Expert Opinion - Secondary prevention following an MI

The new NICE guidance aims to be an integrated resource for the delivery of cardiac care. By Dr Rubin Minhas

Guidelines are an indispensable tool for clinicians seeking to apply evidence in clinical practice.

Multifactorial risk factor intervention and multidisciplinary care are central to optimising recovery for people who have had an MI and to preventing further MIs. This NICE guideline was written by a multidisciplinary team, including cardiologists, GPs, nurses, public health physicians and pharmacists, together with patients, who provided a unique perspective on the decisions that could affect them. The guideline development group used a systematic and transparent approach.

Risk factors
Smoking, diet, physical activity and obesity are key modifiable risk factors that have been recognised as priorities for implementation in this guideline. Often, much emphasis is placed on drug treatments and lifestyle factors can be neglected, although they have a significant role in aiding a full recovery.

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

Advice is also given regarding the type and amount of oily fish that should be consumed - patients are advised to eat 7g of omega-3 fatty acids from two to four portions of fish per week. An accompanying table lists the quantities of beneficial oils to be found in servings of various types of fish. This level of attention to detail is consistent throughout the guideline.

Patients should be advised to be physically active for 20-30 minutes a day, to the point of slight breathlessness. A Mediterranean-style diet should be recommended and alcohol consumption kept within safe limits (no more than 21 units per week for men and 14 units per week for women). The need to provide individually tailored advice on exercise and in the case of diet, tailored advice that can be extended to the whole family, is discussed in detail.

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

Advice regarding clopidogrel is provided for patients who have had ST-elevated MI and non-ST-elevated MI. Eplerenone has been added to the regimen for post-MI patients if there is evidence of heart failure or left ventricular dysfunction - the routine requirement for echocardiography is implicit.

For patients who have had an MI within three months and are not achieving a sufficient dietary intake of fish oils, 1g daily of licensed omega-3-acid ethyl esters should be considered for up to four years. Clinician and patient experience has led to further thought being given to prescribing in diverse clinical situations where polypharmacy or comorbidities may exist, for example, co-administration of aspirin and warfarin, or where the benefits of treatment may be unclear, for example, beta-blockers in low-risk groups.

The lack of benefit of ACE inhibitors in low-risk groups was also considered, but the evidence was insufficient to permit a recommendation. All patients should be offered a cardiological assessment for consideration of revascularisation.

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

The guideline development group recognised the value that such programmes may have in providing a comprehensive approach to risk factor reduction at an important stage for the patient. Guidelines can also target healthcare systems to address barriers such as poor access and deprivation.

These issues have also been considered and recommendations made for those responsible for commissioning cardiac services, to ensure that barriers to care are addressed. Factors such as ethnicity and low socio-economic status have been identified and tailored adjustments to cardiac rehabilitation programmes have been recommended.

This new post-MI guideline is a practical document. The recommendations recognise the difficulties of caring for patients with multiple comorbidities.

Additional recommendations are made for managing depression, impotence and return to work, sports, or other activities. This inclusive approach to guideline development should ensure that issues of importance to patients and the multidisciplinary team have been considered.

Following on from the NSF for CHD, this guideline fittingly begins with a foreword by Professor Roger Boyle, the national director for heart disease and stroke. He acknowledges the progress to date achieved through the NSF and identifies the role of this national guideline as continuing to promote the 'pillars that support a full recovery'.

Too often, clinical medicine and public health may look like railway tracks, running in the same direction but destined never to meet. The NICE guideline on secondary prevention following an MI is an integrated resource for all those who deliver cardiac care and seek to deliver evidence-based care. Patient versions and short summaries have also been produced and are available from NICE .

- Dr Rubin Minhas on behalf of the NICE Guideline Development Group for Secondary Prevention after MI. Dr Minhas is a GP and CHD clinical lead in Gillingham, Kent.

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