1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See About this guideline for details.

1.1 Cardiac rehabilitation after an acute myocardial infarction (MI)

Comprehensive cardiac rehabilitation

1.1.1 All patients (regardless of their age) should be given advice about and offered a cardiac rehabilitation programme with an exercise component. [2007]

1.1.2 Cardiac rehabilitation programmes should provide a range of options, and patients should be encouraged to attend all those appropriate to their clinical needs. Patients should not be excluded from the entire programme if they choose not to attend certain components. [2007]

1.1.3 If a patient has cardiac or other clinical conditions that may worsen during exercise, these should be treated if possible before the patient is offered the exercise component of cardiac rehabilitation. For some patients, the exercise component may be adapted by an appropriately qualified healthcare professional. [2007]

1.1.4 Patients with left ventricular dysfunction who are stable can safely be offered the exercise component of cardiac rehabilitation. [2007]

Encouraging people to attend

1.1.5 Deliver cardiac rehabilitation in a non-judgemental, respectful and culturally sensitive manner. Consider employing bilingual peer educators or cardiac rehabilitation assistants who reflect the diversity of the local population. [new 2013]

1.1.6 Establish people's health beliefs and their specific illness perceptions before offering appropriate lifestyle advice and to encourage attendance to a cardiac rehabilitation programme. [new 2013]

1.1.7 Offer cardiac rehabilitation programmes designed to motivate people to attend and complete the programme. Explain the benefits of attending. [new 2013]

1.1.8 Discuss with the person any factors that might stop them attending a cardiac rehabilitation programme, such as transport difficulties. [new 2013]

1.1.9 Offer cardiac rehabilitation programmes in a choice of venues (including at the person's home, in hospital and in the community) and at a choice of times of day, for example, sessions outside of working hours. Explain the options available. [new 2013]

1.1.10 Provide a range of different types of exercise, as part of the cardiac rehabilitation programme, to meet the needs of people of all ages, or those with significant comorbidity. Do not exclude people from the whole programme if they choose not to attend specific components. [new 2013]

1.1.11 Offer single-sex cardiac rehabilitation programme classes if there is sufficient demand. [new 2013]

1.1.12 Enrol people who have had an MI in a system of structured care, ensuring that there are clear lines of responsibility for arranging the early initiation of cardiac rehabilitation. [new 2013]

1.1.13 Begin cardiac rehabilitation as soon as possible after admission and before discharge from hospital. Invite the person to a cardiac rehabilitation session which should start within 10 days of their discharge from hospital. [new 2013]

1.1.14 Contact people who do not start or do not continue to attend the cardiac rehabilitation programme with a further reminder, such as:

  • a motivational letter

  • a prearranged visit from a member of the cardiac rehabilitation team

  • a telephone call

  • a combination of the above. [new 2013]

1.1.15 Seek feedback from cardiac rehabilitation programme users and aim to use this feedback to increase the number of people starting and attending the programme. [new 2013]

1.1.16 Be aware of the wider health and social care needs of a person who has had an MI. Offer information and sources of help on:

  • economic issues

  • welfare rights

  • housing and social support issues. [new 2013]

1.1.17 Make cardiac rehabilitation equally accessible and relevant to all people 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, people with a learning disability and people with mental and physical health conditions. [2007, amended 2013]

1.1.18 Encourage all staff, including senior medical staff, involved in providing care for people after an MI, to actively promote cardiac rehabilitation. [2013]

Health education and information needs

1.1.19 Comprehensive cardiac rehabilitation programmes should include health education and stress management components. [2007]

1.1.20 A home-based programme validated for patients who have had an MI (such as The heart manual) that incorporates education, exercise and stress management components with follow-ups by a trained facilitator may be used to provide comprehensive cardiac rehabilitation. [2007]

1.1.21 Take into account the physical and psychological status of the patient, the nature of their work and their work environment when giving advice on returning to work. [2007]

