Acute coronary syndromes

Immediately assess eligibility (irrespective of age, ethnicity or sex) for coronary reperfusion therapy (either primary percutaneous coronary intervention [PCI] or fibrinolysis) in people with acute ST‑segment elevation myocardial infarction (STEMI). [2013]

Do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to determine whether a person is eligible for coronary angiography (with follow‑on primary PCI if indicated). [2013]

Deliver coronary reperfusion therapy (either primary PCI or fibrinolysis) as quickly as possible for eligible people with acute STEMI. [2013]

Offer people with acute STEMI a single loading dose of 300-mg aspirin as soon as possible unless there is clear evidence that they are allergic to it. [2010]

Do not offer routine glycoprotein IIb/IIIa inhibitors or fibrinolytic drugs before arrival at the catheter laboratory to people with acute STEMI for whom primary PCI is planned. [2013]

Offer coronary angiography, with follow‑on primary PCI if indicated, as the preferred coronary reperfusion strategy for people with acute STEMI, if:

• presentation is within 12 hours of onset of symptoms and

• primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given. [2013]

Offer coronary angiography, with follow‑on primary PCI if indicated, to people with acute STEMI and cardiogenic shock who present within 12 hours of the onset of symptoms of STEMI. [2013]

Consider coronary angiography, with follow‑on primary PCI if indicated, for people with acute STEMI presenting more than 12 hours after the onset of symptoms if there is evidence of continuing myocardial ischaemia. [2013]

Consider coronary angiography, with a view to coronary revascularisation if indicated, for people with acute STEMI who present more than 12 hours after the onset of symptoms and who have cardiogenic shock or go on to develop it. [2013]

Consider radial (in preference to femoral) arterial access for people undergoing coronary angiography (with follow‑on primary PCI if indicated). [2013]

For people with acute STEMI who are having primary PCI, offer:

• Prasugrel, as part of dual antiplatelet therapy with aspirin, if they are not already taking an oral anticoagulant (use the maintenance dose in the prasugrel summary of product characteristics; for people aged 75 and over, think about whether the person's risk of bleeding with prasugrel outweighs its effectiveness, in which case offer ticagrelor or clopidogrel as alternatives)

• Clopidogrel, as part of dual antiplatelet therapy with aspirin, if they are already taking an oral anticoagulant. [2020]
  
  Also see the NICE technology appraisal guidance on ticagrelor for the treatment of acute coronary syndromes.

Offer unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor in combination with dual antiplatelet therapy to people with acute STEMI undergoing primary PCI with radial access. [2020]

Consider bivalirudin with bailout glycoprotein IIb/IIIa inhibitor in combination with dual antiplatelet therapy for people with acute STEMI undergoing primary PCI when femoral access is needed.

In November 2020, use of bivalirudin with prasugrel and aspirin was off label. See NICE's information on prescribing medicines. [2020]

Consider thrombus aspiration during primary PCI for people with acute STEMI. [2013]

Do not routinely use mechanical thrombus extraction during primary PCI for people with acute STEMI. [2013]

Offer complete revascularisation with PCI for people with acute STEMI and multivessel coronary artery disease without cardiogenic shock. Consider doing this during the index hospital admission. [2020]

Consider culprit vessel only revascularisation with PCI rather than complete revascularisation during the index procedure for people with acute STEMI and multivessel coronary artery disease with cardiogenic shock. [2020]

If stenting is indicated, offer a drug-eluting stent to people with acute STEMI undergoing revascularisation by primary PCI. [2020]

Offer fibrinolysis to people with acute STEMI presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given. [2013]

When treating people with fibrinolysis, give an antithrombin at the same time. [2013]

Offer an electrocardiogram (ECG) to people with acute STEMI treated with fibrinolysis, 60 to 90 minutes after administration. For those who have residual ST‑segment elevation suggesting failed coronary reperfusion:

• offer immediate coronary angiography, with follow‑on PCI if indicated

• do not repeat fibrinolytic therapy. [2013]

