Post-MI Care

1. Post-MI Care Introducing Follow Your Heart: optimal care after a heart attack – a guide for you and your patients

2. Acknowledgements and Conflicts of Interest • Follow Your Heart Steering Committee • Members of HEART UK, PCCS and Pfizer • The Follow Your Heart partnership between HEART UK, the PCCS and Pfizer has been financially supported by Pfizer • Each of the organisations contributed equally through the Steering Committee and enjoyed parity in decision-making • Members of the Steering Committee have received honoraria for their contribution to the Follow Your Heart project, from Pfizer • All recommendations included in this presentation are taken from guidance published on behalf of the Follow Your Heart Steering Committee in the July/August issue of the British Journal of Cardiology1

3. Use of this presentation • This presentation is designed to inform about Follow Your Heart - a project established to promote optimal care of post-MI patients • Presentation can be used: • For desktop review by individual GPs and nurses • To educate HCPs and facilitate discussion in a group setting • Comments are provided in the Notes sections of appropriate slides to give further information/direction about how to use the information in a group session • You can explore areas of the project in more depth by following the hyperlinks where you see this sign:

4. What is Follow Your Heart? • A unique three-way partnership between HEART UK, the PCCS and Pfizer • Multi-disciplinary Steering Group convened to drive project • Steering Group identified a need for simple, consistent, evidence-based post-MI guidance tailored to primary care HCPs and their patients • Consolidated existing clinical evidence and published guidance into a consensus of recommendations for optimal care

5. Steering Committee members Primary care Secondary care Patient Dr Alan Begg Dr Dermot Neely Mr Brian Ellis Dr David Milne Dr Malcolm Walker Dr Jonathan Morrell Dr Michael Norton Michaela Nuttall Stakeholder representatives: Jules Payne (HEART UK), Fran Sivers (PCCS), Ruth Bosworth (Pfizer), Seleen Ong (Pfizer), Andrew Thomas (Pfizer)

6. How and why the guidance was developed

7. Research revealed significant variation in adherence to and implementation of post-MI guidelines in the UK2 • For further details about the research, follow this link:

8. If patients do not receive optimal post-MI care, the individual and socio-economic burden is significant3 • Follow Your Heart Steering Group consolidated existing clinical evidence to create guidance1 that: • Provides succinct recommendations for optimal post-MI management • Includes separate HCP and patient components

9. Guidance designed to: • Encourage two-way dialogue between patients and HCPs • Reduce practice variation • Raise standards of care • Maximise healthcare resource utilisation • Improve outcomes in post-MI patients

10. Guidance covers five key topics: • Cardiac rehabilitation and ongoing care • Lifestyle modification • Goal of intervention • Therapeutic interventions • Integrated communication

11. Five steps to optimal post-MI care

12. 1. Cardiac rehabilitation and ongoing care • Cardiac rehabilitation: • Vital to help post-MI patients improve risk factors for cardiovascular disease (CVD) • Provides link in post-MI care between primary and secondary care • Each post-MI patient should have an individualised plan developed prior to hospital discharge • Each cardiac rehabilitation plan should: • Enable patients to understand and take responsibility for their recovery and continued health • Introduce concept of risk and importance of cardiovascular (CV) risk factors • Address specific areas concerning patients and their partners

13. 2. Lifestyle modification • Lifestyle changes are essential to improve CV health • Partners and family members should be encouraged to adopt positive healthy lifestyle changes together

16. 3. Goal of intervention • Goal of intervention is to achieve optimal control of all modifiable CV risk factors • Clinical evidence consolidated for concise, definitive guidance on optimal targets

17. Key: BMI = body mass index; HbA1c = glycosylated haemoglobin; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TC = total cholesterol

18. 4. Therapeutic interventions: Lipid-lowering therapy • For patients with previous MI: • Simvastatin 40 mg daily (if statin naïve)15 • Follow up at three months and switch to more potent statin if cholesterol target not met e.g. atorvastatin 40-80 mg or rosuvastatin 10 – 40 mg daily20 • If target not met with maximum tolerated dose of statin consider adding ezetimibe 10mg daily21 • For patients with acute MI or ACS: • Higher intensity statin15 e.g. atorvastatin 80 mg • Pre-testing and monitoring: • Monitor liver function15 and lipid profile13

19. Therapeutic interventions: ACE inhibitors and ARBs • For all post-MI patients:12 • Commence ACE inhibitor e.g. ramipril, perindopril • Commence ARB e.g. losartan in ACE-intolerant patients • Titrate upwards and aim for maximum tolerated dose of individual drug • Pre-testing and monitoring: • Urea, creatinine and electrolytes should be measured regularly12

