Secondary prevention of MI. Sep 2003Dr. Sooraj Natarajan Ischaemic heart disease May be broadly...

Secondary Secondary prevention of MIprevention of MI

Sep 2003Sep 2003 Dr. Sooraj NatarajanDr. Sooraj Natarajan

Ischaemic heart Ischaemic heart diseasedisease

May be broadly defined to includeMay be broadly defined to include Myocardial infarction Myocardial infarction AnginaAngina Coronary atherosclerosis Coronary atherosclerosis Heart failure Heart failure often these conditions coexist in patientsoften these conditions coexist in patients.. ..

Epidemiological studies in patient populations Epidemiological studies in patient populations following MI feature following MI feature post-hospital discharge post-hospital discharge mortality rates of 5-10% per yearmortality rates of 5-10% per year


EpidemiologyEpidemiology

Most common cause of death, Most common cause of death, accounting for about a quarter of all accounting for about a quarter of all mortality in England and Wales. mortality in England and Wales.

A general practitioner with a list of 2000 A general practitioner with a list of 2000 patients would expect on average patients would expect on average – 5 deaths, 5 deaths, – 12 hospitalisations 12 hospitalisations – to have 50 patients making 130 primary to have 50 patients making 130 primary

care consultations for ischaemic heart care consultations for ischaemic heart disease each yeardisease each year


Age and Gender Specific Death Rate per Age and Gender Specific Death Rate per annum: Ischaemic Heart Disease (ICD annum: Ischaemic Heart Disease (ICD

410-4,428) England and Wales 1997410-4,428) England and Wales 1997


Over the last 25 years, mortality from Over the last 25 years, mortality from ischaemic heart disease has fallen by ischaemic heart disease has fallen by approximately 40% (Office for National approximately 40% (Office for National Statistics, 1998). Statistics, 1998).

Possible explanations for this decline include Possible explanations for this decline include – the increasing uptakethe increasing uptake– improvement of a range of drugs and surgical improvement of a range of drugs and surgical

techniques, although a techniques, although a – 40% reduction in smoking in adults reported 40% reduction in smoking in adults reported

during the same period is likely to have been during the same period is likely to have been important (OPCS, 1994; Joint Surveys Unit, 1998).important (OPCS, 1994; Joint Surveys Unit, 1998).


Categories of evidence

Ia: evidence from meta-analysis of randomised controlled trials

Ib: evidence from at least one randomised controlled trial

IIa: evidence from at least one controlled study without randomisation

IIb: evidence from at least one other type of quasi-experimental study

III: evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies

IV: evidence from expert committee reports or opinions and/or clinical experience of respected authorities


Strength of recommendation

A directly based on category I evidence

B directly based on category II evidence or extrapolated recommendation from category I evidence

C directly based on category III evidence or extrapolated recommendation from category I or II evidence

D directly based on category IV evidence or extrapolated recommendation from category I, II or III evidence


Patients with prior MI, Patients with prior MI, no heart failureno heart failure


Which drugs?Which drugs?

All patients should be offered long term All patients should be offered long term treatment firstly with a treatment firstly with a – beta-blocker and beta-blocker and – an antiplatelet drug (aspirin), an antiplatelet drug (aspirin),

Then Then – with a statin with a statin – and an ACE inhibitor. and an ACE inhibitor.

This sequencing of initiation reflects the evidence from This sequencing of initiation reflects the evidence from trials and estimates of cost-effectiveness (A) . Not all trials and estimates of cost-effectiveness (A) . Not all ACE inhibitors or statins have a licence for this ACE inhibitors or statins have a licence for this indication.indication.



The precise lower limit of the level of The precise lower limit of the level of cholesterol that should be treated is cholesterol that should be treated is unclear.unclear.

