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Myocardial infarction: rehabilitation and preventing further cardiovascular disease

About

What is covered

This interactive flowchart covers cardiac rehabilitation and preventing further CVD in people aged 18 and over who have had an MI.
It aims to promote the health of people who have had an MI by encouraging them to attend a cardiac rehabilitation programme and advising them on a healthy lifestyle. It also includes advice on drug therapy.

Updates

Updates to this interactive flowchart

10 May 2018 Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups (NICE quality standard 167) added.
13 December 2017 Structure revised, summarised recommendations replaced with full recommendations and title updated.
13 December 2016 Ticagrelor for preventing atherothrombotic events after myocardial infarction (NICE technology appraisal guidance 420) added to antiplatelets and anticoagulants.
3 September 2015 Secondary prevention after a myocardial infarction (NICE quality standard 99) added.
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 (NICE technology appraisal guidance 317) added to antiplatelets and anticoagulants.

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 cardiac rehabilitation and preventing cardiovascular disease after myocardial infarction in an interactive flowchart

What is covered

This interactive flowchart covers cardiac rehabilitation and preventing further CVD in people aged 18 and over who have had an MI.
It aims to promote the health of people who have had an MI by encouraging them to attend a cardiac rehabilitation programme and advising them on a healthy lifestyle. It also includes advice on drug therapy.

Updates

Updates to this interactive flowchart

10 May 2018 Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups (NICE quality standard 167) added.
13 December 2017 Structure revised, summarised recommendations replaced with full recommendations and title updated.
13 December 2016 Ticagrelor for preventing atherothrombotic events after myocardial infarction (NICE technology appraisal guidance 420) added to antiplatelets and anticoagulants.
3 September 2015 Secondary prevention after a myocardial infarction (NICE quality standard 99) added.
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 (NICE technology appraisal guidance 317) added to antiplatelets and anticoagulants.

Quality standards

Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups

These quality statements are taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

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

Designing health and wellbeing programmes

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups have their views represented in setting priorities and designing local health and wellbeing programmes.

Rationale

Health and wellbeing programmes can support positive behaviour changes and contribute to promoting health and preventing premature mortality. People from black, Asian and other minority ethnic groups may not engage with services or may have a poor experience of those programmes and associated services if they are not culturally sensitive and appropriate. Involving people, community organisations and faith leaders who can represent the views of local minority ethnic groups helps to ensure that the services reflect the needs and preferences of the local population.

Quality measures

Structure
a) Evidence of work carried out to gather intelligence about the ethnic diversity of the local population.
Data source: Local data collection, for example, intelligence gathered for the Joint Strategic Needs Assessment.
b) Evidence of work carried out to gain understanding of the needs of black, Asian and other minority ethnic groups living in the local area.
Data source: Local data collection, for example, intelligence gathered for the joint strategic needs assessment.
c) Evidence of actions taken to gather views of local people from black, Asian and other minority ethnic groups on priorities for and design of health and wellbeing programmes.
Data source: Local data collection, for example, from programme planning, records from meetings (agendas or minutes) and focus groups.
d) Evidence of how intelligence on ethnic diversity, the needs and views of the local population is used to inform commissioning.
Data source: Local data collection, for example, information included in local health equality assessments.
Process
a) Proportion of local health and wellbeing programmes that gathered views of people from black, Asian and other minority ethnic groups when setting priorities and designing the programmes.
Numerator – the number in the denominator that gathered views of people from black, Asian and other minority ethnic groups when setting priorities and designing the programmes.
Denominator – the number of health and wellbeing programmes commissioned locally.
Data source: Local data collection, for example, service annual report.
b) Proportion of people representing the views of black, Asian and other minority ethnic groups involved in setting priorities and designing local health and wellbeing programmes who felt that their views were valued.
Numerator – the number in the denominator that felt their views were valued.
Denominator – the number of people representing the views of black, Asian and other minority ethnic groups involved in setting priorities and designing local health and wellbeing programmes.
Data source: Local data collection, for example, surveys carried out with people representing ethnic groups.
Outcome
a) Uptake of local health and wellbeing services among people from black, Asian and other minority ethnic groups.
Data source: Local data collection, for example, service workflow.
b) Proportion of people from black, Asian and other minority ethnic groups referred to local health and wellbeing services who feel that the services meet their needs.
Data source: Local data collection, for example, service user survey.
c) Prevalence of obesity among local people from black, Asian and other minority ethnic groups.
Data source: NHS Digital’s Health Survey for England and National Child Measurement Programme, and local data collection, for example, GP practice data.
d) Physical activity levels among local people from black, Asian and other minority ethnic groups.
Data source: Active Lives, Sport England and local data collection, for example, review of service user records held by the provider.
e) Prevalence of tobacco use among local people from black, Asian and other minority ethnic groups.
Data source: Office for National Statistics’ Annual Population Survey and local data collection, for example, stop smoking service data.
f) Mental wellbeing among local people from black, Asian and other minority ethnic groups.
Data source: Local health data collection, for example mental health and wellbeing joint strategic needs assessment profile.

