Dr Ivan Benett explains the importance of holistic care and understanding for patients who have had a heart attack and how general practice can help improve outcomes
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H eart attacks have a devastating effect on people’s lives and on those who love and care for them. However, in recent years the survival rate has improved dramatically thanks to primary percutaneous coronary interventions (PCI) at the time of the event, and better secondary prevention treatments. A decade ago, mortality at 30 days was 13%; this has now fallen to around 8%.1
In light of recent new evidence, in November 2013, NICE published an update to its 2007 guideline 2 on Myocardial infarction—secondary prevention: secondary prevention in primary and secondary care for patients following a myocardial infarction (see www.nice.org.uk/guidance/CG172).3 Many of the recommendations in the updated guideline3 have implications for GPs and the management of patients. NICE CG172 has been awarded the NICE Accreditation Mark (see Box 1).
|Box 1: NICE Accreditation Mark|
|NICE Clinical Guideline 172 on Myocardial infarction—secondary prevention: secondary prevention in primary and secondary care for patients following a myocardial infarction has been awarded the NICE Accreditation Mark.
This Mark identifies the most robustly produced guidance available.
See evidence.nhs.uk/accreditation for further details.
In England and Wales last year, almost 80,000 people had a heart attack.1 This means that each year, on average, every GP will be responsible for two or three people who have had a new myocardial infarction (MI) during that year.
Heart attacks are defined as either ST-segment elevation myocardial infarction (STEMI), or non-ST-segment elevation myocardial infarction (NSTEMI), according to whether there are ST changes on an electrocardiogram (ECG):3
- STEMI usually involves complete blockage of a coronary artery with subsequent complete ischaemia and death of the myocardium
- NSTEMI usually means partial or temporary occlusion of a coronary artery.
The management of STEMI and NSTEMI differs slightly in clinical practice.
Primary percutaneous coronary interventions
Since 2007, there has been a major change in the management of acute MI, in that primary PCI has replaced thrombolysis in the management of most cases of STEMI.3 Primary PCI relieves the coronary artery obstruction in STEMI and, if carried out quickly enough, prevents myocardial death and subsequent deterioration of function. It involves insertion of a stent, which itself can lead to future thrombosis. The prevention of stent thrombosis is the aim of changes to the way antiplatelet drugs are used, as set out in the updated guideline.3 Stents require slightly different antiplatelet regimens depending on whether they are bare metal or drug-eluting.
NICE guideline update: MI—secondary prevention
People who have had a STEMI or an NSTEMI benefit from treatment to reduce the risk of further MI or other forms of vascular disease. This is known as secondary prevention. The main changes in NICE CG172 for secondary prevention in MI are summarised in Box 2.3 The rest of this article will focus on some of the key implications of CG172 for primary care, in ensuring the best chance of survival for patients following MI.
Box 2: NICE CG172 on secondary prevention for patients following an MI3—key updated recommendations for GPs
Cardiac rehabilitation after an acute MI
- offer cardiac rehabilitation programmes designed to motivate people to attend and complete the programme
- explain the benefits of attending
- begin cardiac rehabilitation as soon as possible after admission and before discharge from hospital
- invite the person to a cardiac rehabilitation session, which should start within 10 days of their discharge from hospital.
Lifestyle changes after an MI
- Diet. Advise people to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on plant oils). There is insufficient evidence to recommend omega-3 supplementation or eating oily fish for the sole purpose of preventing MI
- Exercise. Advise people to be physically active for 20–30 minutes a day to the point of slight breathlessness. People who are not active to this level should increase their activity gradually. They should start at a level that is comfortable, and increase the duration and intensity of activity as they gain fitness
- Smoking. Advise all people who smoke to stop and offer assistance from a smoking cessation service in line with Brief interventions and referral for smoking cessation (NICE public health guidance 1: see www.nice.org.uk/guidance/PH1).
- offer treatment with the following drugs to all people who have had an acute MI:
- ACE inhibitor.Titrate the ACE inhibitor dose upwards at short intervals (e.g. 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. Use an angiotensin II receptor blocker (ARB) as an alternative, if an ACE inhibitor is not tolerated
- Dual antiplatelet therapy (aspirin plus a second antiplatelet agent). Use warfarin with aspirin if there is another indication for anticoagulation. After 1 year, step down to a single antiplatelet (usually aspirin, which should be offered indefinitely unless not tolerated. If aspirin is not tolerated, clopidrogrel can be offered as an alternative)
- Beta blocker. Titrate to the maximum tolerated or target dose (pulse rate <60 bpm). Reconsider the cost and benefit after 1 year, unless the patient has angina
- Statin. Use a high-intensity statin for the first year, then step down if appropriate.
