Introduction

This quality standard covers secondary prevention after a myocardial infarction (MI), including cardiac rehabilitation, in adults (aged 18 years and over). It does not cover the diagnosis and management of myocardial infarction, which is covered by the quality standard on acute coronary syndromes (including myocardial infarction). For more information see the secondary prevention after a myocardial infarction topic overview.

In addition to the areas covered by this quality standard, the Quality Standards Advisory Committee identified the prescribing of high‑dose high‑intensity statins for secondary prevention as an area for quality improvement. The quality standard on cardiovascular risk assessment and lipid modification has a statement about this, which should be referred to for full details. Coronary revascularisation was also identified as an area for quality improvement; this area is covered in the quality standard on acute coronary syndromes (including myocardial infarction).

Why this quality standard is needed

MI is one of the most severe presentations of coronary heart disease (CHD). It is usually caused by blockage of a coronary artery that results in tissue death and is commonly referred to as a heart attack. People who have had an MI benefit from treatment to reduce the risk of another MI and to slow the progression of CHD; this is known as secondary prevention. Examples of secondary prevention for people who have had an MI include the following:

  • Drug treatment such as anti‑platelet drugs, beta‑blockers, angiotensin‑converting enzyme (ACE) inhibitors and statins.

  • Changes in lifestyle such as healthy eating, regular exercise and stopping smoking, which are key components of cardiac rehabilitation programmes.

MI is a preventable complication of CHD. The death rate from CHD has been falling since the early 1970s; for people under 75, the death rate fell by almost 25% between 1996 and 2004. The death rate from CHD varies with age, gender, socioeconomic status, ethnicity and UK geographic location. Death rates in men under 75 are 3 times higher than in women, and death rates in affluent areas in the UK are half of those in deprived areas. People of South Asian origin have almost a 50% higher death rate than the general UK population.

In England and Wales in 2013/14, more than 80,000 hospital admissions were because of MI, according to the Myocardial Ischaemia National Audit Project (MINAP). Twice as many men had MIs as women. The data also showed that 30‑day mortality decreased between 2003/04 and 2013/14 through improved treatment.

The quality standard is expected to contribute to improvements in the following outcomes:

  • life expectancy

  • mortality

  • incidence of cardiovascular disease (CVD) events

  • health‑related quality of life for people with long‑term conditions

  • readmissions

  • functional ability after MI

  • return to employment

  • patient experience

  • psychological wellbeing.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1b Life expectancy at 75 i Males ii Females

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease*

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Improving functional ability in people with long‑term conditions

2.2 Employment of people with long‑term conditions**

Reducing time spent in hospital by people with long‑term conditions

2.3i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)

3 Helping people to recover from episodes of ill health or following injury

Overarching indicator

3b Emergency readmissions within 30 days of discharge from hospital*

Improvement areas

Helping older people to recover their independence after illness or injury

3.6 i Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation service***

ii Proportion offered rehabilitation following discharge from acute or community hospital

4 Ensuring that people have a positive experience of care

Overarching indicator

4b Patient experience of hospital care

Alignment across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF)

** Indicator complementary with Adult Social Care Outcomes Framework (ASCOF)

*** Indicator shared with Adult Social Care Outcomes Framework (ASCOF)

Table 2 The Adult Social Care Outcomes Framework 2015–16

Domain

Overarching and outcome measures

1 Delaying and reducing the need for care and support

Outcome measures

Everybody has the opportunity to have the best health and wellbeing throughout their life, and can access support and information to help manage their care needs.

2b Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services**

Aligning across the health and care system

** Indicator shared

Table 3 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.4 Under 75 mortality rate from cardiovascular diseases (including heart disease and stroke)

4.11 Emergency readmissions within 30 days of discharge from hospital*

Aligning across the health and care system

* Indicator complementary

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to secondary prevention after an MI.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for secondary prevention after an MI specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole secondary prevention pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high-quality care to people after an MI.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing high‑quality interventions for MI are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating people with MI should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source(s) on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting people with MI. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.