What the quality statement means for different audiences

Service providers (primary care services, community care services and services in the wider public, community and voluntary sectors) ensure that the services they provide recognise the beliefs, expectations and values of local people from black, Asian and other minority ethnic groups. They continually review the services to ensure that they are culturally appropriate, accessible and tailored to the diverse needs of the local population.
Health, public health and social care practitioners recognise the beliefs, expectations and values of local people from black, Asian and other minority ethnic groups that they support. They ensure that the services they provide are culturally appropriate and accessible. This may mean working in partnership with existing local community groups or faith leaders who can support delivering some of the programmes in non-traditional community-based settings.
Commissioners (Public Health England, NHS England, local authorities, clinical commissioning groups) gather intelligence and gain understanding of the diversity of the local population and its needs. They ensure that the views of people from minority ethnic groups are represented when priorities are set and local health and wellbeing programmes are designed. This may be through engaging local communities using public consultation or community workshops that discuss future services. These can ensure that the local population is represented by individuals as well as established community groups and educational or religious leaders. The commissioners also ensure that local services have the skills mix and capacity to provide support that is culturally appropriate and tailored to the needs of people from black, Asian and other minority ethnic groups to make positive behaviour changes.
People from black, Asian and other minority ethnic groups advise on what local health and wellbeing programmes should focus on and what culturally sensitive and acceptable services should look like. They share their views during workshops or consultations organised by the commissioners, or through other people who they trust, such as community leaders or faith leaders.

Source guidance

Definitions of terms used in this quality statement

Health and wellbeing programmes
Health and wellbeing programmes cover all strategies, initiatives, services, activities, projects or research that aim to improve health (physical and mental) and wellbeing and reduce health inequalities.
[Adapted from NICE's guideline on community engagement]

Equality and diversity considerations

Due to language and communication difficulties or past experiences of racism and prejudice, some people from black, Asian and other minority ethnic groups may not have had a positive experience of accessing services. This may prevent them from engaging with services and increase their risk of poor health outcomes. Commissioners and providers seeking to obtain the views and understand the needs of people from black, Asian and other minority ethnic groups should work closely with existing community groups, faith leaders and educators who may already have links to groups and individuals with poor access to services.

Peer and lay roles

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups are represented in peer and lay roles within local health and wellbeing programmes.

Rationale

People from black, Asian and other minority ethnic groups are underrepresented in health and wellbeing programmes. To ensure that the programmes are accessed and used by minority ethnic groups, commissioners and providers need to recognise the knowledge, skills and expertise of local communities. People known to and trusted by communities can take on peer and lay roles and encourage uptake of services among groups that may otherwise be reluctant to get involved. They can raise awareness, deliver information and advice in a culturally appropriate manner, and help with designing and providing interventions and services that are relevant, acceptable and tailored to the local population.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people from black, Asian and other minority ethnic groups are represented in peer and lay roles for local health and wellbeing programmes.
Data source: Local data collection, for example, from service planning and service design records, and recruitment records.
b) Evidence of local arrangements to support people from black, Asian and other minority ethnic groups taking on peer and lay roles in local health and wellbeing programmes.
Data source: Local data collection, for example, records of meetings, mentoring sessions, existing support networks or workshops with people taking on peer and lay roles.
Process
Proportion of local health and wellbeing programmes with people working in peer and lay roles who are representative of the local community.
Numerator – the number in the denominator with people working in peer and lay roles who are representative of the local community.
Denominator – the number of local health and wellbeing programmes.
Data source: Local data collection, for example, from service annual reports.
Outcome
a) The number of people from black, Asian and other minority groups who access local health and wellbeing programmes.
Data source: Local data collection, for example, review of service records.
b) The number of people in peer and lay roles supporting black, Asian and other minority ethnic groups to improve their health and wellbeing.
Data source: Local data collection, for example, review of service records.
c) Experience of engaging with local health and wellbeing programmes among people from black, Asian and other minority groups.
Data source: Local data collection, for example, service user survey.
d) Long-term retention of people in peer and lay roles.
Data source: Local data collection, for example, service annual report.

