Recent developments in secondary prevention and cardiac rehabilitation after acute myocardial infarction
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《英国医生杂志》
1 Lower Lemon Street Surgery, Truro TR1 2LZ, 2 Peninsula Medical School, Barrack Road, Exeter EX2 5DW
Correspondence to H Dalal hmdalal@doctors.net.uk
Primary care has a key role in improving the health of patients who have had a myocardial infarction
Introduction
We searched Medline for relevant reviews related to secondary prevention (after acute myocardial infarction) and papers published in the past three years; we also canvassed specialist and generalist colleagues. Recent large trials have included acute myocardial infarction with other cardiovascular diseases, as they share common risk factors8-10; this review reflects this trend. We adopted the Scottish Intercollegiate Guidelines Network's definition of secondary prevention, which encompasses "identification and modification of risk factors by the introduction of lifestyle measures and pharmacological therapy and cardiac rehabilitation."w4
Summary points
Effective implementation of secondary prevention and cardiac rehabilitation after acute myocardial infarction remains suboptimal
Coprescribing of antiplatelet drugs, statins, angiotensin converting enzyme inhibitors, and blockers should be considered in all patients after myocardial infarction
Structured care for chronic cardiac disease management can improve the recording of risk factors
Nurse led clinics for secondary prevention of coronary heart disease may improve clinical outcomes
Exercise based cardiac rehabilitation after myocardial infarction has been shown to reduce all cause mortality
Depression is common after myocardial infarction; the associated increased mortality seems to be refractory to psychological or drug treatment
Drugs and secondary prevention
Recent trials have provided evidence for the effectiveness of structured care in secondary prevention of coronary heart disease (table).w18 Although a validated register of patients who survive acute myocardial infarction is the bedrock of any structured care system in primary care,17 good communication between hospital and primary care, with multidisciplinary working, is a common theme in successful schemes.6 Nurse led clinics for secondary prevention of coronary heart disease may produce improved clinical outcomes.
Evidence for structured systematic care in secondary prevention of coronary heart disease. Adapted from Begg 2003w18
Cardiac rehabilitation
Smoking cessation
Although observational studies have estimated that mortality and subsequent cardiac events are reduced by 50% when patients with coronary heart disease stop smoking, the timing of benefits and amount of risk reduction have been debated. A recent systematic review of 20 high quality prospective cohort studies suggested that stopping smoking in patients with coronary heart disease (acute myocardial infarction and angina) reduced total all cause mortality (relative risk 0.64 (0.58 to 0.71)).20
Smoking cessation clearly is a priority for all patients with coronary heart disease, including elderly patients.w31 The challenge for primary care practitioners is how to achieve lifestyle changes, particularly smoking cessation. Nicotine replacement seems to be safe for patients with coronary heart disease.w32
Psychological problems
Depression is common after myocardial infarction: 15-20% of patients have major depression, and a similar proportion have minor depression.w33 This may be missed in primary care, and several commentators have suggested screening for depression.21
Depression and perception of lack of social support after myocardial infarction are associated with increased mortality, although the precise mechanism remains uncertain. A recent study of 2481 patients with coronary heart disease showed enhanced recovery after cognitive behaviour therapy or antidepressants (sertraline), as patients were less depressed and felt less isolated, but event free survival after 29 months' follow up did not increase.22
Implementation
General practice seems to be responding to new evidence with increasing vigour. The revised definition of myocardial infarction diagnosed by troponin estimation, however, will probably result in increased reporting of myocardial infarction and further increased workloads in primary and secondary care.24 The two sectors need to collaborate and communicate effectively to reduce treatment gaps and build on established models of integrated care with proved effectiveness. The impact of the national service framework, the new general medical services contract for general practitioners, and other initiatives (such as the national primary care collaborative) should improve quality of care after myocardial infarction for patients in the United Kingdom.
