Therapeutic interventions

Report
Post-MI Care
Introducing Follow Your Heart: optimal
care after a heart attack – a guide for you
and your patients
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
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:
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, evidencebased 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
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)
How and why the guidance was
developed
• 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:
• 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
• 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
• Guidance covers five key topics:
1.
2.
3.
4.
5.
Cardiac rehabilitation and ongoing care
Lifestyle modification
Goal of intervention
Therapeutic interventions
Integrated communication
Five steps to optimal post-MI
care
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
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
Eat a healthy
balanced diet4
• Consider a Mediterranean-style diet. Increase fresh food intake and
reduce processed foods5
• Eat less fat. Reduce intake of foods high in saturated fat, e.g. fatty and
processed meat, full-fat dairy products, biscuits, cakes, pastries and some
convenience snack foods. Opt for unsaturated fats, e.g. sunflower and
olive oil (polyunsaturated and monounsaturated fat)6
• Eat more fruit and vegetables – at least five portions of different types a
day7
• Choose wholegrain and high-fibre foods, e.g. wholegrain rice/pasta,
wholemeal bread, oats, seeds, nuts, pulses, etc8.
• Eat oily fish, at least two portions a week to provide omega-3 (e.g.
salmon, trout, mackerel) 9. Consider 1 g Omacor per day as an alternative
• Reduce salt intake, aim for <6 g a day10. Beware of hidden salt content
• Consider foods enriched with plant sterols or stanols, e.g. yoghurt, milk,
margarine spreads11
Limit alcohol
intake12
• Drink alcohol in moderation:, women ≤1–2 units/day, men ≤2–3 units/day
Increase
physical
activity12
• Be physically active, e.g. take the stairs, walk to shops, wash the car
• Aim for at least 20–30 minutes of moderate activity each day to the point
of mild breathlessness, e.g. walking, jogging, cycling, dancing or
swimming
Do not
smoke13
Manage
weight13
• Post-MI patients should not smoke
• Smokers should be offered medication for smoking cessation and
referred to local stop-smoking services
• Balance energy intake with energy expenditure
• Advice should be provided to individuals when body mass index (BMI)
>25 kg/m2 or those with an increased waist circumference
• If overweight aim to lose around 0.5 kg/1 lb per week
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
• <130/80 mmHg13
Blood pressure • <125/75 mmHg for patients with chronic kidney disease (CKD)14
Cholesterol
• TC <4.0 mmol/L13,15
• HDL-C >1.0 mmol/L for males and >1.3 mmol/L for females16
• Non-HDL-C <2.8 mmol/L17-19
• LDL-C <2.0 mmol/L13
• Blood test must be fasting for LDL-C (otherwise non-fasting LDL-C
calculation invalid) 13
Blood sugar
• HbA1c <6.5%13
BMI13
• <25 kg/m2
Weight
Waist circumference16
• Europids
o Male <94 cm
o Female <80 cm
• South Asians and Chinese
o Male <90 cm
o Female <80 cm
Key: BMI = body mass index; HbA1c = glycosylated haemoglobin; HDL-C = high-density
lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TC = total cholesterol
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
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
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
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
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 moderateintensity warfarin for up to four years
– Individualised risk/benefit analysis warranted where combination
therapy is being considered
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
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
• 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
• 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
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
Case studies in post-MI care
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
• 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?
• 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
– 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
• 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)
– 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
• 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
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
• 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?
• 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
• 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
• 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
Overcoming barriers to
implementation
Do you foresee any barriers to
implementing the guidance?
Practical?
Educational?
Potential
barriers
Personal?
Other?
How can we overcome these barriers?
Solutions?
How can HCPs engage patients to become
more involved in their care?
Group activities?
Target-setting?
Communication?
Family
involvement?
Others?
Thank you!
