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, and restoring quality of life.
The central primary-care task is twofold: 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, and adherence is the main thing that determines whether it works.
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; aim for LDL cholesterol ≤ 2.0 mmol/L or non-HDL cholesterol ≤ 2.6 mmol/L 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 within 1–2 weeks of any ACE inhibitor, ARB or aldosterone-antagonist change, then at least annually. |
| 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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