20. Therapeutic interventions: anti-platelet agents • For all post-MI patients: • Commence aspirin 75 mg daily for life12 • Use clopidogrel as add on therapy in patients with: • Non-ST elevation MI (NSTEMI) ACS and who are moderate-to-high risk of MI or death – continue for 12 months12 • STI-elevation MI (STEMI) – continue for at least four weeks unless otherwise indicated12 • PCI with stent insertion – continue for as long as indicated at time of PCI22 • Consider clopidogrel monotherapy for patients with aspirin hypersensitivity12

21. Therapeutic interventions: beta-blockers • For all post-MI patients: • Commence beta blocker before discharge from hospital, e.g. bisoprolol12 • Use beta blocker licensed for heart failure where evidence of left ventricular systolic dysfunction12 • Titrate up to target or maximum tolerated dose12 • Clinical experience suggests continuing treatment indefinitely23

22. Therapeutic interventions: warfarin • For particular post-MI patients:12 • For patients with existing indication for anticoagulation continue warfarin • Consider addition of aspirin if risk of bleeding is low • For patients unable to tolerate aspirin or clopidogrel consider moderate-intensity warfarin for up to four years • Individualised risk/benefit analysis warranted where combination therapy is being considered

23. Therapeutic interventions: aldosterone antagonists • For particular post-MI patients with clinical evidence of heart failure:12 • For patients with significant clinical symptoms and/or signs of heart failure and significant evidence of left ventricular systolic dysfunction, consider treatment with an aldosterone antagonist licensed for post-MI treatment. Initiate 3–14 days post-MI and preferably after introduction of ACE inhibitor • If spironolactone already prescribed at low dose for pre-existing heart failure, continue, or replace with eplerenone in patients intolerant to spironolactone • Pre-testing and monitoring • Urea, creatinine and electrolytes should be measured

24. 5. Integrated communication • Good communication between secondary and primary care, community services and the patient is essential12 • Post-MI hospital discharge summary is vital component of successful communication24

25. Hospital discharge summary: • Confirms diagnosis • Provides results of investigations performed and future investigations required • Documents any in-hospital complications and resulting interventions • Provides details of medication prescribed with guidance on up-titration • Provides recommendations on testing the patient’s relatives • Includes the patient’s agreed care plan • All patients should receive an individualised management plan, which: • Is culturally sensitive • Contains evidence-based information • Includes input from the patient and carers/family • Provides recommendations on daily living25 • Documents what to expect of primary care services

26. A ‘best practice’ discharge summary information sheet has been developed by the Follow Your Heart group on the basis of the recommendations in the guidance • The summary sheet provides a list of information which is necessary to communicate to primary care when a patient is being discharged from hospital following an MI

27. Complemetary tools for HCPs and patients • Based on the guidance, the Follow Your Heart group developed complementary practical, user-friendly tools for primary care clinicians and patients • Tools summarise the guidance for incorporation into day-to-day practice for clinicians and day-to-day life for patients and their families

28. Case studies in post-MI care

29. Case study 1: Mr X • 46 years old • Smoker • HGV driver • Hospitalised yesterday with MI – no previous history of MI • BMI of 34 kg/m2 • Lives with wife and teenage son

30. What would you recommend for Mr X in terms of: • Cardiac rehabilitation? • Lifestyle modification? • What would you want to see included in his hospital discharge summary?

31. Cardiac rehabilitation:1, 26 • Individualised plan for each patient and initiated PRIOR to hospital discharge • Introduce the concept of risk and the usefulness of individualised targets • Highlight the importance of cardiovascular risk factors • Provide results of investigations performed and future investigations required • The programme should address specific areas of concern to the patient and their partners/families: • Education • Allaying misconceptions • Pathophysiology and symptoms • Exercise, smoking, diet, BP, cholesterol • Occupation (Phased return to work. HGV driving rules stricter post-MI than for normal driving and further assessment required) • Sexual dysfunction and sexual intercourse • Psychological • Medical and surgical interventions • CPR

32. Risk factor management • Lifestyle • Physical activity • Diet and weight management • Smoking cessation • Psychological status and quality of life • Valid psychological assessment (anxiety, depression) • Stress management • Discussion of social needs (benefits etc) • Cardioprotective drug therapy • Long-term management strategy • Ongoing care mainly within primary care with specialist intervention • As required; defined pathways • Exercise groups; community dietetic and weight management services