What the quality statement means for different audiences

Service providers (primary care services, community care services and services in the wider public, community and voluntary sectors) ensure that they work with established community groups and educational or religious leaders to identify and recruit members of the local community who can support people from black, Asian and other minority ethnic groups and represent the diverse needs of the local population. They ensure that people in lay roles are supported with resources, information and mechanisms to proactively engage members of the community who may be excluded or disengaged. Service providers also support people in peer and lay roles with feedback, support networks, training and mentoring to allow them to fulfil their responsibilities, reach their full potential and continue with the role.
Commissioners (community and voluntary sector organisations and statutory services) understand the diversity of their local community and make a long-term commitment to funding and supporting effective community engagement approaches, such as peer and lay roles. They secure resources to recruit people to peer and lay roles and provide them with ongoing training and support.
People from black, Asian and other minority ethnic groups are given support and information by other members of their own community who are working closely with organisations that provide local health and wellbeing services. These people represent the interests and concerns of the community and ensure that local health and wellbeing programmes and services recognise the beliefs, expectations and values of people from black, Asian and other minority ethnic groups.

Source guidance

Definitions of terms used in this quality statement

Health and wellbeing programmes
Health and wellbeing programmes cover all strategies, initiatives, services, activities, projects or research that aim to improve health (physical and mental) and wellbeing and reduce health inequalities.
[Adapted from NICE's guideline on community engagement]
Peer and lay roles
Community members working in a non-professional capacity to support health and wellbeing initiatives. 'Lay' is the general term for a community member. 'Peer' describes a community member who shares similar life experiences to the community they are working with. Peer and lay roles may be paid or unpaid (that is, voluntary). Effective peer and lay approaches are:
  • Bridging roles to establish effective links between statutory, community and voluntary organisations and the local community and to determine which types of communication would most effectively help get people involved.
  • Carrying out 'peer interventions'. That is, training and supporting people to offer information and support to others, either from the same community or from similar backgrounds.
  • Community health champions who aim to reach marginalised or vulnerable groups and help them get involved.
  • Volunteer health roles whereby community members get involved in organising and delivering activities.
[NICE's guideline on community engagement]

Equality and diversity considerations

Due to language and communication difficulties or past experiences of racism and prejudice, some people from the black, Asian and other minority ethnic groups may not have had a positive experience of accessing services. This may prevent them from engaging with services and increase their risk of poor health outcomes. People in peer and lay roles may be more successful at engaging with and supporting people from similar backgrounds than traditional health and wellbeing services.

Referring people at high risk of type 2 diabetes

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups at high risk of type 2 diabetes are referred to an intensive lifestyle change programme.

Rationale

People from certain ethnic communities have a higher risk of developing type 2 diabetes than those in the white European population. This includes people of South Asian, Chinese, black African and African-Caribbean family origin. In these populations, the risk of type 2 diabetes increases at an earlier age and at a lower BMI level. Many cases of type 2 diabetes are preventable through changes to a person's diet and physical activity levels. Evidence-based intensive lifestyle change programmes can significantly reduce the risk of developing type 2 diabetes for those at high risk.