Licence indications currently suggest a Licence indications currently suggest a lower limit of 4.8 mmol/l or 5.5 mmol/l lower limit of 4.8 mmol/l or 5.5 mmol/l depending on the drug used. (D) depending on the drug used. (D)

Beta-blockers and ACE inhibitors will also Beta-blockers and ACE inhibitors will also be considered for the management of be considered for the management of symptoms (e.g. in stable angina) or risk symptoms (e.g. in stable angina) or risk factors (e.g. hypertension) (D) factors (e.g. hypertension) (D)



Calcium channel blockers, nitrates, and Calcium channel blockers, nitrates, and potassium channel activators have no effect on potassium channel activators have no effect on premature mortality making their role the premature mortality making their role the management of symptoms and risk factors management of symptoms and risk factors (principally hypertension) (A) They should (principally hypertension) (A) They should therefore only be used in those patients who are therefore only be used in those patients who are intolerant of beta-blockers and ACE inhibitors (D) intolerant of beta-blockers and ACE inhibitors (D)

Given their effect on non-fatal myocardial Given their effect on non-fatal myocardial infarction, verapamil or diltiazem should then be infarction, verapamil or diltiazem should then be considered initially (B) Subsequent necessary considered initially (B) Subsequent necessary treatment with other calcium channel blockers, treatment with other calcium channel blockers, nitrates or potassium channel activators is then nitrates or potassium channel activators is then appropriate (D) appropriate (D)


When to start drug When to start drug treatmenttreatment

Beta-blockers, Antiplatelet drugs Beta-blockers, Antiplatelet drugs (aspirin) and ACE inhibitors(aspirin) and ACE inhibitors

should be initiated whilst patients are should be initiated whilst patients are in hospital as there is evidence to in hospital as there is evidence to support benefit following early support benefit following early initiation.initiation.

If this does not happen then primary If this does not happen then primary care clinicians should initiate them as care clinicians should initiate them as soon after discharge as possible (A) soon after discharge as possible (A)



Although there is no evidence of the Although there is no evidence of the long-term benefit from the use of long-term benefit from the use of statinsstatins initiated prior to 12 weeks post- initiated prior to 12 weeks post-infarct, many patients will have been infarct, many patients will have been taking statins prior to admission or will taking statins prior to admission or will have them initiated in hospital. have them initiated in hospital.

All patients discharged from hospital All patients discharged from hospital who are not already taking a who are not already taking a statin statin should be assessed and have treatment should be assessed and have treatment initiated initiated 12 weeks after a myocardial 12 weeks after a myocardial infarction (A) infarction (A)


Monitoring treatmentMonitoring treatment

Patients being considered for treatment with Patients being considered for treatment with a statin should have an a statin should have an – initial serum cholesterol measurement both to initial serum cholesterol measurement both to

exclude exclude familial lipid disorders andfamilial lipid disorders and to identify those patients with a serum cholesterol to identify those patients with a serum cholesterol

level that does level that does not need treating. not need treating. – further measurement allows further measurement allows

an assessment of response to treatmentan assessment of response to treatment assessment of compliance with treatment. assessment of compliance with treatment.

– The frequency of such monitoring is unclear; the The frequency of such monitoring is unclear; the National Service Framework for Coronary Heart National Service Framework for Coronary Heart Disease suggests annually. (D) Disease suggests annually. (D)



Patients being considered for Patients being considered for treatment with ACE inhibitors treatment with ACE inhibitors should have their renal function should have their renal function checkedchecked– prior to initiation and prior to initiation and – after each significant dose increase. after each significant dose increase.

(D) (D)


Continuation of Continuation of treatmenttreatment

Based on the evidence from the Based on the evidence from the trials, treatment should continue trials, treatment should continue

long term (D) long term (D)


Continuation of Continuation of treatmenttreatment The treatment durations, for which there is at The treatment durations, for which there is at

least one trial that provides direct support, least one trial that provides direct support, are are

three and a half years for antiplatelet drugs three and a half years for antiplatelet drugs (aspirin)(aspirin)

four years for beta-blockers and ACE four years for beta-blockers and ACE inhibitors and inhibitors and

six years for statins. six years for statins. In the absence of a clear reason to stop In the absence of a clear reason to stop

treatment it seems reasonable to continue treatment it seems reasonable to continue treatment indefinitely (D) treatment indefinitely (D)

