Nice | MI secondary prevention

This guideline from Nice, updates the advice regarding the secondary prevention of MI. Much of the guidance is the same. The biggest change is regarding the use of antithrombotics. I have summarised some of the main changes below and the advice regarding antithrombotic use.

Cardiac rehabilitation

Uptake of this is really low (44%). The new guideline advises us to check that patients are attending and to encourage them to go if they aren't. It reduces all cause mortality and increases exercise tolerance.

Lifestyle advice

Oily Fish - we should no longer advise oily fish solely to avoid further MI. There is no evidence of harm though.

Omega-3 supplements - again, we should no longer be advising these for MI prevention, but there is no evidence of harm.

B-blockers

Although all patients should be on these for at least 12m after MI, I hadn't appreciated that there is currently no evidence for their benefit after 12m if there is no Left Ventricular Systolic Dysfunction. However, you can consider continuing them beyond 12m.

Antithrombotic treatment

Generally, all patients should be on at least 2 treatments for the first 12m following MI.

All patients should have a 'bleeding risk assessment' at follow-up. They don't specify what to do for this, but the HASBLED score is one you can use.

Clopidogrel is preferred to aspirin, if the patient has other vascular disease (eg PAD), after the first 12m, or whenever dual antiplatelet therapy is stopped. For the first 12m, they would need aspirin too.

Treatment after NSTEMI

Aspirin + either 12m of Ticagrelor or Clopidogrel

Treatment after STEMI - if no anticoagulation is indicated

This is quite complicated, so I've done the following flow-chart to simplify things. Hopefully, it will be started in secondary care - so we just need to carry it on...

Treatment after MI - if anticoagulation is indicated

This has always been a bit difficult - when do you add in other drugs and when don't you? This clarifies things...

Of note, Ticagrelor and Prasugrel should not routinely be used with anticoagulation.

With the new anticoagulants (rivaroxaban, dabigatran, apixaban), if the patient has an MI whilst on them, you should consider swapping them onto warfarin.

After 12 months, the need for antiplatelet medication should be reviewed and their bleeding risk, indication for an antiplatelet and their preferences etc should all be taken into consideration.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton locum chambers, and Pallant Medical Chambers Clinical Guidelines Lead Partner.

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