If a person with acute STEMI has recurrent myocardial ischaemia after fibrinolysis, seek immediate specialist cardiological advice and, if appropriate, offer coronary angiography, with follow‑on PCI if indicated. [2013]

Consider coronary angiography during the same hospital admission for people with acute STEMI who are clinically stable after successful fibrinolysis. [2013]

Offer ticagrelor, as part of dual antiplatelet therapy with aspirin, to people with acute STEMI not treated with PCI, unless they have a high bleeding risk. [2020]

Consider clopidogrel, as part of dual antiplatelet therapy with aspirin, or aspirin alone, for people with acute STEMI not treated with PCI, if they have a high bleeding risk. [2020]

Offer medical management to people with acute STEMI who are ineligible for any reperfusion therapy. [2013]

Assess left ventricular function in all people who have had a STEMI. [2013]

Offer aspirin as soon as possible to all people with unstable angina or non‑ST‑segment elevation myocardial infarction (NSTEMI) and continue indefinitely unless contraindicated by bleeding risk or aspirin hypersensitivity. [2010]

Offer people with unstable angina or NSTEMI a single loading dose of 300-mg aspirin as soon as possible unless there is clear evidence that they are allergic to it. [2010]

Offer fondaparinux to people with unstable angina or NSTEMI who do not have a high bleeding risk, unless they are undergoing immediate coronary angiography. [2020]

Consider unfractionated heparin, with dose adjustment guided by monitoring of clotting function, as an alternative to fondaparinux for people with unstable angina or NSTEMI and significant renal impairment (creatinine above 265 micromoles per litre). [2010]

Carefully consider the choice and dose of antithrombin for people with unstable angina or NSTEMI who have a high risk of bleeding associated with any of the following:

• advancing age

• known bleeding complications

• renal impairment

• low body weight. [2010]

Do not offer dual antiplatelet therapy to people with chest pain before a diagnosis of unstable angina or NSTEMI is made. [2020]

As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6‑month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]). [2010]

Include in the formal risk assessment:

• a full clinical history (including age, previous myocardial infarction [MI] and previous PCI or coronary artery bypass grafting [CABG])

• a physical examination (including measurement of blood pressure and heart rate)

• a resting 12‑lead ECG, looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia

• blood tests (such as troponin I or T, creatinine, glucose and haemoglobin). [2010]

Record the results of the risk assessment in the person's care record. [2010]

Use risk assessment to guide clinical management, and balance the benefit of a treatment against any risk of related adverse events in the light of this assessment. [2010]

Use predicted 6‑month mortality to categorise the risk of future adverse cardiovascular events as shown in table 1. [2010]

Offer immediate coronary angiography to people with unstable angina or NSTEMI if their clinical condition is unstable. [2020]

Consider coronary angiography (with follow‑on PCI if indicated) within 72 hours of first admission for people with unstable angina or NSTEMI who have an intermediate or higher risk of adverse cardiovascular events (predicted 6‑month mortality above 3.0%) and no contraindications to angiography (such as active bleeding or comorbidity).

See table 2 for information on the benefits and risks of early invasive treatment compared with conservative management. [2020]

Consider coronary angiography (with follow‑on PCI if indicated) for people with unstable angina or NSTEMI who are initially assessed to be at low risk of adverse cardiovascular events (predicted 6‑month mortality 3.0% or less) if ischaemia is subsequently experienced or is demonstrated by ischaemia testing.

See table 2 for information on the benefits and risks of early invasive treatment compared with conservative management. [2020]

Be aware that some younger people with low risk scores for mortality at 6 months may still be at high risk of adverse cardiovascular events and may benefit from early angiography. [2020]

Offer systemic unfractionated heparin in the cardiac catheter laboratory to people with unstable angina or NSTEMI who are undergoing PCI whether or not they have already received fondaparinux.