Sources of information for patients
Hearts for Life (www.heartsforlife.co.uk)—provides patient friendly information on heart attacks, angina, heart failure, and prevention
British Heart Foundation (www.bhf.org.uk)—printable information on heart attack and cardiac rehabilitation, with links to other sites
DIPEx (www.dipex.org)—website about people's experiences of health and illness; the site links video, audio, and written interviews with evidence based information, patients' questions and answers, and links to other resources; information for patients who have had heart attacks will be available from August 2004
BBC Health (www.bbc.co.uk/health)—specific section on how to recover after a heart attack (www.bbc.co.uk/health/features/heart_attack_recovery.shtml)
Additional references and a second patient's perspective are on bmj.com>
We thank Joy Choules for her help with typing the manuscript and Alan Begg, Hugh Bethell, Denis Pereira Gray, Tony Mourant, Rod Taylor, and Jenny Wingham for their comments on earlier drafts of this paper.
Contributors: HD and PHE conducted the literature searches. All three authors contributed to the design of the review and writing the article.
Funding: HD is the lead researcher for Lower Lemon Street Surgery, Truro, which is an NHS research and development practice funded by the Department of Health. The Department of Health through SaNDNet (Somerset and North and East Devon Primary Care Research Network) funds PHE. JLC is the professor of general practice and primary care, funded by the Peninsula Medical School.
Competing interests: None declared.
References
Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation 2001;104: 2746-53.
Bethell HJ, Turner SC, Evans JA, Rose L. Cardiac rehabilitation in the United Kingdom. How complete is the provision? J Cardiopulm Rehabil 2001;21: 111-5.
EUROASPIRE I and II Group, Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. Lancet 2001;357: 995-1001.
Brady AJ, Oliver MA, Pittard JB. Secondary prevention in 24 431 patients with coronary heart disease: survey in primary care. BMJ 2001;322: 1463.
Murchie P, Campbell NC, Ritchie LD, Simpson JA, Thain J. Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care. BMJ 2003;326: 84.
Dalal HM, Evans PH. Achieving national service framework standards for cardiac rehabilitation and secondary prevention. BMJ 2003;326: 481-4.
Pereira Gray D. Role reversal between primary and secondary care. Med Educ 2003;37: 754-5.
Fox KM. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 2003;362: 782-8.
Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000;342: 145-53.
Heart Protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360: 7-22.
Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002;324: 71-86.
CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348: 1329-39.
Flather MD, Yusuf S, Kober L, Pfeffer M, Hall A, Murray G, et al. Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. Lancet 2000;355: 1575-81.
LaRosa JC, He J, Vupputuri S. Effect of statins on risk of coronary disease: a meta-analysis of randomized controlled trials. JAMA 1999;282: 2340-6.
Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 2002;288: 462-7.
Ko DT, Hebert PR, Coffey CS, Sedrakyan A, Curtis JP, Krumholz HM. Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. JAMA 2002;288: 351-7.
Gray J, Majeed A, Kerry S, Rowlands G. Identifying patients with ischaemic heart disease in general practice: cross sectional study of paper and computerised medical records. BMJ 2000;321: 548-50.
Lewin B, Robertson IH, Cay EL, Irving JB, Campbell M. Effects of self-help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services. Lancet 1992;339: 1036-40.
Marchionni N, Fattirolli F, Fumagalli S, Oldridge N, Del Lungo F, Morosi L, et al. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial. Circulation 2003;107: 2201-6.
Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003;290: 86-97.
Mayou RA, Gill D, Thompson DR, Day A, Hicks N, Volmink J, et al. Depression and anxiety as predictors of outcome after myocardial infarction. Psychosom Med 2000;62: 212-9.
Berkman LF, Blumenthal J, Burg M, Carney RM, Catellier D, Cowan MJ, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the enhancing recovery in coronary heart disease patients (ENRICHD) randomized trial. JAMA 2003;289: 3106-16.
Summerskill WSM, Pope C. "I saw the panic rise in her eyes, and evidence-based medicine went out of the door." An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease. Fam Pract 2002;19: 605-10.