Quality measures

Structure
Evidence of local arrangements for identifying and referring people from black, Asian and other minority ethnic groups at high risk of type 2 diabetes.
Data source: Local data collection, for example, GP contracts.
Process
a) Proportion of people from black, Asian and other minority ethnic groups identified as being at high risk of type 2 diabetes who are referred to an intensive lifestyle change programme.
Numerator – the number in the denominator who are referred to an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are identified as being at high risk of type 2 diabetes.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as Commissioning Support Units (CSUs).
b) Proportion of people from black, Asian and other minority ethnic groups referred to an intensive lifestyle change programme who attended the programme.
Numerator – the number in the denominator who attended an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are at high risk of type 2 diabetes referred to an intensive lifestyle change programme.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as CSUs.
c) Proportion of people from black, Asian and other minority ethnic groups referred to an intensive lifestyle change programme who completed the programme.
Numerator – the number in the denominator who completed an intensive lifestyle change programme.
Denominator – the number of people from black, Asian and other minority ethnic groups who are at high risk of type 2 diabetes referred to an intensive lifestyle change programme.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and local data collection, for example, GP patient records or data providers such as CSUs.
Outcome
a) Change in BMI among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
b) Change in blood pressure among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
c) Change in HbA1c among people from black, Asian and other minority ethnic groups completing intensive lifestyle change programmes.
Data source: Local data collection, for example, GP patient records.
d) Prevalence of type 2 diabetes among people from black, Asian and other minority groups.
Data source: The Diabetes UK and NHS Digital National Diabetes Audit and Public Health England’s Diabetes prevalence estimates for local populations.

What the quality statement means for different audiences

Service providers (such as GPs and community healthcare providers) ensure that people from black, Asian and other minority ethnic groups who are identified as being at high risk of developing type 2 diabetes are referred to an intensive lifestyle change programme. They also ensure that systems are in place to start diabetes prevention interventions at a lower BMI threshold in people from minority ethnic groups at increased risk of type 2 diabetes. This may involve people in peer and lay roles raising awareness, assessing risks and providing advice on diabetes prevention among those ethnic minorities.
Health and public health practitioners (such as GPs, practice nurses and community healthcare providers) are aware that some black, Asian and other minority ethnic groups have an increased risk of type 2 diabetes. They refer people who are at high risk to an intensive lifestyle change programme and provide advice to those with a lower level of risk.
Commissioners (clinical commissioning groups, NHS England and local authorities in sustainability and transformation partnership areas) ensure that intensive lifestyle change programmes are available for people from black, Asian and other minority ethnic groups at high risk of type 2 diabetes. They work with ethnic minorities to ensure that programmes include a range of culturally sensitive and appropriate behaviour change interventions.
People from black, Asian and other minority ethnic group at high risk of type 2 diabetes are referred to culturally sensitive and appropriate services that can help them achieve healthy weight and be more active. Those who are not currently at high risk of type 2 diabetes are given information and further support relevant to their needs.

Source guidance

Definitions of terms used in this quality statement

Intensive lifestyle change programme
A structured and coordinated range of interventions provided in different venues for people identified as being at high risk of developing type 2 diabetes. It should be local, evidence-based and quality-assured. The aim is to help people to become more physically active and improve their diet. If the person is overweight or obese, the programme should result in weight loss. Programmes may be delivered to individuals or groups (or involve a mix of both) depending on the resources available. They can be provided by primary care teams and public, private or community organisations with expertise in dietary advice, weight management and physical activity.
[NICE’s guideline on preventing type 2 diabetes in people at high risk, glossary]
High risk of type 2 diabetes
High risk is defined as a fasting plasma glucose level of 5.5–6.9 mmol/litre or an HbA1c level of 42–47 mmol/mol (6.0–6.4%). These terms are used instead of specific numerical scores because risk assessment tools have different scoring systems. Examples of risk assessment tools include: Diabetes risk score assessment tool, QDiabetes risk calculator and Leicester practice risk score. Risk can also be assessed using the NHS Health Check.
[NICE’s guideline on preventing type 2 diabetes in people at high risk, glossary]
Lower thresholds (23 kg/m2 to indicate increased risk and 27.5 kg/m2 to indicate high risk) should be used for BMI to trigger action to prevent type 2 diabetes among Asian (South Asian and Chinese) populations compared to those used for the general population.

Equality and diversity considerations

Due to language and communication difficulties, or past experiences of racism and prejudice, some people from black, Asian and other minority ethnic groups may find it difficult to engage with services. Intensive lifestyle change programmes need to be culturally appropriate, accessible and tailored to the diverse needs of the local population.

Cardiac rehabilitation

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme are given a choice of times and settings for the sessions and are followed up if they do not attend.

