People who have had a heart attack (myocardial infarction, or MI) have a considerably increased risk of having another one. The National Institute for Health and Care Excellence (NICE) has published its updated guidance on the best ways to reduce this risk by improving the care of hundreds of thousands of adults in England and Wales who have survived a heart attack.

Heart attacks are usually caused by a blockage in the coronary artery, a preventable complication of coronary heart disease (CHD). Since the late 1990s there has been a reduction in deaths caused by heart attacks, largely as a result of changes in treatments given immediately following a heart attack and the use of therapies, such as cardiac rehabilitation, to prevent further heart attacks. Even so, heart attacks remain a common cause of death and continuing ill health. When compared internationally, the UK death rate from CHD is relatively high with more than 103,000 deaths per year. There are currently around 1 million men and nearly 500,000 women in the UK who have had a heart attack. For a large number of these people measures to prevent another heart attack are important.

The aim of the guideline, originally published in 2007, is to help prevent further heart attacks and progression of vascular disease in those who have already had a heart attack. A key focus of the new guideline is on cardiac rehabilitation programmesⁱ to help people recover. As heart attack survivor John Walsh, a member of the group which developed the guideline, says: “The treatment heart attack patients receive has changed dramatically and for the better. Survival rates are improving, and it is important that we survivors build on our good fortune by avoiding another heart attack. The best way to do this is to get on a cardiac rehabilitation programme and listen to the advice you get from the people running it: it really should be quite easy. But all too often people come up against barriers that prevent them from getting the most out of cardiac rehabilitation. These are often simple things, like not understanding the benefits of cardiac rehabilitation and what the programme entails, or not having the time to attend the programme and the programme being held at inconvenient times. Ensuring access to timely and appropriately structured cardiac rehabilitation programmes is a key focus of the new guideline, as are measures that healthcare professionals should take to ensure more people understand the benefits of cardiac rehabilitation and are motivated to attend and complete them.”

"This updated guideline addresses ways of improving uptake of cardiac rehabilitation programmes and the need to encourage early attendance” adds Dr Linda Speck, consultant clinical health psychologist and member of the Guideline Development Group. “It also recognises the importance of exploring individuals' health beliefs and illness perceptions which may be significant barriers to attendance."

The guideline recommends that cardiac rehabilitation programme should begin as soon as possible, and before the patient leaves hospital. Once they have gone home, they should be invited to a cardiac rehabilitation session which should start within 10 days of their discharge. Cardiac rehabilitation programmes should be offered 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). The programmes should provide a range of different types of exercise to meet the needs of people of all ages, or those who have other illnesses. Some people, such as those from black and minority ethnic groups, people from rural communities and people with mental and physical health conditions, may be less likely to access cardiac rehabilitation programmes. The guideline therefore recommends that programmes should be made equally accessible and relevant to all groups.

Kathryn Carver, cardiac rehabilitation lead nurse and member of the Guideline Development Group, said: “The national average uptake for cardiac rehabilitation in 2012 was 46%. The recommendation that cardiac rehabilitation should be commenced prior to discharge from hospital with an early invitation to a comprehensive cardiac rehabilitation programme within 10 days of discharge will be challenging. However the evidence is clear that uptake as well as completion and clinical outcomes are better if this can be achieved.”

New evidence shows that the risk of further cardiovascular events such as heart attacks or strokes is very different today because of the new treatments that are now available. This means that any impact an oily fish diet may have on preventing further heart attacks or strokes could be minimal. Therefore the guideline no longer recommends eating oily fish, or taking omega-3 fatty acid capsules or omega-3 fatty acid supplemented foods specifically for the prevention of further heart attacks. The guideline does, however, continue to highlight the important role of lifestyle changes in preventing further heart attacks, including that people who have had a heart attack should be encouraged to exercise for 20 - 30 minutes daily. It also recommends that people who have had a heart attack should eat a Mediterranean-style diet, with more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on plant oils.

