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New NICE guidance on the secondary prevention of MI

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VOL: 103, ISSUE: 22, PAGE NO: 23

NICE has published updated guidance on secondary prevention of MI. This replaces the institute's 2001 guideline, wh...

NICE has published updated guidance on secondary prevention of MI. This replaces the institute's 2001 guideline, which did not give any recommendations on patient advice regarding physical activity or smoking, but noted insufficient evidence on which to base recommendations about diet advice. The new guidance contains several recommendations on lifestyle advice that should be given to patients and expands on previous recommendations about cardiac rehabilitation services. It also updates recommendations on the use of drugs after an MI to ensure they are based on the most current evidence.

In the UK some 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, when compared internationally it is one of the highest in Europe with more than 103,000 deaths per year. CHD death rates vary with age, gender, socioeconomic status, ethnicity and geographic location. Death rates in men under 75 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.

One of the key priorities for implementation states that after an acute MI, confirmation of the diagnosis of acute MI and results of investigations, future management plans and advice on secondary prevention should be part of every discharge summary.

Lifestyle changes

The advice that health professionals should give to patients who have had an MI covers a range of issues: diet, alcohol consumption, regular physical activity, smoking cessation and weight management (see box, p24).

Dietary changes

The guideline makes five recommendations about changing dietary regimen:

- Patients should be advised not to take supplements containing beta-carotene, and should not be advised to take antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk;

- Patients should be advised to consume at least 7g of omega-3 fatty acids per week from 2-4 portions of oily fish;

- For patients who have had an MI within three months and who are not achieving 7g of omega-3 fatty acids per week, consider providing at least 1g daily of omega-3-acid ethyl esters treatment licensed for secondary prevention post-MI for up to four years;

- Initiation of omega-3-acid ethyl esters supplements is not routinely recommended for patients who had an MI more than three months ago;

- Patients should be advised to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; replace butter and cheese with products based on vegetable and plant oils).

The guideline contains three specific recommendations on delivering dietary advice. It states that patients should be given consistent dietary advice tailored to their needs that can be extended to the whole family. They should also be offered an individual consultation to discuss diet, including their current eating habits, and advice on improving their diet.

Other lifestyle factors

NICE recommends that patients who drink alcohol should be advised to keep weekly consumption within safe limits (no more than 21 units of alcohol per week for men, or 14 units per week for women) and to avoid binge drinking (more than three alcoholic drinks in 1-2 hours).

Patients should also be advised to undertake regular physical activity, 'sufficient to increase exercise capacity' and be physically active for 20-30 minutes a day to the point of slight breathlessness. Those who are not achieving this should be advised to increase their activity in a gradual, step-by-step way, to increase their exercise capacity. They should start at a comfortable level and increase the duration and intensity of activity as they gain fitness. The advice on physical activity should involve a discussion about current and past activity levels and preferences, NICE adds.

All smokers should be advised to quit and offered assistance from a smoking cessation service in line with the NICE public health intervention guidance on this topic (NICE, 2006a). All those who want to quit should be offered advice and referred to an intensive support service (for example, the NHS Stop Smoking Services) in line with NICE (2006a) guidance. The guidance on secondary prevention of MI states that if patients are unable or unwilling to accept a referral they should be offered pharmacotherapy in line with the NICE technology appraisal on smoking cessation (NICE, 2002).

On weight management, NICE says that after an MI, all patients who are overweight or obese should be offered advice and support to achieve and maintain a healthy weight in line with the NICE clinical guideline on obesity (NICE, 2006b).

Cardiac rehabilitation

The recommendations on this topic cover five areas: general points on comprehensive cardiac rehabilitation, patient engagement, health education and information, social and psychological support, and sexual activity.

It is recommended that all patients who have had an acute MI (regardless of age) be given advice about, and offered, a cardiac rehabilitation programme with an exercise component. These programmes should offer a range of options and patients should be encouraged to attend all those appropriate to their clinical needs. They should not be excluded from the entire programme if they choose not to attend certain components.

If a patient has any clinical condition that may worsen during exercise, these should be treated before the exercise component of rehabilitation is offered. Patients with left ventricular dysfunction who are stable can safely be offered the exercise component of cardiac rehabilitation.

The section on patient engagement emphasises that cardiac rehabilitation should be equally accessible and relevant to all patients after an MI, particularly those from groups less likely to access the service, such as black and minority ethnic groups, older people, women, people from lower socioeconomic groups and rural communities, and people with mental and physical health comorbidities.

It also states that health professionals should take into account patients' wider health and social needs, which may involve identifying and addressing economic, welfare rights, housing or social support issues. In addition, the programmes should be culturally sensitive and include an exercise component designed to meet the needs of older patients or those with significant comorbidity. Patients should be asked whether they prefer single-sex or mixed classes. Health professionals should actively promote cardiac rehabilitation and use reminders to improve uptake.

The sections on health education/information and psychological/social support cover a range of issues including stress management, returning to work, home-based programmes, travel by air, involvement of partners and carers and depression/anxiety (see

Under sexual activity, the guidance states that 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 one. Those who have made an uncomplicated recovery can resume sexual activity when they feel comfortable - usually after about four weeks.

Lifestyle advice

- Improving diet: advise patients to consume at least 7g of omega-3 fatty acids per week from 2-4 portions of oily fish, and encourage a Mediterranean-style diet.

- Controlling alcohol consumption: advise patients to avoid binge drinking and to keep their weekly alcohol consumption within safe limits (no more than 21 or 14 units per week for men or women respectively).

- Improving physical activity levels: encourage patients to do sufficient regular physical activity to increase their exercise capacity, aiming for 20-30 minutes a day to the point of slight breathlessness.

- Smoking cessation: advise smokers to quit and offer support from a smoking cessation service; for smokers who say they want to quit, offer support, advice and refer them to an intensive support service.

- Controlling weight: offer patients who are overweight or obese advice and support to achieve and maintain a healthy weight.

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