different audiences

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.
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. [NICE’s full guideline on acute coronary syndromes]
Cardiac rehabilitation programmes should include a range of interventions with health education, lifestyle advice, stress management and physical exercise components. [NICE’s guideline on acute coronary syndromes, recommendations 1.8.1 and 1.8.19]

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 different audiences

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.
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

Acute coronary syndromes. NICE guideline NG185 (2020), recommendations 1.8.1 and 1.8.9

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. [NICE’s full guideline on acute coronary syndromes]
Cardiac rehabilitation programmes should include a range of interventions with health education, lifestyle advice, stress management and physical exercise components. [NICE’s guideline on acute coronary syndromes, recommendations 1.8.1 and 1.8.19]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

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

Benefits and risks of early invasive treatment (coronary angiography with PCI if needed) compared with conservative management for people with unstable angina or NSTEMI

Benefits/risks/other factors
Coronary angiography and possible PCI within 72 hours
Conservative management with later coronary angiography if problems continue or develop
Benefits (advantages)
Reduced deaths from all causes at 6 to 12 months and at 2 years. Reduced deaths from heart problems at 1 and 2 years.
Reduced incidence of MI at 30 days, 6 to 12 months and 2 years.
Reduced incidence of stroke at 1 year, particularly in people at high risk of future adverse events.
Reduced readmission to hospital and difficult-to-treat angina in the medium term, particularly in people at high risk of future adverse events.
Psychological benefits – people are not anxious about delaying angiography.
Avoid the immediate risks of invasive treatment, including:
  • death within 4 months related to the procedure from causes other than MI
  • procedure-related MI
  • major bleeding in hospital and up to 2 years after the procedure.
These are particularly relevant for people at low risk of future adverse events.
Psychological benefits – people are not anxious about having an invasive procedure.
Risks (disadvantages)
Increased risk of death during the first 4 months, particularly for people at low risk of future adverse events.
Risk of procedure-related MI.
Increased risk of major bleeding during the index admission, at 30 days and 2 years.
Emergency treatment leaves little time for shared decision making.
Increased risk of MI after 6 months.
Increased risk of stroke at 1 year, particularly in the people at high risk of future adverse events.
Psychological factors – people may be anxious about delaying angiography.
Other factors
Recent advances in PCI might increase early benefit, particularly reducing bleeding.
Coronary angiography within 72 hours ensures speedy intervention while allowing time for the correct diagnosis, identifying other conditions and treating symptoms.
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Offer ticagrelor, as part of dual antiplatelet therapy with aspirin, to people with acute STEMI not treated with PCI, unless they have a high bleeding risk.
Consider clopidogrel, as part of dual antiplatelet therapy with aspirin, or aspirin alone, for people with acute STEMI not treated with PCI, if they have a high bleeding risk.
Assess left ventricular function in all people who have had a STEMI.
After an acute MI, ensure that the following are part of every discharge summary:
  • confirmation of the diagnosis of acute MI
  • results of investigations
  • incomplete drug titrations (see ACE inhibitors and beta-blockers in the NICE Pathway on acute coronary syndromes: drug therapy for secondary prevention for further information)
  • future management plans
  • advice on secondary prevention.
Offer a copy of the discharge summary to the person.
Offer ticagrelor, as part of dual antiplatelet therapy with aspirin, to people with unstable angina or NSTEMI when PCI is not indicated, unless they have a high bleeding risk.
Consider clopidogrel, as part of dual antiplatelet therapy with aspirin, or aspirin alone, for people with unstable angina or NSTEMI when PCI is not indicated, if they have a high bleeding risk.
To detect and quantify inducible ischaemia, consider ischaemia testing before discharge for people whose condition has been managed conservatively and who have not had coronary angiography.
Assess left ventricular function in all people who have had an NSTEMI.
Consider assessing left ventricular function in all people with unstable angina.
Record measures of left ventricular function in the person's care record and in correspondence with the primary healthcare team and the person.
NICE is unable to make a recommendation about the use in the NHS of cangrelor for reducing atherothrombotic events in adults undergoing percutaneous coronary intervention or awaiting surgery requiring interruption of anti-platelet therapy because no evidence submission was received from The Medicines Company.
Prasugrel 10 mg in combination with aspirin is recommended as an option within its marketing authorisation, that is, for preventing atherothrombotic events in adults with acute coronary syndrome (unstable angina, NSTEMI or STEMI) having primary or delayed PCI.
Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months as a treatment option in adults with acute coronary syndromes that is, people:
  • with NSTEMI or
  • admitted to hospital with unstable angina – defined as ST or T wave changes on electrocardiogram suggestive of ischaemia plus one of the characteristics defined below. Before ticagrelor is continued beyond the initial treatment, the diagnosis of unstable angina should first be confirmed, ideally by a cardiologist.
For the purposes of this guidance, characteristics to be used in defining treatment with ticagrelor for unstable angina are: age 60 years or older; previous myocardial infarction or previous CABG; coronary artery disease with stenosis of 50% or more in at least two vessels; previous ischaemic stroke; previous transient ischaemic attack, carotid stenosis of at least 50%, or cerebral revascularisation; diabetes mellitus; peripheral arterial disease; or chronic renal dysfunction, defined as a creatinine clearance of less than 60 ml per minute per 1.73 m2 of body-surface area.
NICE has published guidance on the following procedures with normal arrangements for clinical governance, consent and audit:
NICE has published guidance on the following procedures with special arrangements for consent and audit or research:

Glossary

(use of glycoprotein inhibitor when the PCI operator has not intended to use GPI from the outset, but considers that clinical or angiographic features (such as worsening or persistent thrombus burden) have changed during the course of the procedure, such that there may be benefit to giving the patient GPI)
coronary artery bypass grafting
electrocardiogram
Global Registry of Acute Coronary Events
myocardial infarction
non-ST-segment elevation myocardial infarction
primary percutaneous coronary intervention
percutaneous coronary intervention
percutaneous coronary interventions
myocardial infarction with ST-segment elevation

Paths in this pathway

Pathway created: November 2020 Last updated: November 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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