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First in a series on myocardial infarction: Secondary prevention after MI - the role of the Junior Doctor

Since the late 1990s the Myocardial Ischaemia National Audit Project (MINAP) has documented the reduction in mortality resulting from changes in acute treatment of MI and the application of secondary prevention measures [1]. This has been confirmed by several studies over recent decades (PLATO, CAPRIE, etc.). From the diagnosis of MI to patient discharge, Junior Doctors play a significant role. It is up to the Cardiology Team (consultants, Junior Doctors, nurses, cardiac rehabilitation leads, pharmacists, etc.) to achieve the best results for their patients. Up to 45% of deaths following a myocardial infarction could be prevented [2] with the correct secondary prevention strategy, and this can be achieved only if Junior Doctors adhere to all current guidelines available (ESC, AHA, NICE). The success of secondary prevention cannot really be stressed enough. It is as important as acute cardiovascular care.

Risk Factors, Epidemiology, Rehabilitation and Sports Cardiology


Introduction

Cardiovascular disease (CVD) is the world’s number one killer, accounting for one in five deaths in Europe. The biggest consequence of CVD is myocardial infarction (MI). One in five people who survive an MI have a second cardiovascular event in the first year - even when receiving optimal treatment and care.

In England and Wales in 2011 and 2012, more than 79,000 hospital admissions were caused by MI, according to the Myocardial Ischaemia National Audit Project (MINAP). Of these, 41% were ST-elevation myocardial infarctions (STEMI) and 59% were non-ST-elevation myocardial infarctions (NSTEMI) [3]. Twice as many men as women had MIs. People who have had a STEMI or an NSTEMI benefit from treatment to reduce the risk of further MI or other manifestations of vascular disease. This is known as secondary prevention. Since the late 1990s, MINAP has documented the reductions in mortality resulting from changes in the acute treatment of MI and the application of secondary prevention measures. Although 30-day mortality was almost 13% for STEMI in 2003/04, it fell to 8% in 2011/12, with similar falls for NSTEMI [1].

Evidence shows that effective secondary prevention measures outlined in clinical practice guidelines can significantly reduce the risk of a subsequent cardiovascular event [4,5]. The Junior Doctor’s role is crucial as a mediator between the different members of the team (consultants, Junior Doctors, nurses, cardiac rehabilitation leads, pharmacists, etc.) in order to achieve the best results for their patients. The way a Junior Doctor can achieve this goal is by following a stepwise approach and using a tick box document in their everyday practice.

Step 1. Initiation of treatment, dose up-titration and communication of plans

The Junior Doctor (senior house officer or cardiology registrar) is the first point of contact and in most cases the first doctor to assess a patient with MI. The plan for secondary prevention needs to be started in the acute phase. Junior Doctors should be well informed in order to offer all patients who have had an acute MI treatment the following drugs: angiotensin-converting enzyme (ACE) inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), a beta-blocker and a statin.

Initiation of treatment is as important as the up-titration of the doses of ACE inhibitors, beta-blockers and statins. The responsibility lies with the Cardiology Team but the person who follows up the patient from admission to discharge is the Junior Doctor and he/she can have a significant impact on achieving the secondary prevention goals. All guidelines include treatment targets for blood pressure, heart rate and lipid control, in addition to recommendations on diet, smoking cessation, physical activities and weight management. Clinical guidelines from the National Institute for Health and Clinical Excellence (NICE), American Heart Association (AHA)/American College of Cardiology (ACC) and European Society of Cardiology (ESC) emphasise risk factor modification through optimisation of drug therapies for secondary prevention following MI [6-9]. Guidelines should be applied by the Junior Doctors and they should regularly review their service against current guidelines by performing audits. Up to 45% of deaths following an MI could be prevented with the correct secondary prevention strategy [1].

It is crucial for the Junior Doctor to review the blood tests and observation of the patient and initiate changes in the medication dose according to blood pressure, heart rate and creatinine. Titration of ACE inhibitor dose upwards should be carried out at short intervals (for example, every 12-24 hours) before the patient 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.