1.1.22 Be up to date with the latest Driver and Vehicle Licensing Agency (DVLA) guidelines. Regular updates are published on the DVLA website. [2007]

1.1.23 After an MI without complications, people who wish to travel by air should seek advice from the Civil Aviation Authority. People who have had a complicated MI need expert individual advice. [2007, amended 2013]

1.1.24 People who have had an MI who hold a pilot's licence should seek advice from the Civil Aviation Authority. [2007]

1.1.25 Take into account the patient's physical and psychological status, as well as the type of activity planned when offering advice about the timing of returning to normal activities. [2007]

1.1.26 An estimate of the physical demand of a particular activity, and a comparison between activities, can be made using tables of metabolic equivalents (METS) of different activities (for further information please refer to the Centers for Disease Control and Prevention website). Advise patients how to use a perceived exertion scale to help monitor physiological demand. Patients who have had a complicated MI may need expert advice. [2007]

1.1.27 Advice on competitive sport may need expert assessment of function and risk, and is dependent on what sport is being discussed and the level of competitiveness. [2007]

Psychological and social support

1.1.28 Offer stress management in the context of comprehensive cardiac rehabilitation. [2007]

1.1.29 Do not routinely offer complex psychological interventions such as cognitive behavioural therapy. [2007]

1.1.30 Involve partners or carers in the cardiac rehabilitation programme if the patient wishes. [2007]

1.1.31 For recommendations on the management of patients with clinical anxiety or depression, refer to Anxiety (NICE clinical guideline 113), Depression in adults (NICE clinical guideline 90) and Depression in adults with a chronic physical health problem (NICE clinical guideline 91). [2007]

Sexual activity

1.1.32 Reassure patients that after recovery from an MI, sexual activity presents no greater risk of triggering a subsequent MI than if they had never had an MI. [2007]

1.1.33 Advise patients who have made an uncomplicated recovery after their MI that they can resume sexual activity when they feel comfortable to do so, usually after about 4 weeks. [2007]

1.1.34 Raise the subject of sexual activity with patients within the context of cardiac rehabilitation and aftercare. [2007]

1.1.35 When treating erectile dysfunction, treatment with a PDE5 (phosphodiesterase type 5) inhibitor may be considered in men who have had an MI more than 6 months earlier and who are now stable. [2007]

1.1.36 PDE5 inhibitors must be avoided in patients treated with nitrates or nicorandil because this can lead to dangerously low blood pressure. [2007]

1.2 Lifestyle changes after an MI

Changing diet

1.2.1 Advise people to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on plant oils). [2007]

1.2.2 Do not routinely recommend eating oily fish for the sole purpose of preventing another MI. If people after an MI choose to consume oily fish, be aware that there is no evidence of harm, and fish may form part of a Mediterranean-style diet. [new 2013]

1.2.3 Do not offer or advise people to use the following to prevent another MI:

  • omega-3 fatty acid capsules

  • omega-3 fatty acid supplemented foods.

    If people choose to take omega-3 fatty acid capsules or eat omega-3 fatty acid supplemented foods, be aware that there is no evidence of harm. [new 2013]

1.2.4 Advise people not to take supplements containing beta-carotene. Do not recommend antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk. [2007]

1.2.5 Offer people an individual consultation to discuss diet, including their current eating habits, and advice on improving their diet. [2007]

1.2.6 Give people consistent dietary advice tailored to their needs. [2007]

1.2.7 Give people healthy eating advice that can be extended to the whole family. [2007]

Alcohol consumption

1.2.8 Advise people who drink alcohol to keep weekly consumption within safe limits (no more than 21 units of alcohol per week for men, or 14 units per week for women) and to avoid binge drinking (more than 3 alcoholic drinks in 1–2 hours). [2007]

Regular physical activity

1.2.9 Advise people to undertake regular physical activity sufficient to increase exercise capacity. [2007]

1.2.10 Advise people to be physically active for 20–30 minutes a day to the point of slight breathlessness. Advise people who are not active to this level 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. [2007]