Patients with prior myoPatients with prior myocardial infarction who hcardial infarction who have diabetesave diabetes


Insulin therapyInsulin therapy

There is evidence that intensive There is evidence that intensive insulin therapy initiated soon after insulin therapy initiated soon after admission for acute myocardial admission for acute myocardial infarction reduces mortality (B) infarction reduces mortality (B)

To achieve the benefits To achieve the benefits demonstrated in the single trial in demonstrated in the single trial in this area involves 4 daily insulin this area involves 4 daily insulin injections continuing for at least injections continuing for at least three months (B) three months (B)

Patients with prior myoPatients with prior myocardial infarction and hcardial infarction and heart failureeart failure


Patients with prior myocardial Patients with prior myocardial infarction and heart failure are a infarction and heart failure are a relatively ill group of patients and relatively ill group of patients and care is required when initiating care is required when initiating drug treatments (D) drug treatments (D)


Long term treatmentLong term treatment

All patients should be offered long term All patients should be offered long term treatment with treatment with

an an ACE inhibitorACE inhibitor and and then a then a Beta-blockerBeta-blocker (not all beta-blockers (not all beta-blockers

have a licence for this indication). have a licence for this indication). In addition they should be treated with an In addition they should be treated with an

antiplatelet drug (aspirin).antiplatelet drug (aspirin). Patients who have moderate or severe heart Patients who have moderate or severe heart

failure (New York Heart Association (NYHA) failure (New York Heart Association (NYHA) grade 3 or 4) should be treated with grade 3 or 4) should be treated with SpironolactoneSpironolactone..

All of these treatments are cost effective (A) All of these treatments are cost effective (A)



Patients are likely to continue to need Patients are likely to continue to need symptomatic treatment with a loop symptomatic treatment with a loop diuretic (D) diuretic (D)

In patients with mild symptoms of In patients with mild symptoms of heart failure (NYHA grade 1 or 2) it is heart failure (NYHA grade 1 or 2) it is unclear whether spironolactone unclear whether spironolactone decreases premature mortality. It may decreases premature mortality. It may represent a reasonable choice of represent a reasonable choice of adjuvant symptomatic therapy (D) adjuvant symptomatic therapy (D)



As patients with heart failure were As patients with heart failure were almost always excluded from trials there almost always excluded from trials there is no evidence on which to recommend is no evidence on which to recommend the use of statins in such patients. the use of statins in such patients.

Statin use will be influenced by clinical Statin use will be influenced by clinical and practical considerations, such as and practical considerations, such as whether patients were treated with whether patients were treated with them prior to developing heart failure them prior to developing heart failure (D) (D)



ACE inhibitorsACE inhibitors and and antiplatelet drugs antiplatelet drugs (aspirin)(aspirin)

should be initiated whilst patients are should be initiated whilst patients are in hospital as there is evidence to in hospital as there is evidence to support benefit following early support benefit following early initiation. initiation.

If this does not happen then primary If this does not happen then primary care clinicians should initiate them as care clinicians should initiate them as soon after discharge as possible (A) soon after discharge as possible (A)



Beta-blockers can be initiated at Beta-blockers can be initiated at any point. any point.

Treatment should start with low Treatment should start with low doses and should be slowly doses and should be slowly increased, for example at increased, for example at fortnightly intervals, over a period fortnightly intervals, over a period of up to 12 weeks (A) of up to 12 weeks (A)


Initiating Beta Initiating Beta blockersblockers Given the limited experience initiating beta-Given the limited experience initiating beta-

blockers it is currently unclear whether this blockers it is currently unclear whether this can be done safely in primary care. can be done safely in primary care.

Whilst the BNF recommends hospital Whilst the BNF recommends hospital supervision it seems possible that there are a supervision it seems possible that there are a group of patients with heart failure for whom group of patients with heart failure for whom general practitioners (based on their general practitioners (based on their knowledge of the patient's clinical condition) knowledge of the patient's clinical condition) may feel able to initiate treatment in primary may feel able to initiate treatment in primary care. care.

