Secondary Prevention in Primary and Secondary Care for Patients Following a Myocardial Infarction (TA48)

Clinical Guideline 48

Source: National Institute for Health and Care Excellence  

1.  Key priorities for implementation
A number of key priority recommendations have been identified for implementation listed below. These recommendations are considered by the GDG to have the most significant impact on patients’ care and patients’ outcomes.

• After an acute myocardial infarction (MI), confirmation of the diagnosis of acute MI and results of investigations, future management plans and advice on secondary prevention should be part of every discharge summary (GPP).

• Patients should be advised to undertake regular physical activity sufficient to increase exercise capacity (Grade B).

• Patients should be advised to be physically active for 20-30 mins a day to the point of slight breathlessness. Those who are not achieving this should be advised to increase their activity in a gradual step by step fashion, aiming to increase exercise capacity. They should start at a level that is comfortable and increase the duration and intensity of activity as they gain fitness (GPP).

• All patients who smoke should be advised to quit and be offered assistance from a smoking cessation service in line with ‘Brief interventions and referral for smoking cessation in primary care and other settings’ (NICE public health intervention guidance 1) (Grade A).

• Patients should be advised to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils) (Grade A).

• Cardiac rehabilitation should be equally accessible and relevant to all patients after an MI; particularly people from groups that are less likely to access this service. These include people from black and minority ethnic groups, older people, people from lower socioeconomic groups, women, people from rural communities and people with mental and physical health comorbidities.

• All patients who have had an acute MI should be offered treatment with a combination of the following drugs (Grade A):
− ACE (angiotensin-converting enzyme) inhibitor
− aspirin
− beta blocker
− statin.

• For patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment should be initiated within 3–14 days of the MI, preferably after ACE inhibitor therapy (Grade B).

• Treatment with clopidogrel in combination with low-dose aspirin should be continued for 12 months after the most recent acute episode of non-ST-segment-elevation acute coronary syndrome. Thereafter, standard care, including treatment with low-dose aspirin alone, is recommended unless there are other indications to continue dual antiplatelet therapy (Grade A).

• After an ST-segment-elevation MI, patients treated with a combination of aspirin and clopidogrel during the first 24 hours after the MI should continue this treatment for at least 4 weeks. Thereafter, standard treatment including low-dose aspirin should be given, unless there are other indications to continue dual antiplatelet therapy (Grade A).

• All patients should be offered a cardiological assessment to consider whether coronary revascularisation is appropriate. This should take into account comorbidity (Grade A).

The criteria the GDG used to select these key priorities for implementation included whether a recommendation is likely to:
• have a high impact on patients’ outcomes in particular mortality and morbidity
• have a high impact on reducing variation in the treatment offered to patients
• lead to a more efficient use of NHS resources
• enable patients to reach important points in the care pathway more rapidly


A copy of the full document and a summary of the evidence is available on the Internet at

An abridged version of this guidance (a 'quick reference guide') is also available. Printed copies of the quick reference guide can be obtained by contacting 0845 003 7783 or emailing and quoting reference number N1251. It is also available on the Internet at

This guidance represents the view of the Institute which was arrived at after careful consideration of the available evidence. Health professionals are expected to fully take it into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

© Copyright National Institute for Health and Care Excellence. All rights reserved. This material may be freely reproduced for educational and not for profit purposes within the NHS. No reproduction by or for commercial organisations is permitted without the express written permission of the Institute.

Enquiries concerning the guidance should be addressed to: National Institute for Health and Care Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA. email:

Secondary Prevention in Primary and Secondary Care for Patients Following a Myocardial Infarction.
Issue Date: May 2007
Review Date: TBA

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