Assessment of left ventricular function
- assess by echocardiogram for all people who have had an MI. Repeat subsequently if the patient develops new symptoms of ventricular dysfunction (e.g. breathlessness or fatigue).
Communication of diagnosis and advice
- after an acute MI, ensure a comprehensive discharge summary that includes:
- confirmation of the diagnosis of acute MI
- results of investigations
- incomplete drug titrations
- future management plans
- advice on secondary prevention.
CG=clinical guideline; MI=myocardial infarction; ACE=angiotensin-converting enzyme
Role of the GP
General practitioners must be up to date with the modern biomedical interventions that manage symptoms (e.g. breathlessness, angina, fatigue, erectile dysfunction) and reduce the risk of deterioration or recurrence. They must also be able to identify complications early. It is important to optimise medication within the first 6 weeks or so, and to encourage patients to make the recommended lifestyle changes.3 General practitioners should be proactive about this and begin the process as soon as possible after the patient has been discharged from hospital.
The holistic management of patients through illness and loss remains the domain of general practice. The psychosocial impact of surviving a life-threatening event, especially one that may recur, can be profound and unpredictable. General practitioners are used to exploring ideas, concerns, and expectations, and this is never more important than with a person who has recently had an MI. The sudden change in perceived fitness, intimations of mortality, and interruption to expected life trajectory, can lead to depression, anxiety, anger, and social disruption. Many people go through this grieving process. Denial can lead to refusal to take medication, attend appointments, or adhere to lifestyle changes. General practitioners need to be aware of these possible reactions following an MI, and help the patient and family through them.
Cardiac rehabilitation programmes should be commissioned taking into account the barriers to attending these programmes. These include location and transport difficulties, inadequate referral information, and the lack of a choice between home-based and centre-based cardiac rehabilitation. Some people are reluctant to exercise, lack motivation, or may have comorbidities that affect their ability to concentrate. Sometimes people feel that classes are overcrowded, or that they do not attend to their individual needs. Some do not like group or mixed sex classes. Others feel there is inadequate support for mental, emotional, or cognitive issues, or they may lack understanding about the benefits of cardiac rehabilitation. People from black and minority ethnic groups, in particular, are less likely to attend cardiac rehabilitation, probably because the known barriers are accentuated for them. Other groups that find it hard to access cardiac rehabilitation programmes are people:3
- with mental health issues
- with physical or learning disabilities
- who are unemployed
- from rural communities.
Cardiac rehabilitation services offered should be flexible in terms of venue (including at the person’s home, in hospital, and in the community) and the time of day. They should be delivered in a non-judgemental, respectful, and culturally sensitive manner, and include single-sex classes if there is sufficient demand. Consideration should be given to employing bilingual peer educators or assistants who reflect the diversity of the local population. Programmes should be designed to be motivational.3
Recent evidence regarding antithrombotic therapy, ACE inhibitors, and beta blockers also contributed to the need for an updated guideline.
The dose of an ACE inhibitor (an angiotensin II receptor blocker [ARB] can be offered if there is intolerance to an ACE inhibitor) can be titrated upwards at short intervals until the maximum tolerated or target dose is reached, provided renal function is monitored at the same time.3 The introduction of a beta blocker needs to be done more slowly, and include explanation to patients that there may be transient fatigue. The maximum tolerated dose should be aimed for, in accordance with advice in the British National Formulary. 4 The relative benefits of beta blockers diminish after 1 year; at this time, continuation can be reconsidered. Beta-blocker therapy should be continued indefinitely if the patient has impaired systolic function.5
NICE recommends the provision of antiplatelet therapy alongside the other drug therapies for the first 12 months following an MI (see Figure 1) and includes treatment strategies for people who are intolerant to aspirin and who have an indication for anticoagulation.3
Advice for patients
After a heart attack, patients will often ask for advice about various issues; GPs should also proactively offer advice, as appropriate.
