Surveillance decision

Surveillance decision

We will plan an update of the guideline on myocardial infarction: secondary prevention (CG172). The update will focus on:

  • Beta-blocker treatment for patients without left ventricular dysfunction.

We will also amend the guideline to replace recommendations on alcohol consumption and antiplatelet therapy for people without an indication for anticoagulation. The following amendments will be made:

  • Recommendation 1.2.8 will be replaced with a cross referral to the most recent guidance from the Department of Health on how to keep health risks from drinking alcohol to a low level.

  • Recommendations 1.3.12–1.3.21 about antiplatelet therapy for people without an indication for anticoagulation will be stood down. The NICE guideline on unstable angina and NSTEMI: early management published in 2010, is currently undergoing update and a cross referral to this guideline will be made after publication.

During surveillance editorial or factual corrections were identified. Details are included in appendix A: summary of evidence from surveillance.

Reason for the decision

Assessing the evidence

We found 55 studies through surveillance of this guideline.

Evidence that could affect recommendations was identified. Topic experts, including those who helped to develop the guideline, advised us about whether the following sections of the guideline should be updated:

Lifestyle changes after myocardial infarction
  • What is the effectiveness of low/ moderate alcohol consumption versus high alcohol consumption to improve outcome in patients after myocardial infarction (MI)?

  • What is the effectiveness of no/ low/moderate alcohol consumption versus high alcohol consumption to improve outcome in patients after MI?

Although no new evidence was identified during the surveillance review, a topic expert highlighted that the current recommendation (1.2.8) is not in line with the latest guidance from the Department of Health. Topic experts were in agreement that recommendation 1.2.8 should be replaced with a cross referral to this guidance.

Decision: Recommendations under these questions should be removed. They will be replaced with a cross referral to the most recent guidance from the Department of Health on how to keep health risks from drinking alcohol to a low level.

Drug therapy – beta-blockers
  • What is the clinical and cost effectiveness of adding a beta-blocker versus placebo to improve outcome in people after an MI i) with and ii) without left ventricular dysfunction and is there an optimal duration?

The 4-year surveillance review identified new evidence on the use of beta-blockers in people without left ventricular dysfunction which may have an impact on current recommendations. The new evidence suggests that long term treatment with beta-blockers in this group of patients may increase the risk of heart failure, cardiogenic shock and drug discontinuation. Furthermore, there may be no mortality benefit of continuing beta-blockers beyond one year. NICE guideline CG172 currently recommends continuing a beta-blocker for at least 12 months after an MI in people without left ventricular systolic dysfunction or heart failure. Topic experts agreed that the optimum duration of beta-blocker treatment in this group is currently an area of uncertainty for practitioners and this recommendation (1.3.32) may need updating in light of the new evidence.

Decision: This question should be updated.

Drug therapy – antiplatelet therapy for people without an indication for anticoagulation
  • In people with a proven MI in the past who were not initiated on dual antiplatelet therapy (clopidogrel, prasugrel or ticagrelor in combination with aspirin), should this be initiated?

  • What is the optimal duration that clopidogrel should be continued in patients after an MI?

Any recommendations relating to antiplatelet therapy for patients without an indication for anticoagulation will potentially overlap with recommendations in NICE guideline CG94, which is currently undergoing update. Topic experts were in agreement that recommendations in this section of the guideline should therefore be stood down and replaced with a link to the updated NICE guideline CG94 once it is published.

Decision: should be removed. The NICE guideline on unstable angina and NSTEMI: early management published in 2010, is currently undergoing update and a cross referral will be made after publication. Recommendations 1.3.12–1.3.21

Other clinical areas

We also found evidence that supports current recommendations on:

  • Comprehensive cardiac rehabilitation.

  • Factors associated with a person's uptake and adherence to cardiac rehabilitation programmes.

  • Interventions to increase engagement and/or adherence to cardiac rehabilitation programmes.

  • Health education and information needs.

  • Use of ACE inhibitors in people after an MI.

  • Use of ACE inhibitors with ARBs in people after an MI.

  • Use of antiplatelet therapy in combination with anticoagulant therapy.

  • The optimal time for a beta-blocker to be initiated in people who have had an MI.

We found evidence on the off-label use of colchicine and L-carnitine, which are not covered in the guideline. However, the evidence was insufficient to add new recommendations in these areas at this time.

We found evidence on a range of specific psychological interventions to address depression and anxiety in patients with MI, which are not currently advised in the guideline. We also found evidence on omega-3 fatty acids, which the guideline does not currently recommend. However for both of these areas, the evidence was insufficient to impact the recommendations at this time.

We did not find any evidence related to:

  • sexual activity

  • changing diet

  • oily fish consumption

  • advice on regular physical activity

  • smoking cessation

  • weight management

  • the optimal time for ACE inhibitors to be initiated in people who have had an MI

  • calcium channel blockers

  • potassium channel blockers

  • aldosterone antagonists in patients with heart failure and left ventricular dysfunction

  • coronary revascularisation after an MI

  • patients with hypertension.

For any evidence relating to published or ongoing NICE technology appraisals, the guideline surveillance review deferred to the technology appraisal decision. This included Vorapaxar for reducing atherothrombotic events after a myocardial infarction or in peripheral vascular disease.

Equalities

No equalities issues were identified during the surveillance process.

Overall decision

After considering all the evidence and views of topic experts, it was decided that a partial update is necessary for this guideline.

See how we made the decision for further information.


This page was last updated: 25 May 2017