Next, they should offer a beta-blocker as soon as possible after an MI, when the patient is haemodynamically stable. Communicate plans for titrating beta-blockers up to the maximum tolerated or target dose - for example, in the discharge summary [2]. They should aim to continue a beta-blocker for at least 12 months after an MI in patients without left ventricular systolic dysfunction (unless there is another reason for the beta-blockers) or indefinitely if there is any LV impairment/heart failure [2].

If beta-blockers are contraindicated or need to be discontinued, diltiazem or verapamil may be considered for secondary prevention in patients without pulmonary congestion or left ventricular systolic dysfunction.

Statin, in the highest tolerated dose lifelong, and dual antiplatelets have to be included in the medication regime as this has been shown to reduce the incidence of secondary events post MI.

Dual antiplatelet therapy (aspirin and clopidogrel/ticagrelor) for at least 12 months, except as otherwise advised by the consultant, is a cornerstone in order to reduce mortality from cardiovascular events. In the acute phase, a bleeding risk assessment should be documented (CRUSADE). There are cases where expert opinion is still dominant, such as triple therapy with dual antiplatelets and an anticoagulant for patients in atrial fibrillation (AF), for metallic valves or pericardial effusion. Until more concrete results are drawn from trials Junior Doctors should seek advice from consultants.

Step 2. Treating secondary risk factors

Without secondary prevention, one in five people who survive an MI have a second cardiovascular event (MI, stroke, arrhythmias, etc.) in the first year, even when receiving optimal acute treatment and care. Current evidence suggests that the earlier the secondary prevention measures are implemented the better the results are [1].

Lifestyle changes after MI are associated with improved prognosis in randomised trials and in observational studies: a meta-analysis of smoking cessation after a myocardial infarction showed a relative risk reduction for coronary mortality of 46%, and a Cochrane meta-analysis reported a 36% reduction in all-cause mortality [2].

The EUROASPIRE IV, conducted in 78 centres in 24 European countries, demonstrated a high prevalence of unhealthy lifestyles (smoking, little or no physical activity), uncontrolled modifiable risk factors (obesity, diabetes, high blood pressure, dyslipidaemia), and inadequate use of drug therapies to achieve blood pressure and lipid goals in CAD patients and patients at high risk of developing cardiovascular disease. Of note, only 50.7% had been advised to participate in a cardiac rehabilitation or secondary prevention programme [10,11].

It is crucial for the Junior Doctor to assess the risk factors of each individual and offer patient-centred care. The presence and severity of traditional risk factors must be assessed. Age, gender, smoking, diabetes, hypertension and total cholesterol to HDL ratio must be taken into account. Blood tests, including full blood count, urea and electrolytes, cholesterol, glucose, Hb1Ac and thyroid-stimulating hormone (TSH) must be carried out when the patient is still an in-patient and should be repeated in the out-patient clinic.

The targets to be achieved are summarised in Table 1. In general, “lower is better” with regard to LDL-C, systolic BP (as long as postural hypotension is avoided and renal perfusion maintained) and glycated haemoglobin (HbA1c; as long as hypoglycaemia is avoided). For HDL-C, “higher is better”. A case can be made to achieve HDL-C levels above 1.2 mmol/L in women and above 1.0 mmol/L in men, because of the gender difference in HDL-C levels within the population. The target in very high risk patients is a matter of discussion [12].

Risk factor

Target level

Smoking

No exposure to tobacco in any form

Diet

Low in saturated fat with a focus on wholegrain products, vegetables, fruit and fish

Physical activity

At least 150 minutes a week of moderate aerobic PA (30 minutes for 5 days/week) or 75 minutes a week of vigorous aerobic PA (15 minutes for 5 days/week) or a combination thereof.

Body weight

BMI 20-25 kg/m².  Waist circumference <94 cm (men) or <80 cm (women).