Post-MI Care
Variation in availability, awareness, content
and implementation of post-MI guidelines
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
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 postMI care
– Focus on:
•
Cardiac rehabilitation
•
Lifestyle modification
•
Clinical management targets
•
Therapeutic interventions
•
Communication between primary and secondary care
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
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
Results – Content of guidelines / relevance
to clinical practice
Recommendations in PCT/CN
guidelines
Primary care survey results
Cardiac rehabilitation
Included in 87% of guidelines Psychological/social well-being,
relaxation, exercise, return to work,
social services and benefits, driving and
travel, sexual activity
88% of respondents indicated CR
services available in their area
Lifestyle modifications
Included in 87% of guidelines - Diet,
weight management, exercise, smoking
cessation, alcohol reduction
Smoking cessation prioritised as most
important intervention by 79% of
respondents
Recommendations in PCT/CN
guidelines
Primary care survey results
Clinical management targets
Blood pressure
Included in 53% of guidelines; targets vary
– most recommend 140/90 mmHg; one
recommends 150/90 mmHg (consistent
with QOF)
Blood pressure
Respondents more likely to follow
JBS-2 (130/90 mmHg – 53%) than
QOF; respondents in East Midlands
and North East more likely to follow
QOF (150/90 mmHg)
Blood lipids
Included in 53% of guidelines; targets vary
but include:
• TC <5 mmol/L and LDL-C <3 mmol/L or
30% reduction in these parameters,
whichever is greatest
• TC <4 mmol/L and LDL-C <2 mmol/L
Blood lipids
Considerable variation in clinical
practice QOF (33%) and NICE (33%) most
commonly followed
JBS-2 most commonly followed in
the North West
Recommendations in PCT/CN guidelines Primary care survey results
Therapeutic interventions
Blood pressure
ACE inhibitors recommended in 80% of
guidelines – e.g. ramipril, perindopril,
lisinopril – dose recommendations vary
Beta-blockers recommended in 80% of
guidelines – e.g. Atenolol, bisporolol,
carvedilol, metoprolol – dose
recommendations vary
Calcium channel blockers and
angiotensin receptor antagonists – each
recommended in 7% of guidelines
Blood pressure
High level of prescribing throughout
the UK of ACE inhibitors (92%)
and Beta-blockers (83%)
Recommendations in PCT/CN guidelines Primary care survey results
Therapeutic interventions
Blood lipids
Statins recommended in 87% of guidelines
Some guidelines recommend only generic
statins; other recommend higher-intensity
satins if cholesterol levels not adequately
controlled
Simvastatin 40mg usually recommended
first line
Antiplatelets
Aspirin and clopidogrel recommended in
80% of guidelines
Blood lipids
Simvastatin 40mg first-line
treatment of choice in statin-naive
patients (56%)
Simvastatin 40mg also therapy
option of choice in ACS patients
(45%)
Antiplatelets
High level of prescribing throughout
the UK (88%)
Recommendations in PCT/CN guidelines Primary care survey results
Communication between primary and secondary care
Included in 60% of guidelines
Main channel of communication assumed
to be discharge summary
Referral back to secondary care advised in
cases of recurrent CV events or failure of
risk factor control
Most commonly used discharge
letters are generic (57%) – only
respondents in East of England,
South Central and the South East
Coast more likely to receive a
tailored letter
Routine verbal exchange between
primary care secondary care
reported by only 5% of respondents
Results - Guideline Implementation
Research
• CNs feel they can only offer clinicians guidance
• Implementation of CN developed guidelines limited and variable methods include:
–
–
–
–
Distribution to every practice OR individual clinician in the area
Distribution only on request
Embedding in GP operating systems
Training events
Survey
• 27% of clinicians feel ‘obliged’ to follow local post-MI guidelines
– Where applicable, enforcement predominantly through practice (48%) or
PCT-led (39%) audits and alignment to QOF (39%)
Conclusions
• Considerable regional variation in guidelines
followed
– Little consistency in availability, content and implementation of
local post-MI guidelines
• May contribute to significant variation in clinical
practice, as reported by HCPs
• In some areas, patient care may not be
optimal
References
1.
Sivers, F et al. Follow your heart: optimal care after a heart attack – a guide for you and your
patients. Br J Cardiol 2009;16:187-91
2.
Ong S, Milne D and Morrell J (on behalf of the Follow Your Heart Steering Committee). Post-MI
clinical guidelines: Variation in availability, development, content and implementation across the
UK. Br J Cardiol 2009; 16:142-146
3.
British Heart Foundation. Healthcare and economic costs of CVD and CHD. Available from:
http://www.heartstats.org/datapage.asp?id=101 [accessed May 2009]
4.
Food Standards Agency. Healthy diet. Available from: http://www.eatwell.gov.uk/healthydiet/
[accessed May 2009]
5.
HEART UK. Healthy eating fact sheet D10: Mediterranean diet. Available from:
http://www.heartuk.org.uk/images/uploads/healthylivingpdfs/HUK_factsheet_D10_MediterraneanD
iet.pdf [accessed May 2009]
6.
Food Standards Agency. Saturated fat. Available from:
http://www.eatwell.gov.uk/healthydiet/fss/fats/satfat/ [accessed May 2009]
7.
HEART UK. Healthy eating factsheet D04. Available from:
http://www.heartuk.org.uk/images/uploads/healthylivingpdfs/HUK_factsheet_D04_fruitVeg.pdf
[accessed May 2009]
References
8.
9.