In November 2020, this was an off‑label use of unfractionated heparin. See NICE's information on prescribing medicines. [2020]

For people with unstable angina or NSTEMI who are having coronary angiography, offer:

• prasugrel or ticagrelor, as part of dual antiplatelet therapy with aspirin, if they have no separate indication for ongoing oral anticoagulation (if using prasugrel, only give it once coronary anatomy has been defined and PCI is intended, and use the maintenance dose in the prasugrel summary of product characteristics; for people aged 75 and over, think about whether the person's risk of bleeding with prasugrel outweighs its effectiveness)

• clopidogrel, as part of dual antiplatelet therapy with aspirin, if they have a separate indication for ongoing oral anticoagulation. [2020]

If stenting is indicated, offer a drug-eluting stent to people with unstable angina or NSTEMI undergoing revascularisation by PCI. [2020]

Consider conservative management without early coronary angiography for people with unstable angina or NSTEMI who have a low risk of adverse cardiovascular events (predicted 6‑month mortality 3.0% or less). [2020]

Offer ticagrelor, as part of dual antiplatelet therapy with aspirin, to people with unstable angina or NSTEMI when PCI is not indicated, unless they have a high bleeding risk. [2020]

Consider clopidogrel, as part of dual antiplatelet therapy with aspirin, or aspirin alone, for people with unstable angina or NSTEMI when PCI is not indicated, if they have a high bleeding risk. [2020]

Offer people with unstable angina or NSTEMI clear information about the risks and benefits of the treatments offered so that they can make informed choices about management strategies. Information should be appropriate to the person's underlying risk of a future adverse cardiovascular event and any comorbidities. [2010]

When advising people with unstable angina or NSTEMI about the choice of revascularisation strategy (PCI or CABG), take account of coronary angiographic findings, comorbidities, and the benefits and risks of each intervention. [2010]

When the role of revascularisation or the revascularisation strategy is unclear, resolve this by discussion involving an interventional cardiologist, cardiac surgeon and other healthcare professionals relevant to the needs of the person. Discuss the choice of revascularisation strategy with the person. [2010]

To detect and quantify inducible ischaemia, consider ischaemia testing before discharge for people whose condition has been managed conservatively and who have not had coronary angiography. [2010]

Assess left ventricular function in all people who have had an NSTEMI. [2013]

Consider assessing left ventricular function in all people with unstable angina. [2010]

Record measures of left ventricular function in the person's care record and in correspondence with the primary healthcare team and the person. [2010]

Manage hyperglycaemia in people admitted to hospital for an acute coronary syndrome by keeping blood glucose levels below 11.0 mmol/litre while avoiding hypoglycaemia. In the first instance, consider a dose-adjusted insulin infusion with regular monitoring of blood glucose levels. [2011]

Do not routinely offer intensive insulin therapy (an intravenous infusion of insulin and glucose with or without potassium) to manage hyperglycaemia (blood glucose above 11.0 mmol/litre) in people admitted to hospital for an acute coronary syndrome unless clinically indicated. [2011]

Offer all people with hyperglycaemia after acute coronary syndrome and without known diabetes tests for:

• HbA1c levels before discharge

• fasting blood glucose levels no earlier than 4 days after the onset of acute coronary syndrome.
  
  These tests should not delay discharge. [2011]

Do not routinely offer oral glucose tolerance tests to people with hyperglycaemia after acute coronary syndrome and without known diabetes if HbA1c and fasting blood glucose levels are within the normal range. [2011]

Offer people with hyperglycaemia after acute coronary syndrome and without known diabetes lifestyle advice on the following:

• healthy eating

• physical exercise

• weight management

• smoking cessation

• alcohol consumption.
  
  See the section on lifestyle changes after an MI for more information. [2011]

Advise people without known diabetes that if they have had hyperglycaemia after an acute coronary syndrome, they:

• are at increased risk of developing type 2 diabetes

• should consult their GP if they experience the following symptoms:

  • frequent urination

  • excessive thirst

  • weight loss

  • fatigue

• should be offered tests for diabetes at least annually. [2011]

Inform GPs that they should offer at least annual monitoring of HbA1c or fasting blood glucose levels to people without known diabetes who have had hyperglycaemia after an acute coronary syndrome. [2011]