Major changes in the treatments given immediately after a heart attack since the original guideline was published, particularly the use of stents rather than drugs to widen blocked or narrowed coronary arteries (primary percutaneous coronary intervention), have also been taken into account.ⁱⁱ

Other key priorities for implementation in the new guideline include those on the use of drugs after a heart attack. These reflect new findings on treatments to prevent blood clots (antithrombotic therapy) and on the use of drugs to reduce blood pressure and control heart rhythm and rate such as angiotensin-converting enzyme inhibitors (ACE inhibitors) and beta-blockers.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: “Despite the improvements in the number of people surviving a heart attack, heart disease remains the UK's biggest killer. It also causes ongoing health problems for many thousands of others. This updated guideline takes on board the latest evidence on the best ways to prevent further heart attacks or strokes in people who have already suffered a heart attack. Its aim is to ensure the growing number of people who now survive a heart attack are provided with the good quality, systematic care that is essential to improving long term outcomes and quality of life.”

Dr Phil Adams, retired consultant cardiologist and Chair of the Guideline Development Group, said: “People who have had a heart attack, almost 80,000 in England and Wales in 2011-12, are at increased risk of a further attack, but there is a lot we can do to help them reduce this risk. The guideline stresses the importance of starting cardiac rehabilitation very early so that people can straight away start to learn about the lifestyle changes that will help, for instance stopping smoking, and can make plans for exercise when they are ready. The guideline also makes recommendations to make drug treatment as effective as possible, bringing in the new drugs to stop clotting in the arteries, and most important emphasising communication about drug plans between all those caring for people who have had a heart attack.”

Dr Ivan Benett, a GP with a special interest in cardiology and member of the Guideline Development Group, said: “This updated guideline provides the latest evidence that will save lives after a heart attack. The challenge for clinicians and commissioners is to make sure that everyone receives the care outlined here, reliably and consistently. Everyone who has had a heart attack should expect the quality of care defined here.”'

Ends

The guideline on the secondary prevention of myocardial infarction in primary and secondary care will be available on the NICE website from 13 November. Embargoed copies are available on request from the NICE press office. To support the implementation of this guideline NICE has produced a suite of implementation support tools. These include shared learning examples and a costing tool and will be available on the NICE website.

Notes to Editors

References

i. Cardiac rehabilitation is the coordinated sum of interventions required to ensure the best possible physical, psychological and social conditions to enable the CHD patient to preserve or resume optimal functioning in society. It also aims to slow or reverse progression of the disease. Cardiac rehabilitation cannot be regarded as an isolated form or stage of therapy, but must be integrated within secondary prevention services, of which it forms only one facet (WHO definition, 1993).
The 2013 National Audit of Cardiac Rehabilitation Report shows only 46% of people started outpatient cardiac rehabilitation programmes in England, Northern Ireland and Wales, following an MI. The report also describes an average 53 day wait for the beginning of an outpatient rehabilitation programme. The Cardiovascular Disease Outcomes Strategy (03/13) recommends improvements in delivery and access to cardiac rehabilitation services for all patients with cardiovascular disease.

ii. Primary percutaneous coronary intervention (PPCI) has replaced thrombolysis in most cases of STEMI. In 2007 15% cases underwent PPCI, 60% receiving lytic therapy. The Myocardial Ischaemia National Audit Project (MINAP) report for 2011-12 demonstrates that only 5% of people with STEMI underwent thrombolysis, 30% had no reperfusion therapy (due to contraindications or late presentation) the remaining 65% undergoing PPCI.

About the guideline

Other key priorities for implementation include:

• 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.
• Offer an assessment of left ventricular function to all people who have had an MI.
• 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.
• Make arrangements (for example, in the discharge summary) to ensure that titration of beta-blockers occurs up to the maximum tolerated or target dose.

About heart attacks

1. Changes seen on an electrocardiogram (ECG) help to divide heart attacks into 2 distinct types: ST-segment elevation myocardial infarction (STEMI) generally caused by complete and persisting blockage of the artery; and non-ST-segment elevation myocardial infarction (NSTEMI), reflecting partial or intermittent blockage.

2. The 2012 MINAP report describes the reductions in mortality as a result of heart attacks since the late 1990s. Since 2003/04 there has been an almost 40% reduction in death rates, from 13 to 8 per 100 heart attacks. These figures are based on 30-day mortality and are for STEMI; the NSTEMI results are similar.

3. The 2012 MINAP report describes more than 79,000 hospital admissions in England and Wales due to MI in the previous year, 41% STEMI and 59% NSTEMI. Twice as many men had MIs as women, their average age for a first MI being 65 years, while women had their first MI at 73 years.

About NICE

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