Blood pressure

<140/90 mmHga

Lipidsb

 

 

LDLis the primary target

Very high risk: <1.8 mmol/L (<70 mg/dL), or a reduction of at least 50% if the baseline is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL)d.

High risk: <2.6mmol/L (<100 mg/dL), or a reduction of at least 50% if the baseline is between 2.6 and 5.1 mmol/L (100 and 200 mg/dL)

Low to moderate risk: <3.0 mmol/L (<115 mg/dL).

HDL-C

No target but >1.0 mmol/L (>mg/dL) in men and >1.2 mmol/L (>45 mg/dL) in women indicate lower risk.

Triglycerides

No target but <1.7mmol/L (<150 mg/dL) indicates lower risk and higher levels indicate a need to look for other risk factors.

Diabetes

HbAIc <7% (<53 mmol/mol)

Table 1. Risk factor goals and target levels for important cardiovascular risk factors (from ESC Guidelines, CVD Prevention in Clinical Practice 2016 [12]).

  1. Blood pressure <140/90 mmHg is the general target. The target can be higher in frail elderly patients, or lower in most patients with DM (see chapter 3.a.8 in the “Guidelines”) and in some (very) high-risk patients without DM who can tolerate multiple blood pressure-lowering drugs (see chapter 3.a.9 in the “Guidelines”).
  2. Non-HDL-C is a reasonable and practical alternative target because it does not require fasting. Non-HDL-C secondary targets of <2.6, <3.3 and <3.8 mmol/L (<100, <130 and <145 mg/dL) are recommended for very high, high and low to moderate risk subjects, respectively. See section 3a.7.10 for more details.
  3. A view was expressed that primary care physicians might prefer a single general LDL-C goal of 2.6 mmol/L (100 mg/dL). While accepting the simplicity of this approach and that it could be useful in some settings, there is better scientific support for the three targets matched to level of risk.
  4. This is the general recommendation for those at very high risk. It should be noted that the evidence for patients with chronic kidney disease (CKD) is less strong.

BMI: body mass index; HbA1c: glycated haemoglobin; HDL-C: high-density lipoprotein cholesterol; LDL-C: low-density lipoprotein cholesterol

Step 3. Discharge and follow-up by the cardio-rehab team            

After an acute MI, Junior Doctors should ensure that the following are part of every discharge summary: confirmation of the diagnosis of acute MI, results of investigations, incomplete drug titrations, future management plans and advice on secondary prevention.

Diet and lifestyle are important factors in patients with chronic heart disease (CHD). All means of support must be used to promote a healthy lifestyle, including partners and groups such as rehabilitation clinics. Self-monitoring can be assisted with regular feedback to nurses or other “prevention coaches”.

The classic methods to induce behavioural change are required. The following questions should be answered. Is the patient ready to change? Does he or she understand the need for change? Have appropriate treatment targets been set? Are monitoring programmes in place? Is referral necessary (e.g., to a dietitian, exercise physiologist, physiotherapist, clinical psychologist, etc.)?

Patients should be advised to be physically active for 20-30 minutes a day to the point of slight breathlessness. Patients who are not achieving this should be advised to increase their activity in a gradual, step-by-step way, aiming to increase their exercise capacity.

All patients who smoke should be advised to quit and be offered assistance from a smoking cessation service in line with “Brief interventions and referral for smoking cessation in primary care and other settings” (NICE public health intervention guidance 1).

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).

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. These include people from black and ethnic minority groups, older people, people from lower socio-economic groups, women, people from rural communities and people with mental and/or physical health comorbidities.

All patients should be offered a cardiological assessment to consider whether coronary revascularisation is appropriate. This should take into account any other comorbidities.

Conclusion

Studies have suggested that a significant proportion of CHD patients were on suboptimal secondary prevention drug therapies at the point of their re-admission to hospital with an acute coronary syndrome (ACS) despite ESC/AHA/ACC/NICE guidelines [13]. Failure to adhere to these guidelines could potentially increase the risk of recurrent coronary events and increase hospital re-admission rates. Thus, it is clear that early and effective interventions by Junior Doctors could reduce the burden of the disease.