Risk of re-infarction
The annual risk of re-infarction or death is low, estimated to be about 10%, or as low as 3% if the patient has good exercise tolerance.6
In the case of driving, GPs should be up to date with the latest Driver and Vehicle Licensing Agency (DVLA) regulations.7,8 For example, the DVLA need not be notified if the patient has been successfully treated by coronary angioplasty. Driving may recommence after 1 week provided that there is no other urgent revascularisation planned within 4 weeks from the acute event, and as long as left ventricular ejection fraction is at least 40% prior to hospital discharge. Otherwise, driving may recommence after 4 weeks. Group 2 licence holders should refer to DVLA advice and be assessed by a cardiologist.8
Patients should be reassured that after recovery from an MI, sexual activity presents no greater risk of triggering a subsequent MI than if they had never had an MI. A full assessment and diagnosis should be made if the patient has erectile dysfunction. If it is a new presentation, there may be a psychogenic component, or some of the drugs may be contributory factors.3
A clear implication of NICE CG172 is the need to review the patient at 1 year. This consultation should include discussion of lifestyle changes, assessment of psychosocial adjustment (further help should be instituted if necessary), and a medication review. Antiplatelet treatment can be reduced to monotherapy, and the need for beta blockers can be reviewed. Overall cardiac status can be reviewed, including exercise tolerance, symptoms of angina, breathlessness or fatigue, and erectile dysfunction.3
There is also a responsibility to ensure that the whole healthcare system is working as best as it can. Any actions that could have been carried out better by the hospital should be identified. For example, discharge communication often falls short of the highest standards and needs to be addressed. NICE CG172 highlights the need to ensure that discharge summaries contain the appropriate information, including the results of investigations, details of incomplete drug titrations, and future management (see Box 2). The guideline also recommends that a copy of the discharge summary should be offered to the patient.3
A significant event analysis (SEA) not only identifies actions by the hospital that could have been done better, but can also assess whether there were missed opportunities in the management of the patient before the MI, or after it. The SEA can also highlight shortcomings in the commissioning of cardiac rehabilitation, and other system failures.
Obstacles to implementation
It is often unclear who has the primary responsibility (along with the patient) for ensuring implementation and adherence to biomedical changes for MI. This is particularly so when there are implicit shared-care arrangements. It is therefore important to agree within each health economy which clinician is primarily responsible for up-titrating medication. As there is such a significant psychosocial element to post-MI care, and the drugs are now familiar to GPs, it would seem sensible for primary care to take on this role. This responsibility needs to be specified in detail in a locality-defined pathway that includes what to do in each setting, and when to refer from one setting to the other.
Availability and access to cardiac rehabilitation is very variable from one health economy to the next. Primary PCI centres often cover a large geographical area, with many different cardiac rehabilitation programmes and providers. Ideally, these should be streamlined and co-ordinated at a regional or sub-regional level.
The extra cost of implementing NICE CG172 is likely to put pressure on cash-limited economies. Local champions should be identified to make the case for these changes, in particular for greater provision of and accessibility to cardiac rehabilitation. So often a ‘Cinderella’ service, rehabilitation needs to be promoted to commissioners, and given higher priority. In particular, new services need to be developed that take into account accessibility by public transport, parking, cultural sensitivities, single-sex classes, and other factors that will ensure motivation and adherence. Existing services need to review their provision in this respect, to improve referrals and attendance.3
The updated NICE guideline on secondary prevention after an MI brings together the evidence for new interventions and highlights the need for improved services, especially for cardiac rehabilitation. General practitioners are central to ensuring that the guideline is implemented, both through the holistic management of individuals, and by reform of the whole system through audit and commissioning.
Once someone has had a heart attack, their life will never be the same again, nor should it be. This guideline provides the evidence for the changes that should happen, and GPs have a key role in making them happen.
- MINAP, NICOR. Myocardial Ischaemia National Audit Project (MINAP). How the NHS cares for patients with heart attack Annual Public Report April 2011—March 2012. 2012. Available at: www.ucl.ac.uk/nicor/audits/minap/publicreports/pdfs/minap2012publicreportlowres
- NICE. MI: secondary prevention: secondary prevention in primary and secondary care for patients following a myocardial infarction. Clinical Guideline 48. NICE, 2007.
Available at: www.nice.org.uk/guidance/CG48
- NICE. MI: secondary prevention: secondary prevention in primary and secondary care for patients following a myocardial infarction. Clinical Guideline 172. NICE, 2013. Available at: www.nice.org.uk/guidance/CG172
- British National Formulary website. www.bnf.org/bnf/index.htm (accessed 24 January 2014).
- NICE. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. Clinical Guideline 108. NICE, 2010. Available at: www.nice.org.uk/guidance/CG108
- Moss A, Benhorin J. Prognosis and management after a first myocardial infarction. NEJM 1990; 322 (11): 743–753.
- Gov.UK website. Health conditions and driving. www.gov.uk/health-conditions-and-driving (accessed 31 January 2014).
- Driver and Vehicle Licensing Agency. For medical practitioners: a guide to the current medical standards of fitness to drive. Swansea: DVLA, 2013. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/258991/aagv1.pdfG