MI: secondary prevention

National Institute for Health and Clinical Excellence

The following recommendations have been identified as priorities for implementation

• 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
• Patients should be advised to undertake regular physical activity sufficient to increase exercise capacity Patients should be advised to be physically active for 20–30 minutes a day to the point of slight breathlessness.
• Patients who are not achieving this should be advised to increase their activity in a gradual, step-by-step way, aiming to increase their exercise capacity. They should start at a level that is comfortable, and increase the duration and intensity of activity as they gain fitness
• 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)
• 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)
• 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:
  • ACE 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
• 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
• 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
• All patients should be offered a cardiological assessment to consider whether coronary revascularisation is appropriate. This should take into account comorbidity

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG48

National Institute for Health and Clinical Excellence. MI: secondary prevention. Secondary prevention in primary and secondary care for patients following a myocardial infarction. Quick Reference Guide. May 2007