Ferguson JL, Beckett GJ, Stoddart M, Walker SW, Fox KA. Myocardial infarction redefined: the new ACC/ESC definition, based on cardiac troponin, increases the apparent incidence of infarction. Heart 2002;88: 343-7.(Hasnain Dalal, general pr)
Correspondence to H Dalal hmdalal@doctors.net.uk
Primary care has a key role in improving the health of patients who have had a myocardial infarction
Introduction
We searched Medline for relevant reviews related to secondary prevention (after acute myocardial infarction) and papers published in the past three years; we also canvassed specialist and generalist colleagues. Recent large trials have included acute myocardial infarction with other cardiovascular diseases, as they share common risk factors8-10; this review reflects this trend. We adopted the Scottish Intercollegiate Guidelines Network's definition of secondary prevention, which encompasses "identification and modification of risk factors by the introduction of lifestyle measures and pharmacological therapy and cardiac rehabilitation."w4
Summary points
Effective implementation of secondary prevention and cardiac rehabilitation after acute myocardial infarction remains suboptimal
Coprescribing of antiplatelet drugs, statins, angiotensin converting enzyme inhibitors, and blockers should be considered in all patients after myocardial infarction
Structured care for chronic cardiac disease management can improve the recording of risk factors
Nurse led clinics for secondary prevention of coronary heart disease may improve clinical outcomes
Exercise based cardiac rehabilitation after myocardial infarction has been shown to reduce all cause mortality
Depression is common after myocardial infarction; the associated increased mortality seems to be refractory to psychological or drug treatment
Drugs and secondary prevention
Recent trials have provided evidence for the effectiveness of structured care in secondary prevention of coronary heart disease (table).w18 Although a validated register of patients who survive acute myocardial infarction is the bedrock of any structured care system in primary care,17 good communication between hospital and primary care, with multidisciplinary working, is a common theme in successful schemes.6 Nurse led clinics for secondary prevention of coronary heart disease may produce improved clinical outcomes.
Evidence for structured systematic care in secondary prevention of coronary heart disease. Adapted from Begg 2003w18
Cardiac rehabilitation
Smoking cessation
Although observational studies have estimated that mortality and subsequent cardiac events are reduced by 50% when patients with coronary heart disease stop smoking, the timing of benefits and amount of risk reduction have been debated. A recent systematic review of 20 high quality prospective cohort studies suggested that stopping smoking in patients with coronary heart disease (acute myocardial infarction and angina) reduced total all cause mortality (relative risk 0.64 (0.58 to 0.71)).20
Smoking cessation clearly is a priority for all patients with coronary heart disease, including elderly patients.w31 The challenge for primary care practitioners is how to achieve lifestyle changes, particularly smoking cessation. Nicotine replacement seems to be safe for patients with coronary heart disease.w32
Psychological problems
Depression is common after myocardial infarction: 15-20% of patients have major depression, and a similar proportion have minor depression.w33 This may be missed in primary care, and several commentators have suggested screening for depression.21
Depression and perception of lack of social support after myocardial infarction are associated with increased mortality, although the precise mechanism remains uncertain. A recent study of 2481 patients with coronary heart disease showed enhanced recovery after cognitive behaviour therapy or antidepressants (sertraline), as patients were less depressed and felt less isolated, but event free survival after 29 months' follow up did not increase.22
Implementation
General practice seems to be responding to new evidence with increasing vigour. The revised definition of myocardial infarction diagnosed by troponin estimation, however, will probably result in increased reporting of myocardial infarction and further increased workloads in primary and secondary care.24 The two sectors need to collaborate and communicate effectively to reduce treatment gaps and build on established models of integrated care with proved effectiveness. The impact of the national service framework, the new general medical services contract for general practitioners, and other initiatives (such as the national primary care collaborative) should improve quality of care after myocardial infarction for patients in the United Kingdom.