Rationale

Cardiac rehabilitation programmes improve clinical outcomes for people who have had a cardiac event. However, uptake among people from black, Asian and other ethnic minority groups is lower than in the general population. Providing programmes that are culturally appropriate and sensitive, at settings and times that are convenient can increase uptake. Following up people who do not attend allows for a discussion about potential barriers to attendance and how to overcome them. It also gives the opportunity to motivate people to start or to continue with the programme.

Quality measures

Structure
a) Evidence of local arrangements to discuss any factors that might stop people from black, Asian or other minority ethnic groups from attending a cardiac rehabilitation programme, before they receive a referral.
Data source: Local data collection, for example, from service level agreements.
b) Evidence of local arrangements to provide cardiac rehabilitation sessions for people from black, Asian and other minority ethnic groups in a variety of settings including at home, in the community or in a hospital.
Data source: Local data collection, for example, from service level agreements.
c) Evidence of local arrangements to provide cardiac rehabilitation sessions for people from black, Asian and other minority ethnic groups at a choice of times, for example, sessions outside working hours.
Data source: Local data collection, for example, from service level agreements.
Process
a) Proportion of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who are offered sessions in a variety of settings including home, the community or a hospital.
Numerator – the number in the denominator offered sessions in a variety of settings including home, the community or a hospital.
Denominator – the number of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme.
Data source: Local data collection, for example, from patient records.
b) Proportion of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who did not start the programme who were contacted with a reminder.
Numerator – the number in the denominator who were contacted with a reminder.
Denominator – the number of people from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme who did not start the programme.
Data source: Local data collection, for example, from patient records.
c) Proportion of people from black, Asian and other minority ethnic groups who missed their cardiac rehabilitation appointment who were contacted with a reminder.
Numerator – the number in the denominator who were contacted with a reminder.
Denominator – the number of people from black, Asian and other minority ethnic groups participating in a cardiac rehabilitation programme who missed their appointment.
Data source: Local data collection, for example, from patient records.
Outcome
a) Rate of uptake of cardiac rehabilitation programmes among people from black, Asian and other minority ethnic groups.
Data source: National data on the uptake of cardiac rehabilitation are available from the British Heart Foundation’s National audit of cardiac rehabilitation. Local data collection, for example, from cardiac rehabilitation programme data collection system.
b) Rates of adherence to cardiac rehabilitation programmes among people from black, Asian and other minority ethnic groups.
Data source: National data on the uptake of cardiac rehabilitation are available from the British Heart Foundation’s National audit of cardiac rehabilitation. Local data collection, for example, from cardiac rehabilitation programme data collection system.
c) Service user experience among people from black, Asian and other minority ethnic groups who accessed cardiac rehabilitation programmes.
Data source: Local data collection, for example, surveys carried out with people referred to cardiac rehabilitation.

What the quality statement means for different audiences

Service providers (secondary and tertiary care services) ensure they provide individualised support for people from black, Asian and other minority ethnic groups to attend and continue with cardiac rehabilitation programmes. This may include working on overcoming barriers with people who are not willing to engage with services due to poor past experiences or ensuring that the programmes are run on different days, at different times and at venues that are culturally appropriate and convenient. Providers also ensure that a varied range of acceptable and culturally sensitive exercise is available, and people are followed up to continue with the programme.
Healthcare professionals (such as cardiologists and cardiac nurses) identify barriers to attending a cardiac rehabilitation programme and offer individualised support to people from black, Asian and other minority ethnic groups. They offer cardiac rehabilitation programmes on different days, at different times and venues (such as community centres or places of worship) and ensure that they are culturally appropriate and suitable. Healthcare professionals also follow-up people to motivate them to continue with the programme or understand the obstacles that may prevent people from using the service.
Commissioners (clinical commissioning groups) commission cardiac rehabilitation services that have the capacity and expertise to provide people from black, Asian and other minority ethnic groups with programmes that are suitable, acceptable and culturally appropriate. They also ensure that the services support people from black, Asian and other minority ethnic groups to attend and adhere to the programme by addressing the barriers to participation.
People from black, Asian and other minority ethnic groups referred to a cardiac rehabilitation programme are supported to attend and keep going to the sessions. This might mean that sessions are available at venues and times convenient to the person or that the sessions are acceptable to them culturally, for example, single sex or with bilingual staff.

