About this guideline

NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales.

NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover.

This guideline was developed by the National Clinical Guideline Centre, which is based at the Royal College of Physicians. The Centre worked with a Guideline Development Group, comprising healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, which reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation.

The methods and processes for developing NICE clinical guidelines are described in The guidelines manual.

Update information

This guideline updates and replaces NICE clinical guideline 48 (published May 2007). NICE clinical guideline 48 replaced NICE inherited guideline A (2001).

Recommendation 1.3.18 updates and replaces recommendation 1.3 from 'Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome', NICE technology appraisal guidance 80.

Recommendations are marked as [new 2013], [2013], [2007] or [2007, amended 2013]:

  • [new 2013] indicates that the evidence has been reviewed and the recommendation has been added or updated

  • [2013] indicates that the evidence has been reviewed but no change has been made to the recommended action

  • [2007] indicates that the evidence has not been reviewed since 2007

  • [2007, amended 2013] indicates that the evidence has not been reviewed since 2007, but changes have been made to the recommendation wording that change the meaning (see below).

Recommendations from NICE clinical guideline 48 that have been amended

Recommendations are labelled [2007, amended 2013] if the evidence has not been reviewed since 2007 but changes have been made to the recommendation wording that change the meaning.

Recommendation in NICE clinical guideline 48

Recommendation in current guideline

Reason for change

After an MI without complications, patients can usually travel by air within 2−3 weeks. Patients who have had a complicated MI need expert individual advice. [1.2.3.5]

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]

This recommendation has been amended to reflect updated information on air travel after an MI from the Civil Aviation Authority.

All patients who have had an acute MI should be offered treatment with a combination of the following drugs:

  • ACE (angiotensin-converting enzyme) inhibitor

  • aspirin

  • beta-blocker

  • statin. [1.3.1.1]

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]

This recommendation has been amended to reflect that dual antiplatelet therapy should be given to all patients after an MI (excluding those with contraindications).

Aspirin should be offered to all patients after an MI and should be continued indefinitely. [1.3.3.1]

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]

This recommendation has been amended to include situations where aspirin would not be offered indefinitely.

After an acute 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. [1.6.1]

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]

This recommendation has been amended to reflect the importance of including details of any incomplete titrations in the discharge summary. This reflects new recommendations on titration of ACE inhibitors and beta-blockers included in the guideline update.

Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Development Group is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also Patient-centred care).

Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally we use 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a 'strong' recommendation

We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, 'Do not offer…') when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of 'The guidelines manual' (January 2009). This does not apply to any recommendations ending [2007] (see 'Update information' box above for details about how recommendations are labelled). In particular, for recommendations labelled [2007], the word 'consider' may not necessarily be used to denote the strength of the recommendation.

Other versions of this guideline

The full guideline, 'MI – secondary prevention: secondary prevention in primary and secondary care for patients following a myocardial infarction' contains details of the methods and evidence used to develop the guideline. It is published by the National Clinical Guideline Centre.

The recommendations from this guideline have been incorporated into a NICE Pathway.

We have produced information for the public about this guideline.

Implementation

Implementation tools and resources to help you put the guideline into practice are also available.

Changes after publication

November 2013: minor maintenance

Your responsibility

This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance 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, and informed by the summaries of product characteristics of any drugs.

Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, 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 guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Copyright

© National Institute for Health and Care Excellence 2013. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.

ISBN: 978-1-4731-0354-2

  • National Institute for Health and Care Excellence (NICE)