Unfortunately the characteristics of this Unfortunately the characteristics of this patient group are not currently clear. patient group are not currently clear. Discussion at a local level may inform Discussion at a local level may inform appropriate methods of treatment initiation (D) appropriate methods of treatment initiation (D)


SpironolactoneSpironolactone

Spironolactone can be initiated at any Spironolactone can be initiated at any point.point.

In patients with moderate to severe In patients with moderate to severe symptoms of heart failure (NYHA grade 3 symptoms of heart failure (NYHA grade 3 or 4), given the time involved in or 4), given the time involved in achieving full dosages of beta-blockers, achieving full dosages of beta-blockers, it seems reasonable to consider initiating it seems reasonable to consider initiating spironolactone before beta-blockers (D) spironolactone before beta-blockers (D)



Patients being considered for Patients being considered for treatment with ACE inhibitors treatment with ACE inhibitors should have their renal function should have their renal function checked prior to initiation and checked prior to initiation and after each significant dose after each significant dose increase (D) increase (D)



Patients being treated with Patients being treated with spironolactone should have their spironolactone should have their serum potassium monitored (D) serum potassium monitored (D)


Continuation of Continuation of TreatmentTreatment

Based on the evidence from the trials, Based on the evidence from the trials, treatment should continue long term (D) The treatment should continue long term (D) The treatment durations, for which there is at treatment durations, for which there is at least one trial that provides direct support, least one trial that provides direct support,

are are 3 ½3 ½ yrs for yrs for ACE inhibitorsACE inhibitors 2 ½2 ½ years for years for Beta-blockers Beta-blockers 22 years for years for SpironolactoneSpironolactone In the absence of a clear reason to stop In the absence of a clear reason to stop

treatment it seems reasonable to continue treatment it seems reasonable to continue treatment indefinitely (D) treatment indefinitely (D)


Comparative cost of drug treatments for patients with Comparative cost of drug treatments for patients with

previous myocardial infarctionprevious myocardial infarction Drug classDrug class Drug 1Drug 1 Daily Dose 2Daily Dose 2 Cost/year 3Cost/year 3

Patients with myocardial infarctionPatients with myocardial infarction

ACE InhibitorsACE Inhibitors ramipril (tritace)ramipril (tritace) 5mg twice daily5mg twice daily 249249

Antiplatelet drugsAntiplatelet drugs aspirin (generic)aspirin (generic) 75mg once daily75mg once daily 22

Beta-blockersBeta-blockers propranolol (generic)propranolol (generic) 80mg three times daily80mg three times daily 88

metoprolol (betaloc)metoprolol (betaloc) 100mg twice daily100mg twice daily 4545

StatinsStatins pravastatin (lipostat)pravastatin (lipostat) 40mg once daily40mg once daily 387387

simvastatin (zocor)simvastatin (zocor) 20-40mg once daily20-40mg once daily 387387

Patients with myocardial infarction Patients with myocardial infarction

and heart failureand heart failure

ACE InhibitorsACE Inhibitors captopril (generic)captopril (generic) 25-50mg three times daily25-50mg three times daily 3636

ramipril (tritace)ramipril (tritace) 2.5-5mg twice daily2.5-5mg twice daily 241241

Beta-blockersBeta-blockers propranolol (generic)propranolol (generic) 40mg three times daily40mg three times daily 44

bisoprolol (emcor/monocor)bisoprolol (emcor/monocor) 5-10mg once daily5-10mg once daily 118118

SpironolactoneSpironolactone spironolactone (generic)spironolactone (generic) 25mg once daily25mg once daily 2222

Non Drug TreatmentNon Drug Treatment


RehabilitationRehabilitation

Patients should be offered enrolment Patients should be offered enrolment in a rehabilitation programme that has in a rehabilitation programme that has a a prominent exercise componentprominent exercise component within it (A) within it (A)

Although many of the trials imposed Although many of the trials imposed upper age limits for recruitment, the upper age limits for recruitment, the guideline development group felt that guideline development group felt that in a service setting it was more in a service setting it was more appropriate appropriate


DietDiet

Given the nature of the available Given the nature of the available evidence of the effectiveness of evidence of the effectiveness of dietary manipulation as a dietary manipulation as a strategy for secondary strategy for secondary prophylaxis it is not possible to prophylaxis it is not possible to recommend specific dietary recommend specific dietary manipulation (B) .manipulation (B) .


