National Institute for Health and Clinical Excellence (NICE)
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New NICE guidelines are set to reduce premature deaths in people who have had a heart attack
Updated guidelines from the National Institute for Health and Clinical Excellence (NICE) launched this week are set to have a significant impact in reducing premature deaths by improving the care received by hundreds of thousands of adults in England and Wales who have survived a heart attack (myocardial infarction or MI).
Produced by the National Collaborating Centre for Primary Care (NCC-PC), the guideline on secondary prevention of MI replaces NICE’s previous guideline published in 2001. It updates recommendations on the use of drugs after a heart attack ensuring they are based on the most current evidence.
The previous guidance from 2001 did not make any recommendations on advice for patients on physical activity or smoking and only identified that there was not sufficient evidence on which to base recommendations about diet advice. Today’s guidance contains several recommendations on the “lifestyle” advice that should be given to patients, such as giving up smoking, being physically active for 20-30 minutes a day and eating a Mediterranean diet.
The updated guidance also expands on previous recommendations around cardiac rehabilitation services and recommends that patients should be considered for a cardiological assessment to identify those that may benefit from heart surgery.
Heart attacks are a complication of coronary heart disease (CHD) which is preventable. In the UK, about 838,000 men and 394,000 women have had an MI at some point in their lives. Although the death rate from CHD has been falling in the UK since the early 1970s (for people aged below 75, rates have fallen by almost 25% since 1996), when compared internationally, the UK death rate from CHD is one of the highest in Europe with more than 103,000 deaths per year. CHD death rates vary with age, gender, socio-economic status, ethnicity and UK geographic location.
Death rates in men aged less than 75 years are three times as high as those 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 compared with the general population.
Dr Gill Leng, NICE Implementation Systems Director and Executive Lead for the guideline, said: “This new guideline compiles evidence-based recommendations on best practice in the management of people who have suffered a heart attack. Its overall aim is to provide the growing number of people who now survive a heart attack with the good quality systematic care that is essential to improving long term outcomes and quality of life. The guideline will help ensure there is a coherent and consistent approach amongst clinicians of all disciplines and places of practice involved in post-MI management. This in turn should prevent the confusion for patients caused by inconsistent messages that can lead to patient disengagement and sub-optimal care.”
Professor Gene Feder, Professor of Primary Care Research and Development and Chair of the Guideline Development Group (GDG), said: “The important role of drugs and smoking cessation in preventing a second heart attack is recognised by GPs and practice nurses who provide most of the long term health care to people with a previous heart attack. By way of contrast, the growing evidence that cardiac rehabilitation and specific lifestyle changes reduces the risk of second heart attacks, as well as improving quality of life, is not widely recognised. This guideline highlights the central role of cardiac rehabilitation and emphasizes the importance of lifelong dietary changes and engagement in exercise. These need to be integrated into the review and follow up of patients once they have been discharged from hospital after their heart attack.”
Dr Jane Skinner, Consultant Community Cardiologist and Clinical Advisor on the GDG, said: “It is important that this guideline is recognised as requiring implementation in both primary and secondary care. In patients after acute MI, secondary prevention management will be initiated in secondary care, with further monitoring, refinement and optimisation in primary care. This requires integration and effective communication between the two to plan and provide seamless care.”
John Walsh, patient representative on the GDG, said: “I am particularly pleased that the guideline makes a number of key recommendations about access to cardiac rehabilitation. “Rehab” is extremely important since it’s the bridge that allows a post-MI patient to rejoin ordinary life in good shape. The recommendations on lifestyle are also significant, especially, in my view, the points relating to diet. ‘We are what we eat’ is literally true and this guideline recognises the importance of eating more of what is good for us, especially maintaining a Mediterranean-style diet, in order to reduce the risk of further MIs.”
Anne White, British Heart Foundation Cardiac Specialist Nurse and member of the GDG, commented: “This guidance will help to empower cardiac rehabilitation teams to provide equitable, patient-centred rehab programmes which are accessible to everyone who has had an MI. The guidance should inspire creative and innovative ways in which the rehabilitation teams can engage with not only the broadest patient group but also the extensive range of healthcare professionals involved with people who have had an MI.”
Dr Kiran Patel, Chairman of Trustees, South Asian Health Foundation, said: “We very much welcome this new guideline from NICE which has recognised and responded to the high rates of heart disease seen in the UK South Asian community. This new guideline also makes important recommendations that address the access issues that have previously represented another hurdle for high risk groups. We believe this guideline has set important new standards for both improving cardiovascular health and engaging with stakeholders.”
Notes to Editors
1. The guidance, together with a costing template and costing report, are available at www.nice.org.uk/CG48 (from 23 May). In addition, the following implementation tools will be available on the website shortly: a slide set; key messages for local discussion, implementation advice; practical suggestions on how to address potential barriers to implementation and audit criteria.
Key recommendations in the guideline include:
2. Every discharge summary after an MI should confirm this diagnosis and include the results of investigations, future management plans and advice on secondary prevention.
3. Patients should be advised to be physically active for 20-30 minutes a day to the point of slight breathlessness.
4. Patients who smoke should be advised to quit.
5. Patients should be advised to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils).
6. Cardiac rehabilitation should be equally accessible and relevant to all patients after an MI, particularly people from groups that are less likely to access this service.
7. All patients who have had an acute MI should be offered treatment with an ACE inhibitor, aspirin, Beta-blocker and statin.
8. For patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy.
9. Treatment with clopidogrel, in combination with low-dose aspirin should be continued for 12 months after the most recent episode of non-ST-segment-elevation acute coronary syndrome.
10. After an ST-segment-elevation MI, patients treated with a combination of aspirin and clopidogrel during the first 24 hours after the MI should continue this treatment for at least 4 weeks.
11. All patients should be offered a cardiological assessment to consider whether coronary revascularisation is appropriate.
12. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.
13. NICE produces guidance in three areas of health:
• public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS
• clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.