1.2.11 Advice on physical activity should involve a discussion about current and past activity levels and preferences. The benefit of exercise may be enhanced by tailored advice from a suitably qualified professional. [2007]

Smoking cessation

1.2.12 Advise all people who smoke to stop and offer assistance from a smoking cessation service in line with Brief interventions and referral for smoking cessation (NICE public health guidance 1). [2007]

1.2.13 All patients who smoke and who have expressed a desire to quit should be offered support and advice, and referral to an intensive support service (for example, the NHS Stop Smoking Services) in line with Brief interventions and referral for smoking cessation (NICE public health guidance 1). If a patient is unable or unwilling to accept a referral they should be offered pharmacotherapy in line with the recommendations in Smoking cessation services (NICE public health guidance 10). [2007]

Weight management

1.2.14 After an MI, offer all patients who are overweight or obese advice and support to achieve and maintain a healthy weight in line with Obesity (NICE clinical guideline 43). [2007]

1.3 Drug therapy

1.3.1 Offer all people who have had an acute MI treatment with the following drugs:

  • ACE (angiotensin-converting enzyme) inhibitor

  • dual antiplatelet therapy (aspirin plus a second antiplatelet agent)

  • beta-blocker

  • statin. [2007, amended 2013]

1.3.2 Ensure that a clear management plan is available to the person who has had an MI and is also sent to the GP, including:

  • details and timing of any further drug titration

  • monitoring of blood pressure

  • monitoring of renal function. [new 2013]

1.3.3 Offer all people who have had an MI an assessment of bleeding risk at their follow-up appointment. [new 2013]

1.3.4 Offer an assessment of left ventricular function to all people who have had an MI. [2013]

ACE inhibitors

1.3.5 Offer people who present acutely with an MI an ACE inhibitor as soon as they are haemodynamically stable. Continue the ACE inhibitor indefinitely. [new 2013]

1.3.6 Titrate the ACE inhibitor dose upwards at short intervals (for example, every 12–24 hours) before the person leaves hospital until the maximum tolerated or target dose is reached. If it is not possible to complete the titration during this time, it should be completed within 4–6 weeks of hospital discharge. [new 2013]

1.3.7 Do not offer combined treatment with an ACE inhibitor and an angiotensin II receptor blocker (ARB) to people after an MI, unless there are other reasons to use this combination. [new 2013]

1.3.8 Offer people after an MI who are intolerant to ACE inhibitors an ARB instead of an ACE inhibitor. [new 2013]

1.3.9 Renal function, serum electrolytes and blood pressure should be measured before starting an ACE inhibitor or ARB and again within 1 or 2 weeks of starting treatment. Patients should be monitored as appropriate as the dose is titrated upwards, until the maximum tolerated or target dose is reached, and then at least annually. More frequent monitoring may be needed in patients who are at increased risk of deterioration in renal function. Patients with chronic heart failure should be monitored in line with Chronic heart failure (NICE clinical guideline 108). [2007]

1.3.10 Offer an ACE inhibitor to people who have had an MI more than 12 months ago. Titrate to the maximum tolerated or target dose (over a 4–6-week period) and continue indefinitely. [new 2013]

1.3.11 Offer people who have had an MI more than 12 months ago and who are intolerant to ACE inhibitors an ARB instead of an ACE inhibitor. [new 2013]

Antiplatelet therapy

1.3.12 Offer aspirin to all people after an MI and continue it indefinitely, unless they are aspirin intolerant or have an indication for anticoagulation. [2007, amended 2013]

1.3.13 Offer aspirin to people who have had an MI more than 12 months ago and continue it indefinitely. [new 2013]

1.3.14 For patients with aspirin hypersensitivity, clopidogrel monotherapy should be considered as an alternative treatment. [2007]

1.3.15 People with a history of dyspepsia should be considered for treatment in line with Dyspepsia (NICE clinical guideline 17). [2007, amended 2013]

1.3.16 After appropriate treatment, people with a history of aspirin-induced ulcer bleeding whose ulcers have healed and who are negative for Helicobacter pylori should be considered for treatment in line with Dyspepsia (NICE clinical guideline 17). [2007, amended 2013]

This guidance incorporates NICE technology appraisal guidance 236 on ticagrelor for the treatment of acute coronary syndromes. Guidance on prasugrel for the treatment of acute coronary syndromes has not been incorporated in this guidance because this technology appraisal is currently scheduled for update. For further information about this appraisal, see the NICE website.