Indicators, proposed methods of Indicators, proposed methods of Data collection and monitoring in Data collection and monitoring in

secondary prevention of IHDsecondary prevention of IHD

IndicatorIndicator PointsPoints Payment Payment stagesstages

RecordsRecords

CHD 1. the practice can produce register CHD 1. the practice can produce register of patients with CHDof patients with CHD 66Diagnosis and Initial Diagnosis and Initial managementmanagement

CHD2 the percentage of patients with CHD2 the percentage of patients with newly diagnosed Angina(after ist April newly diagnosed Angina(after ist April 2003) who are reffeerred to exercise 2003) who are reffeerred to exercise testing or specialist assessmenttesting or specialist assessment

77 25-90%25-90%


Indicators, proposed methods of Data Indicators, proposed methods of Data collection and monitoring in secondary collection and monitoring in secondary

prevention of IHDprevention of IHD


Ongoing managementOngoing management

CHD 3 % of patients with CHD whose CHD 3 % of patients with CHD whose notes record smoking status in the past notes record smoking status in the past 15 months, except those who have never 15 months, except those who have never smoked where it need be recorded once.smoked where it need be recorded once.

77 25-90%25-90%

CHD 4 5 of patients with CHD whose CHD 4 5 of patients with CHD whose notes contain a record that smoking notes contain a record that smoking cessation advice or referral to specialist cessation advice or referral to specialist service where available has been offeredservice where available has been offered

44 25-70%25-70%

CHD 5 % of CHD patients whose notes CHD 5 % of CHD patients whose notes have a record of the BP in the past 15 have a record of the BP in the past 15 monthsmonths

77 25-90%25-90%

CHD 6 the % of patients with CHD in CHD 6 the % of patients with CHD in whom the last BP reading measured in whom the last BP reading measured in the last 15 months is 150/90 or lessthe last 15 months is 150/90 or less

1919 25-70%25-70%






CHD 7. % of CHD patients whose notes CHD 7. % of CHD patients whose notes have a record of total cholesterol in the have a record of total cholesterol in the previous 15 monthsprevious 15 months

77 25-90%25-90%

CHD 8.% of CHD patients whose last CHD 8.% of CHD patients whose last measured Cholesterol level ( in the last measured Cholesterol level ( in the last 15 months) is 5mmols/L or less15 months) is 5mmols/L or less

1616 25-60%25-60%

CHD 9.% of CHd patients with a record in CHD 9.% of CHd patients with a record in the last 15 months of aspirin or the last 15 months of aspirin or alternative antiplatelet therapy, or anti-alternative antiplatelet therapy, or anti-coagulant being taken( unless a CI or SE coagulant being taken( unless a CI or SE recorded)recorded)

77 25- 90%25- 90%






CHD 10. % of CHD patients who are CHD 10. % of CHD patients who are currently on a beta blocker (unless CI / Se currently on a beta blocker (unless CI / Se recorded)recorded)

77 25-50%25-50%

CHD11. the % of patients with ahistory of CHD11. the % of patients with ahistory of MI (diagnosed after April 2003) who are MI (diagnosed after April 2003) who are on an ACE inhibitoron an ACE inhibitor

77 25-70%25-70%

CHD 12. 5 of patients with CHD who have CHD 12. 5 of patients with CHD who have a record of influenza immunisation in the a record of influenza immunisation in the preceeding September to 31 Marchpreceeding September to 31 March

77 25-85%25-85%

Secondary prevention of MI. Sep 2003Dr. Sooraj Natarajan Ischaemic heart disease May be broadly...

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