Sources of information for patients
Hearts for Life (www.heartsforlife.co.uk)—provides patient friendly information on heart attacks, angina, heart failure, and prevention
British Heart Foundation (www.bhf.org.uk)—printable information on heart attack and cardiac rehabilitation, with links to other sites
DIPEx (www.dipex.org)—website about people's experiences of health and illness; the site links video, audio, and written interviews with evidence based information, patients' questions and answers, and links to other resources; information for patients who have had heart attacks will be available from August 2004
BBC Health (www.bbc.co.uk/health)—specific section on how to recover after a heart attack (www.bbc.co.uk/health/features/heart_attack_recovery.shtml)
Additional references and a second patient's perspective are on bmj.com>
We thank Joy Choules for her help with typing the manuscript and Alan Begg, Hugh Bethell, Denis Pereira Gray, Tony Mourant, Rod Taylor, and Jenny Wingham for their comments on earlier drafts of this paper.
Contributors: HD and PHE conducted the literature searches. All three authors contributed to the design of the review and writing the article.
Funding: HD is the lead researcher for Lower Lemon Street Surgery, Truro, which is an NHS research and development practice funded by the Department of Health. The Department of Health through SaNDNet (Somerset and North and East Devon Primary Care Research Network) funds PHE. JLC is the professor of general practice and primary care, funded by the Peninsula Medical School.
Competing interests: None declared.
References
Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation 2001;104: 2746-53.
Bethell HJ, Turner SC, Evans JA, Rose L. Cardiac rehabilitation in the United Kingdom. How complete is the provision? J Cardiopulm Rehabil 2001;21: 111-5.
EUROASPIRE I and II Group, Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. Lancet 2001;357: 995-1001.
Brady AJ, Oliver MA, Pittard JB. Secondary prevention in 24 431 patients with coronary heart disease: survey in primary care. BMJ 2001;322: 1463.
Murchie P, Campbell NC, Ritchie LD, Simpson JA, Thain J. Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care. BMJ 2003;326: 84.
Dalal HM, Evans PH. Achieving national service framework standards for cardiac rehabilitation and secondary prevention. BMJ 2003;326: 481-4.
Pereira Gray D. Role reversal between primary and secondary care. Med Educ 2003;37: 754-5.
Fox KM. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 2003;362: 782-8.
Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000;342: 145-53.
Heart Protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360: 7-22.
Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002;324: 71-86.
CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348: 1329-39.
Flather MD, Yusuf S, Kober L, Pfeffer M, Hall A, Murray G, et al. Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. Lancet 2000;355: 1575-81.
LaRosa JC, He J, Vupputuri S. Effect of statins on risk of coronary disease: a meta-analysis of randomized controlled trials. JAMA 1999;282: 2340-6.
Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 2002;288: 462-7.
Ko DT, Hebert PR, Coffey CS, Sedrakyan A, Curtis JP, Krumholz HM. Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. JAMA 2002;288: 351-7.
Gray J, Majeed A, Kerry S, Rowlands G. Identifying patients with ischaemic heart disease in general practice: cross sectional study of paper and computerised medical records. BMJ 2000;321: 548-50.
Lewin B, Robertson IH, Cay EL, Irving JB, Campbell M. Effects of self-help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services. Lancet 1992;339: 1036-40.
Marchionni N, Fattirolli F, Fumagalli S, Oldridge N, Del Lungo F, Morosi L, et al. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial. Circulation 2003;107: 2201-6.
Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003;290: 86-97.
Mayou RA, Gill D, Thompson DR, Day A, Hicks N, Volmink J, et al. Depression and anxiety as predictors of outcome after myocardial infarction. Psychosom Med 2000;62: 212-9.
Berkman LF, Blumenthal J, Burg M, Carney RM, Catellier D, Cowan MJ, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the enhancing recovery in coronary heart disease patients (ENRICHD) randomized trial. JAMA 2003;289: 3106-16.
Summerskill WSM, Pope C. "I saw the panic rise in her eyes, and evidence-based medicine went out of the door." An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease. Fam Pract 2002;19: 605-10.
Ferguson JL, Beckett GJ, Stoddart M, Walker SW, Fox KA. Myocardial infarction redefined: the new ACC/ESC definition, based on cardiac troponin, increases the apparent incidence of infarction. Heart 2002;88: 343-7.(Hasnain Dalal, general pr)