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
|
|
|
LDLc is 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]).
- 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”).
- 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.
- 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.
- 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.
Our mission: To reduce the burden of cardiovascular disease.