Source guidance

Definitions of terms used in this quality statement

Cardiac rehabilitation
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 and through improved health behaviour, slow or reverse progression of the disease. Cardiac rehabilitation should consist of a multidisciplinary, integrated approach delivering care in lifestyle risk factor management, psychosocial health, medical risk factor management and the optimal use of cardioprotective therapies, underpinned by psychologically informed methods of health behaviour change and education.
Cardiac rehabilitation programmes should include a range of interventions with health education, lifestyle advice, stress management and physical exercise components.
[NICE’s guideline on myocardial infarction, full guideline and recommendations 1.1.1 and 1.1.19]

Equality and diversity considerations

Due to language and communication difficulties, or past experiences of racism and prejudice, some people from the black, Asian and other minority ethnic groups may find it difficult to engage with services. Also, some traditions and religious practices may stop people from accessing services on certain days or certain times of the day. Behaviour change programmes need to acknowledge those differences, be culturally appropriate, accessible and tailored to the diverse needs of the local population.

Support for people with mental health problems

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups can access mental health services in a variety of community-based settings.

Rationale

People from black, Asian and other minority ethnic groups are less likely to access mental health treatment than the general population. Mental health illness can be associated with a considerable stigma among people from black, Asian and other minority ethnic groups. Some people may find community-based services, such as a person’s home or other residential settings, community centres and social centres, more appealing, accessible and culturally appropriate than traditional healthcare services. To help combat the stigma and encourage people with mental health problems to access support early, the services need to be visible, accessible and responsive to the needs of the local population.

Quality measures

Structure
a) Evidence of local arrangements to improve access to mental health services for people from black, Asian and other minority ethnic groups.
Data source: Local data collection, for example, from local commissioning plans.
b) Evidence of local arrangements to ensure that mental health services are provided in a variety of settings that people from black, Asian and other minority ethnic groups can choose from.
Data source: Local data collection, for example, from service level agreements.
Process
Proportion of people from black, Asian and other minority ethnic groups accessing mental health services who are offered support in community-based settings.
Numerator – the number in the denominator offered support in community-based settings.
Denominator – the number of people from black, Asian and other minority ethnic groups accessing mental health services.
Data source: Local data collection, for example, from patient records.
Outcome
a) Rates of uptake of mental health services among people from black, Asian and other minority ethnic groups.
Data source: Local data collection for example, from GP records.
b) Proportion of people from black, Asian and other minority ethnic groups who complete treatment from mental health services.
Data source: Local data collection for example, from GP records.
c) Service user experience among people from black, Asian and other minority ethnic groups who accessed mental health services.
Data source: Local data collection, for example, surveys carried out with people referred to mental health services.

What the quality statement means for different audiences

Service providers (such as GP practices, community health services, mental health services and independent providers) collaborate with local communities and people from black, Asian and other minority ethnic groups, healthcare professionals and commissioners to develop local care pathways that promote mental health services tailored to the needs of the local population. They ensure that services are provided in settings accessible and acceptable to people from black, Asian and other minority ethnic groups with mental health problems.
Healthcare professionals (such as GPs, psychiatrists, mental health nurses) offer people from black, Asian and other minority ethnic groups different options for where they can access mental health support to ensure they can choose acceptable and culturally appropriate services. They also collaborate with service providers, commissioners, communities and people from black, Asian and other minority ethnic groups to develop local care pathways that promote mental health services tailored to the needs of the local population.
Commissioners (such as clinical commissioning groups and local authorities) collaborate with local communities, people from black, Asian and other minority ethnic groups, healthcare professionals and service providers to develop local care pathways tailored to the needs of the local population. They ensure that mental health services are provided in a variety of settings and a range of support is available to facilitate access and uptake of services among people from black, Asian and other minority ethnic groups.
People from black, Asian and other minority ethnic groups are given a choice of places to access mental health support. Locations may include their own home, a community or social centre, a GP practice or other local health clinic.

Source guidance

Common mental health problems: identification and pathways to care (2011) NICE guideline CG123, recommendation 1.1.1.7

Definitions of terms used in this quality statement

Community-based settings
Community-based settings include the person's home or other residential settings, community centres and social centres.
[NICE’s guideline on common mental health problems, recommendation 1.1.1.7]

Equality and diversity considerations

Stigma attached to mental health problems among people from the black, Asian and other minority ethnic groups and fear of being sectioned or having children taken away by social services may stop people from accessing mental health support early. To ensure they are culturally appropriate and tailored to the diverse needs of the local population, members of the community should be involved in designing and reviewing the services as well as represented in peer and lay roles to ensure good links into the community.