1.3.17 Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months as a treatment option in adults with acute coronary syndromes (ACS) that is, people:

  • with ST-segment-elevation myocardial infarction (STEMI) – defined as ST elevation or new left bundle branch block on electrocardiogram – that cardiologists intend to treat with primary percutaneous coronary intervention (PCI) or

  • with non-ST-segment-elevation myocardial infarction (NSTEMI).

This recommendation is from Ticagrelor for the treatment of acute coronary syndromes (NICE technology appraisal guidance 236). [new 2013]

1.3.18 Offer clopidogrel as a treatment option for up to 12 months to:

  • people who have had an NSTEMI, regardless of treatment[1]

  • people who have had a STEMI and received a bare-metal or drug-eluting stent. [new 2013]

1.3.19 Offer clopidogrel as a treatment option for at least 1 month and consider continuing for up to 12 months to:

  • people who have had a STEMI and medical management with or without reperfusion treatment with a fibrinolytic agent. [new 2013]

1.3.20 Continue the second antiplatelet agent for up to 12 months in people who have had a STEMI and who received coronary artery bypass graft (CABG) surgery. [new 2013]

1.3.21 Offer clopidogrel instead of aspirin to people who also have other clinical vascular disease, in line with Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (NICE technology appraisal guidance 210), and who have:

  • had an MI and stopped dual antiplatelet therapy or

  • had an MI more than 12 months ago. [new 2013]

Antiplatelet therapy in people with an indication for anticoagulation

1.3.22 Take into account all of the following when thinking about treatment for people who have had an MI and who have an indication for anticoagulation:

  • bleeding risk

  • thromboembolic risk

  • cardiovascular risk. [new 2013]

1.3.23 Unless there is a high risk of bleeding, continue anticoagulation and add aspirin to treatment in people who have had an MI who otherwise need anticoagulation and who:

  • have had their condition managed medically or

  • have undergone balloon angioplasty or

  • have undergone CABG surgery. [new 2013]

1.3.24 Continue anticoagulation and add clopidogrel to treatment in people who have had an MI, who have undergone percutaneous coronary intervention (PCI) with bare-metal or drug-eluting stents and who otherwise need anticoagulation. [new 2013]

1.3.25 Offer clopidogrel with warfarin to people with a sensitivity to aspirin who otherwise need anticoagulation and aspirin and who have had an MI. [new 2013]

1.3.26 Do not routinely offer warfarin in combination with prasugrel or ticagrelor to people who need anticoagulation who have had an MI. [new 2013]

1.3.27 After 12 months since the MI, continue anticoagulation and take into consideration the need for ongoing antiplatelet therapy, taking into account all of the following:

  • the indication for anticoagulation

  • thromboembolic risk

  • bleeding risk

  • cardiovascular risk

  • the person's wishes. [new 2013]

1.3.28 Do not add a new oral anticoagulant (rivaroxaban, apixaban or dabigatran) in combination with dual antiplatelet therapy in people who otherwise need anticoagulation, who have had an MI. [new 2013]

1.3.29 Consider using warfarin and discontinuing treatment with a new oral anticoagulant (rivaroxaban, apixaban or dabigatran) in people who otherwise need anticoagulation and who have had an MI, unless there is a specific clinical indication to continue it. [new 2013]

Beta-blockers

1.3.30 Offer people a beta-blocker as soon as possible after an MI, when the person is haemodynamically stable. [new 2013]