References


  1. Myocardial infarction: cardiac rehabilitation and prevention of further MI, NICE guidelines [CG172]. Published date: November 2013, p.4. 
  2. Secondary Prevention after Myocardial Infarction. Could your patients benefit from better secondary prevention management programmes after MI?
  3. Charles Rivers Associates. The burden of acute coronary syndromes in the UK. London: CRA; 2010.
  4. British Association for Cardiovascular Prevention and Rehabilitation. The BACPR standards and core components for cardiovascular disease prevention and rehabilitation 2012 (2nd Ed.). London: BACPR; March 2012.
  5. Clark AM, Hartling L, Vandermeer B, McAlister F. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med. 2005;143:659-72.
  6. National Institute for Health and Clinical Excellence. MI: secondary prevention. NICE clinical guideline 48. Developed by the National Collaborating Centre for Primary Care. London: NICE, May 2007.
  7. Smith SC Jr, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, Grundy SM, Hiratzka L, Jones D, Krumholz HM, Mosca L, Pasternak RC, Pearson T, Pfeffer MA, Taubert KA; AHA/ACC; National Heart, Lung, and Blood Institute. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006 May 16;113(19):2363-72.
  8. Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA; World Heart Federation and the Preventive Cardiovascular Nurses Association. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. Circulation. 2011 Nov 29;124(22):2458-73.
  9. Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, Albus C, Benlian P, Boysen G, Cifkova R, Deaton C, Ebrahim S, Fisher M, Germano G, Hobbs R, Hoes A, Karadeniz S, Mezzani A, Prescott E, Ryden L, Scherer M, Syvänne M, Scholte op Reimer WJ, Vrints C, Wood D, Zamorano JL, Zannad F; European Association for Cardiovascular Prevention & Rehabilitation (EACPR); ESC Committee for Practice Guidelines (CPG). European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J. 2012 Jul;33(13):1635-701.
  10. Kotseva K, Wood D, De Bacquer D, De Backer G, Rydén L, Jennings C, Gyberg V, Amouyel P, Bruthans J, Castro Conde A, Cífková R, Deckers JW, De Sutter J, Dilic M, Dolzhenko M, Erglis A, Fras Z, Gaita D, Gotcheva N, Goudevenos J, Heuschmann P, Laucevicius A, Lehto S, Lovic D, Miličić D, Moore D, Nicolaides E, Oganov R, Pajak A, Pogosova N, Reiner Z, Stagmo M, Störk S, Tokgözoğlu L, Vulic D; EUROASPIRE Investigators. EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol. 2016 Apr;23(6):636-48.
  11. Kotseva K, Wood D, De Backer G, De Bacquer D, Pyörälä K, Keil U; EUROASPIRE Study Group. EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries. Eur J Cardiovasc Prev Rehabil. 2009 Apr;16(2):121-37.
  12. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FD, Løchen ML, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WM; Authors/Task Force Members. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts): Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016 May 23. pii: ehw106. [Epub ahead of print].
  13. Rathod KS, Siddiqui S, Sin B, Hogan J, Gupta S. Secondary prevention regimens and risk factors are not optimised in patients re-admitted with ACS. Br J Cardiol. 2012;19:167-9. doi:10.5837/bjc.2012.029

Notes to editor


Authors:

Dr Evangelos Tzolos, MD; Dr Waleed Mohammad, MD

ST3, Cardiology Department, Pinderfields General Hospital, Wakefield, West Yorkshire, United Kingdom

 

Corresponding author:

Dr Evangelos Tzolos

38 Admiral Street, Leeds, LS11 5NG, United Kingdom

Email: Evan.tzolos@gmail.com

 

Author disclosures:

The authors have no conflicts of interest to declare.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.