33. Lifestyle modification: • Eat a healthy, balanced diet • Increase fresh food and reduce processed foods; consider a Mediterranean style diet5 • Eat less fat – decrease intake of foods high in saturated fat and opt for foods which have unsaturated (polyunsaturated and monounsaturated )fats6 • Eat more fruit and veg – 5 a day7 • Increase whole grain and high in fibre foods8 • Oily fish – at least 2 portions a week; consider Omacor 1g daily as an alternative9 • Reduce salt intake (<6g/day).10 Remember hidden salt content of foods • Consider foods enriched with plant sterols or stanols eg.yoghurt, milk,margarine11 • Limit alcohol intake12 • Men : <2-3 units per day • Increase physical activity12 • Build up gradually over 4-6 weeks • Aim for at least 20-30 mins of moderate activity each day to the point of mild breathlessness (walking, jogging, cycling, dancing or swimming)

34. Do not smoke13 • Should be offered a combination of medication for smoking cessation and behavioural support (i.e. referred to local stop smoking services)diet and weight management • Manage weight13 • Education regarding balancing energy intake with energy expenditure • Advice as BMI >25 • To lose around 0.5kg/1lb per week

35. Hospital discharge summary should include:1 • Confirm diagnosis • Modifiable risk factors • Significant past medical history • Family history • Investigations and results • Procedures and any complications • Medication prescribed and guidance on up titration • Recommendations on testing patient’s family • Cardiac rehabilitation information (offered/accepted; coordinator) • Planned follow up

36. Case study 2: Mrs Y • 76 years old • Seen in practice for hypertension review • Noted previous MI, 12 years ago • LDL-C of 5.6 mmol/L • BP of 150/90 mmHg • Evidence of left ventricular systolic dysfunction • Allergic to aspirin • Lives alone

37. What would you recommend for Mrs Y in terms of: • Goals of intervention? • Therapeutic interventions? • Who, beyond the primary care team, would you alert to her care needs?

38. Goals of intervention: • BP <130/80 mmHg13 • TC<4.0 mmol/L13,15 • LDL-C <2.0mmol/L13 • HbA1C <6.5%13 • BMI <25kg/m2 13

39. Therapeutic interventions: • Lipid lowering • Patient has had previous MI so simvastatin 40mg (as patient is statin naïve) 15 • Follow up at three and 12 months to ensure cholesterol target met • Check annually once target achieved • LFTs prior to initiation and three and 12 months after initiation and then at 12 months (but not again unless clinically indicated) • Beta Blocker12 • Hypertension and has evidence of left ventricular systolic dysfunction • ACE inhibitor12 • Titrate upwards at short intervals • Pre-testing and monitoring of renal function • Clopidogrel12 • Allergic to aspirin • Aldost antagonists12 • If echo reveals evidence of left ventricular systolic dysfunction

40. Guidance designed to: • Encourage two-way dialogue between patients and HCPs • Reduce practice variation • Raise standards of care • Maximise healthcare resource utilisation • Improve outcomes in post-MI patients

41. Overcoming barriers to implementation

42. Do you foresee any barriers to implementing the guidance? Practical? Educational? Potential barriers Personal? Other?

43. How can we overcome these barriers? Solutions?

44. How can HCPs engage patients to become more involved in their care? Group activities? Target-setting? Family involvement? Communication? Others?

45. Thank you!

46. Post-MI Care Variation in availability, awareness, content and implementation of post-MI guidelines

47. Research • These slides provide a summary of the key findings of the Follow Your Heart research2 • Supporting information is provided in the ‘Notes’ section of each slide • Should you wish to return to the ‘Guidance’ section of the presentation, click on the hyperlinked arrow on each slide

48. Rationale • Qualitative research project • To examine availability and content of local guidelines for management of post-MI patients in primary care • To identify if there are subsequent regional variations in post-MI care • Focus on: • Cardiac rehabilitation • Lifestyle modification • Clinical management targets • Therapeutic interventions • Communication between primary and secondary care

49. Methodology • Search to identify guidelines available online • PCTs • Cardiac networks (CNs) • Telephone interviews with cardiac networks to identify additional guidelines not available online and better understand uptake and implementation of guidelines • Online survey of 1,003 UK primary care clinicians27 • 802 GPs and 201 practice nurses • Establish awareness of locally developed guidelines, use vs. national guidelines and identify areas of variation in clinical practice

50. Results – Availability and Awareness of Local Guidelines Research • 15 local post-MI guidelines identified • 8 PCT developed • 7 CN developed • Where local guidelines not available, CNs typically recommend following NICE Survey • 60% of clinicians aware of local guidelines in their area