GPAtlas🧭 When to review – post-MI secondary prevention
This article covers the longer-term primary-care management of everyone discharged after a myocardial infarction (MI) – whether ST-elevation MI (STEMI), non-ST-elevation MI (NSTEMI) or unstable angina.
The goal is secondary prevention:
• Reducing the risk of a further acute coronary syndrome (ACS).
• Managing complications such as heart failure or arrhythmia.
• Restoring quality of life.
Make sure the four core secondary-prevention drugs are prescribed, tolerated and actually taken, and keep the person engaged with cardiac rehabilitation and risk-factor control.
• No single agent delivers the benefit on its own – it is the package that lowers mortality.
• The main thing that determines whether it works is adherence.
Conduct a structured review at least annually (sooner after any dose change). Two things should always be to hand: the discharge summary (type of MI, stents, latest left ventricular ejection fraction) and an up-to-date medication list.
| Review domain | What to assess and optimise |
|---|---|
| Medicines & adherence | • Confirm the four core drugs are prescribed, tolerated and taken • Ask about side effects • Assess bleeding risk • Check how long dual antiplatelet therapy should continue |
| Blood pressure | Optimise control as part of overall cardiovascular risk reduction. |
| Lipids | • Full lipid profile • Low-density lipoprotein (LDL) or non-HDL cholesterol to target on a high-intensity statin |
| Glycaemia | HbA1c at least annually – risk of type 2 diabetes is increased after ACS. |
| Renal function & electrolytes | U&E before and after any ACE inhibitor, ARB or aldosterone-antagonist change, then at least annually. |
| Left ventricular (LV) function & symptoms | • Confirm the latest left ventricular ejection fraction • Reassess if heart-failure status changes (it drives beta-blocker, aldosterone-antagonist and device decisions) |
| Lifestyle | Smoking, diet, physical activity, weight and alcohol. |
| Mood | Screen for depression and anxiety, which are common and worsen outcomes. |
| Cardiac rehabilitation | Confirm whether referred, attending or completed. |
| Vaccination | Annual influenza and a one-off pneumococcal vaccine (chronic heart disease is an at-risk group). |
Source: NICE NG185 · NICE NG238
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