Physical health checks for people with serious mental illness

This quality statement is taken from the promoting health and preventing premature mortality in black, Asian and other minority ethnic groups quality standard. The quality standard defines clinical best practice for promoting health and preventing premature mortality in black, Asian and other minority ethnic groups and should be read in full.

Quality statement

People from black, Asian and other minority ethnic groups with a serious mental illness have a physical health assessment at least annually.

Rationale

Life expectancy for adults with a serious mental illness is significantly lower than for people in the general population. People from some black, Asian and other minority ethnic groups are at an increased risk of cardiovascular disease and type 2 diabetes and these conditions can be exacerbated by the use of antipsychotics. An annual health check helps to pick up on early signs of physical health conditions and enables action to be taken to prevent worsening health.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people from black, Asian and other minority ethnic groups with a serious mental illness have a physical health assessment at least annually.
Data source: Local data collection, for example, using NHS England’s practical toolkit for mental health trusts and commissioners.
b) Evidence of local primary and secondary care services working together to monitor and address the physical health needs of people affected by serious mental illness as part of the Rethink Mental Health Integrated Physical Health Pathway.
Data source: Local data collection, for example, using NHS England’s practical toolkit for mental health trusts and commissioners.
Process
Proportion of people from black, Asian and other minority ethnic groups with a serious mental illness who have had a physical health assessment within the past 12 months.
Numerator – the number in the denominator who have had a physical health assessment within the past 12 months.
Denominator – the number of people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, from practice risk registers.
Outcome
a) Premature mortality rates among people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, from practice risk registers.
b) Prevalence of type 2 diabetes among people from black, Asian and other minority ethnic groups with a serious mental illness.
Data source: Local data collection, for example, GP patient records or data providers such as Commissioning Support Units (CSUs).

What the quality statement means for different audiences

Service providers (such as GPs or mental health services) have systems in place to ensure that physical health assessments are carried out at least annually for people from black, Asian and other minority ethnic groups with a serious mental illness. The results are shared (under shared care arrangements) when the service user is in the care of both primary and secondary services. Service providers may involve people in peer and lay roles to support raising awareness of the increased risks and importance of physical health checks among people from black, Asian and other ethnic minority groups with a serious mental illness.
Healthcare professionals (such as GPs or nurses) carry out physical health assessments at least annually for people from black, Asian and other minority ethnic groups with a serious mental illness. They share the results (under shared care arrangements) when the service user is in the care of both primary and secondary services. They also highlight the increased risks and importance of physical health checks to people from black, Asian and other ethnic minority groups with a serious mental illness.
Commissioners (such as NHS England local area teams) ensure that they commission services that can demonstrate they are carrying out physical health assessments at least annually in people from black, Asian and other minority ethnic groups with a serious mental illness, and include this requirement in continuous training programmes. They also ensure that shared care arrangements are in place when the service user is in the care of both primary and secondary services, to ensure that the results of assessments are shared.
People from black, Asian and other minority ethnic groups with serious mental health problems have regular health checks (at least once a year). This is to check for problems that are common in people being treated for a serious mental illness, such as weight gain, diabetes, and heart, lung and breathing problems. The results are shared between their GP surgery and mental health team.

Source guidance

Definitions of terms used in this quality statement

Serious mental illness
Schizophrenia, bipolar affective disorder and other psychoses.
Physical health assessment
A comprehensive health check focused on physical health problems such as cardiovascular disease, diabetes, obesity and respiratory disease. The annual check should include:
  • weight or BMI, diet, nutritional status and level of physical activity
  • cardiovascular status, including pulse and blood pressure
  • metabolic status, including fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
  • liver function
  • renal and thyroid function, and calcium levels, for people taking long-term lithium.
[Adapted from NICE’s guideline on bipolar disorder, recommendations 1.2.11 and 1.2.12]

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

If beta-blockers are contraindicated or need to be discontinued, diltiazem or verapamil may be considered for secondary prevention in patients without pulmonary congestion or left ventricular systolic dysfunction.

Glossary

angiotensin-converting enzyme
angiotensin II receptor blocker
coronary artery bypass graft
cardiovascular disease
myocardial infarction
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 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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