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At the heart of general practice since 1960

June 2007: Updated NICE guidance will improve GP management of CVD

What new recommendations are in the updated NICE guidelines for CVD?

How will the guidelines affect my care of patients with CVD?

What evidence was used to influence the changes in the guidelines?

What new recommendations are in the updated NICE guidelines for CVD?

How will the guidelines affect my care of patients with CVD?

What evidence was used to influence the changes in the guidelines?

Cardiovascular disease, and in particular coronary heart disease, forms a significant part of the GP workload, and this importance is reflected in the high number of cardiovascular indicators in QOF2 (see table 1, attached). Fortunately, there are also a number of guidelines with clear and robust evidence to underpin our approach to care.

Two national bodies have issued updated guidance this year: in February, SIGN updated its advice on risk estimation and prevention of cardiovascular disease,1 and in May, NICE issued MI: Secondary Prevention, aimed at both primary and secondary care clinicians.2

The NICE guideline draws on the most recent evidence to update recommendations on drug therapy following myocardial infarction (MI) and to underscore the importance of lifestyle advice and a comprehensive programme of cardiac rehabilitation for these patients.

Drug Therapy

The updated NICE guideline advises that following an acute MI all patients should be treated with a combination of ACE inhibitor, aspirin, ß-blocker and statin. The SIGN guideline and the 2005 Joint British Societies' guidelines (JBS2)3 support this; both recommend aspirin 75 mg and simvastatin for all patients with established cardiovascular disease.

NICE advocates titrating ACE inhibitors and ß-blockers to the target, or maximum tolerated dose; and is clear that angiotensin-II receptor blockers should not be routinely prescribed unless the patient has a genuine intolerance to ACE inhibitors. NICE also recommends that left ventricular (LV) function should be formally assessed in all patients who have had an MI. Echo is the current gold standard for assessing LV function, although information is often obtained from left ventriculogram at time of cardiac catheter.

Drug treatment will be continued for life in most patients, although it is not yet clear how beneficial drugs such as ß-blockers and ACE inhibitors are in the long term in patients without significant LV systolic dysfunction.

Further recommendations relate to antiplatelet agents in non-ST segment elevation MI, with advice to treat patients with clopidogrel and low-dose aspirin for 12 months; and following an ST segment elevation MI, to use this combined therapy for at least four weeks if it has been started within the first 24 hours. After four weeks, clopidogrel can be stopped unless there is a compelling reason to continue.

For patients unable to tolerate either aspirin or clopidogrel, moderate-intensity warfarin (INR 2-3) can be used, or, for those intolerant to clopidogrel alone, an aspirin and warfarin combination. If warfarin is already being taken for another indication it should be continued; and for patients who are taking moderate-intensity warfarin and have a low risk of bleeding, aspirin can be added. The combination of warfarin and clopidogrel was not advocated.

While NICE recommends statin therapy for all patients as soon as possible after an MI, it makes no recommendations for lipid targets. However, the SIGN guideline suggests, as a minimum, a target of 5 mmol/l or less for total cholesterol, which is more in line with the QOF, rather than the lower target of <4mmol/l recommended by JBS2. It was felt that until further studies on mortality, safety and cost effectiveness were available the lower target could not be supported.1

As far as blood pressure is concerned, NICE recommends a target of 140/90 mmHg or lower, depending on comorbidities. Both SIGN and JBS2 opt for a slighter lower target of <140/85 mmHg, and lower still for patients with coexistent diabetes, renal disease or evidence of target organ damage.

Heart failure

Post-MI patients with left ventricular systolic dysfunction and symptoms and/or signs of heart failure should begin treatment with an aldosterone antagonist within 3-14 days of the acute event, preferably following ACE inhibitor therapy. This combination reduces total mortality and readmission for cardiovascular events.

It is not clear at present whether the new aldosterone antagonist eplerenone is more effective than spironolactone in patients with heart failure and left ventricular dysfunction in the early stages following MI.

Lifestyle advice

The lifestyle advice contained in the NICE guideline is broadly in line with that given by SIGN and the Joint British Societies and provides a robust base for reviewing patients in coronary heart disease clinics.

Smoking

Naturally, smoking is to be actively discouraged, and patients should be offered access to support and advice if they wish to quit. Alternatively, nicotine replacement therapy or other drug therapy may be appropriate.

Exercise

Patients should be encouraged to undertake regular physical activity, gradually building up to 20-30 minutes each day, and exerting themselves to the point of slight breathlessness. At present, exercise advice is not listed as a QOF marker but should form part of a routine structured practice recall programme for post-MI patients.

Diet

The advantages of following a Mediterranean-style diet have been clear for some time and the NICE guideline endorses this commonsense advice. The key message should be to eat more fruit, vegetables and fish, and less meat and dairy produce, substituting butter and cheese with vegetable-based products. I would be tempted to add to this the advice, omitted by the guideline, to reduce salt intake, too.

Interestingly, rather than merely recommending omega-3-fatty-acid ethyl esters, the guideline quantifies the amount; at least 7g, or two to four portions of oily fish, per week. If this is not achieved within the first three months post MI, patients should be offered at least 1g daily of omega-3 supplements licensed for secondary prevention, continued for up to four years. However, the guideline does not recommend routinely initiating these supplements in patients whose MI occurred more than three months previously.

It was heartening to see clear advice also against taking supplements such as beta-carotene, vitamins C and E and folic acid, for which there is no evidence of benefit and which may, indeed, cause harm.

Alcohol

The NICE guideline makes no new recommendations on alcohol consumption, but endorses the Department of Health advice on the limits of sensible drinking: 21 units for men and 14 units for women per week,4 and the need to avoid binge drinking, defined as more than three alcoholic drinks in 1-2 hours.

Weight management

Advice on weight management is general and recommends only that overweight or obese patients should be offered support to achieve and maintain a healthy weight.

Cardiac rehabilitation

Cardiac rehabilitation has traditionally been seen as a hospital-based service and is not among the QOF indicators at present, although some would argue that it should be included.

The key components of cardiac rehabilitation programmes are exercise, health education and stress management. Certainly, it is accepted that the exercise component of cardiac rehabilitation can improve outcomes,5 but it is less clear whether the non-exercise component adds any benefit. In practice, however, the qualitative benefit from stress management and lifestyle advice is likely to ensure that patients continue to receive all three components.

The NICE guideline recommends that all healthcare professionals caring for patients after MI should promote cardiac rehabilitation for patients irrespective of their age and comorbidity, including those with LV dysfunction who are stable.

Most patients who have had an MI can resume work. Occupational issues should therefore form part of any discussion and take into account the nature of the work as well as the work environment.

It is important to tailor any cardiac rehabilitation programme to the individual, and as such home-based programmes are a viable alternative to more traditional programmes.

Conclusion

The updated NICE recommendations broadly cover the current QOF indicators but go further, addressing the finer points such as appropriate use of clopidogrel, statin prescribing and aldosterone antagonists.

These recommendations provide a framework to deliver the highest quality of care. However, successful implementation will depend on good communication between specialist and generalist care, in which the discharge summary will play an important role. Clear and seamless integration between secondary and primary care is crucial for effective management strategies in post-MI patients.

author Author

Dr Peter Savill
BSc MB BS PGDipCard
GPSI Cardiology, Southampton

key points Key points QOF2 Table 1: QOF2: Secondary prevention of coronary heart disease indicators

QOF2

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