1.3.31 Communicate plans for titrating beta-blockers up to the maximum tolerated or target dose – for example, in the discharge summary. [new 2013]

1.3.32 Continue a beta-blocker for at least 12 months after an MI in people without left ventricular systolic dysfunction or heart failure. [new 2013]

1.3.33 Continue a beta-blocker indefinitely in people with left ventricular systolic dysfunction. [new 2013]

1.3.34 Offer all people who have had an MI more than 12 months ago, who have left ventricular systolic dysfunction, a beta-blocker whether or not they have symptoms. For people with heart failure plus left ventricular dysfunction, manage the condition in line with Chronic heart failure (NICE clinical guideline 108). [new 2013]

1.3.35 Do not offer people without left ventricular systolic dysfunction or heart failure, who have had an MI more than 12 months ago, treatment with a beta-blocker unless there is an additional clinical indication for a beta-blocker. [new 2013]

Calcium channel blockers

1.3.36 Do not routinely offer calcium channel blockers to reduce cardiovascular risk after an MI. [2007]

1.3.37 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. [2007]

1.3.38 For patients who are stable after an MI, calcium channel blockers may be used to treat hypertension and/or angina. For patients with heart failure, use amlodipine, and avoid verapamil, diltiazem and short-acting dihydropyridine agents in line with Chronic heart failure (NICE clinical guideline 108). [2007]

Potassium channel activators

1.3.39 Do not offer nicorandil to reduce cardiovascular risk in patients after an MI. [2007]

Aldosterone antagonists in patients with heart failure and left ventricular dysfunction

1.3.40 For patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, initiate treatment with an aldosterone antagonist licensed for post-MI treatment within 3–14 days of the MI, preferably after ACE inhibitor therapy. [2007]

1.3.41 Patients who have recently had an acute MI and have clinical heart failure and left ventricular systolic dysfunction, but who are already being treated with an aldosterone antagonist for a concomitant condition (for example, chronic heart failure), should continue with the aldosterone antagonist or an alternative, licensed for early post-MI treatment. [2007]

1.3.42 For patients who have had a proven MI in the past and heart failure due to left ventricular systolic dysfunction, treatment with an aldosterone antagonist should be in line with Chronic heart failure (NICE clinical guideline 108). [2007]

1.3.43 Monitor renal function and serum potassium before and during treatment with an aldosterone antagonist. If hyperkalaemia is a problem, halve the dose of the aldosterone antagonist or stop the drug. [2007]

Statins and other lipid lowering agents

1.3.44 Statin therapy is recommended for adults with clinical evidence of cardiovascular disease in line with Statins for the prevention of cardiovascular events (NICE technology appraisal guidance 94) and Lipid modification (NICE clinical guideline 67). [2007]

Recommendations about statins and other lipid lowering agents have been removed from the update of the guideline. Recommendations on the use of statins and other lipid lowering agents can be found in Lipid modification (NICE clinical guideline 67) and Statins for the prevention of cardiovascular events (NICE technology appraisal guidance 94).

1.4 Coronary revascularisation after an MI

1.4.1 Offer everyone who has had an MI a cardiological assessment to consider whether coronary revascularisation is appropriate. This should take into account comorbidity. [2007]

1.5 Selected patient subgroups

Patients with hypertension

1.5.1 Treat hypertension in line with Hypertension (NICE clinical guideline 127). [2007, amended 2013]

Patients with left ventricular systolic dysfunction

1.5.2 Patients who have left ventricular systolic dysfunction should be considered for an implantable cardioverter defibrillator in line with Implantable cardioverter defibrillators for arrhythmias (NICE technology appraisal guidance 95). [2007]

1.6 Communication of diagnosis and advice

1.6.1 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

  • future management plans

  • advice on secondary prevention. [2007, amended 2013]

1.6.2 Offer a copy of the discharge summary to the patient. [2007]



[1] This recommendation updates and replaces recommendation 1.3 in Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome (NICE technology appraisal guidance 80).

  • National Institute for Health and Care Excellence (NICE)