10.
11.
12.
13.
NHS Choices. Why is fibre important? Available from: http://www.nhs.uk/chq/pages/1141.aspx
[accessed May 2009]
Food Standards Agency. Oily fish. Available from:
http://www.eatwell.gov.uk/healthydiet/nutritionessentials/fishandshellfish/#cat232819 [accessed
May 2009]
Food Standards Agency. Salt. Available from: http://www.eatwell.gov.uk/healthydiet/fss/salt/
[accessed May 2009]
HEART UK. Healthy eating factsheet F06. Available from:
http://www.heartuk.org.uk/images/uploads/healthylivingpdfs/HUK_factsheet_F06_PlantSterols.pdf
[accessed May 2009]
National Institute for Health and Clinical Excellence. NICE CG 48. Secondary prevention in
primary and secondary care for patients following a myocardial infarction. London: NICE, May
2007. Available from: http://www.nice.org.uk/nicemedia/pdf/CG48NICEGuidance.pdf [accessed
May 2009]
Joint British Societies. JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular
disease in clinical practice. Heart 2005;91(SupplV):v1–v52
References
14. Williams B, Poulter NR, Brown MJ et al. British Hypertension Society. Guidelines for management
of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS
IV. J Hum Hypertens 2004;18:139–85
15. National Institute for Health and Clinical Excellence. NICE CG67. Lipid modification:
cardiovascular risk assessment and the modification of blood lipids for the primary and secondary
prevention of cardiovascular disease. London: NICE, May 2008. Available from:
http://www.nice.org.uk/nicemedia/pdf/CG067NICEGuideline.pdf [accessed May 2009]
16. International Diabetes Federation. IDF Consensus worldwide definition of the metabolic
syndrome, 2006. Available from: http://www.idf.org/webdata/docs/MetS_def_update2006.pdf
[accessed May 2009].
17. Brunzell JD, Davidson M, Curt D et al. Lipoprotein management in patients with cardiometabolic
risk: consensus report from the American Diabetes Association and the American College of
Cardiology Foundation. J Am Coll Cardiol 2008;51:1512–24
18. Charlton-Menys V, Betteridge DJ, Colhoun H et al. Targets of statin therapy: LDL cholesterol, nonHDL cholesterol, and apolipoprotein B in type 2 diabetes in the Collaborative Atorvastatin
Diabetes Study (CARDS). Clin Chem 2009;53:473–80
References
19. Robinson JG, Songfeng Wang MS, Smith BJ et al. Meta-analysis of the relationship between nonhigh-density lipoprotein cholesterol reduction and coronary heart disease risk. J Am Coll Cardiol
2009;53:316–22
20. Law M, Wald N, Rudnicka A. Quantifying effect of statins on low density lipoprotein cholesterol,
ischaemic heart disease, and stroke: systematic review and meta-analysis. BMJ 2003;326:1423–9
21. National Institute for Health and Clinical Excellence. NICE Technology Appraisal Guidance 132.
Ezetimibe for the treatment of primary (heterozygous-familial and non-familial)
hypercholesterolaemia. London: NICE, November 2007. Available from:
http://www.nice.org.uk/nicemedia/pdf/TA132QRGFINAL.pdf [accessed May 2009].
22. Silber S, Albertsson P, Aviles FF et al. Guidelines for percutaneous coronary interventions. The
Task Force for percutaneous coronary interventions of the European Society of Cardiology. Eur
Heart J 2005;26:804–47
23. Scottish Intercollegiate Guidelines Network. SIGN CG 93. Acute coronary syndromes: a national
clinical guideline. Edinburgh: SIGN, February 2007. Available from:
http://www.sign.ac.uk/pdf/sign93.pdf [accessed May 2009]
References
24. NHS Quality Improvement Scotland. Draft clinical standards for prevention and treatment of
coronary heart disease. Standard Statement 2. Edinburgh: NHS Quality Improvement Scotland,
February 2009. Available from:
http://www.nhshealthquality.org/nhsqis/files/HeartDisease_CHDDraftStandards_FEB09.pdf
[accessed May 2009]
25. National Institute for Health and Clinical Excellence. NICE CG83. Rehabilitation after critical
illness. London: NICE, March 2009. Available from:
http://www.nice.org.uk/nicemedia/pdf/CG083NICEGuideline.pdf [accessed May 2009]
26. British Association for Cardiac Rehabilitation. Standards and Core Components for Cardiac
Rehabilitation, 2007
27. Post Myocardial Infarction Care in Practice. Online survey conducted by medeConnect Healthcare
insight (part of the Doctors.net.uk group), March 2009
Back to Guidance

similar documents