Offer people who present acutely with an MI, an ACE inhibitor as soon as they are haemodynamically stable. Continue the ACE inhibitor indefinitely. [2013]

Titrate the ACE inhibitor dose upwards at short intervals (for example, every 12 to 24 hours) before the person 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 to 6 weeks of hospital discharge. [2013]

Do not offer combined treatment with an ACE inhibitor and an angiotensin II receptor blocker (ARB) to people after an MI, unless there are other reasons to use this combination. [2013]

After an MI, offer people who are intolerant to ACE inhibitors, an ARB instead of an ACE inhibitor. [2013]

Renal function, serum electrolytes and blood pressure should be measured before starting an ACE inhibitor or ARB and again within 1 or 2 weeks of starting treatment. People should have appropriate monitoring as the dose is titrated upwards, until the maximum tolerated or target dose is reached, and then at least annually. More frequent monitoring may be needed in people who are at increased risk of deterioration in renal function. People with chronic heart failure should be monitored in line with the NICE guideline on chronic heart failure in adults. [2007]

Offer an ACE inhibitor to people who have had an MI more than 12 months ago. Titrate to the maximum tolerated or target dose (over a 4‑ to 6‑week period) and continue indefinitely. [2013]

Offer people who have had an MI more than 12 months ago and who are intolerant to ACE inhibitors an ARB instead of an ACE inhibitor. [2013]

Offer aspirin to all people after an MI and continue it indefinitely, unless they are aspirin intolerant or have an indication for anticoagulation (see the section on antiplatelet therapy for people with an ongoing separate indication for anticoagulation). [2007, amended 2013]

Offer aspirin to people who have had an MI more than 12 months ago and continue it indefinitely. [2013]

Continue dual antiplatelet therapy for up to 12 months after an MI unless contraindicated (see recommendations 1.1.11, 1.1.24, 1.1.25, 1.2.17, 1.2.20 and 1.2.21 for more information about dual antiplatelet therapy). [2020]

For people with aspirin hypersensitivity who have had an MI, clopidogrel monotherapy should be considered as an alternative treatment. [2007]

People with a history of dyspepsia should be considered for treatment in line with the NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults. [2007, amended 2013]

After appropriate treatment, people with a history of aspirin-induced ulcer bleeding whose ulcers have healed and who are negative for Helicobacter pylori should be considered for treatment in line with the NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults. [2007, amended 2013]

Offer clopidogrel instead of aspirin to people who also have other clinical vascular disease, in line with the NICE technology appraisal guidance on clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events, and who have:

• had an MI and stopped dual antiplatelet therapy or

• had an MI more than 12 months ago. [2013]

Offer people a beta-blocker as soon as possible after an MI, when the person is haemodynamically stable. [2013]

Communicate plans for titrating beta-blockers up to the maximum tolerated or target dose – for example, in the discharge summary. [2013]

Consider continuing a beta-blocker for 12 months after an MI for people without reduced left ventricular ejection fraction. [2020]

Discuss the potential benefits and risks of stopping or continuing beta-blockers beyond 12 months after an MI for people without reduced left ventricular ejection fraction. Include in the discussion:

• the lack of evidence on the relative benefits and harms of continuing beyond 12 months

• the person's experience of adverse effects. [2020]

Continue a beta-blocker indefinitely in people with reduced left ventricular ejection fraction. [2013]

Offer all people who have had an MI more than 12 months ago, who have reduced left ventricular ejection fraction, a beta-blocker whether or not they have symptoms. For people with heart failure plus reduced left ventricular ejection fraction, manage the condition in line with the NICE guideline on chronic heart failure in adults. [2013]

Do not offer people without reduced left ventricular ejection fraction or heart failure, who have had an MI more than 12 months ago, treatment with a beta-blocker unless there is an additional clinical indication for a beta-blocker. [2013]

Do not routinely offer calcium channel blockers to reduce cardiovascular risk after an MI. [2007]

If beta-blockers are contraindicated or need to be discontinued, diltiazem or verapamil may be considered for secondary prevention in people without pulmonary congestion or reduced left ventricular ejection fraction. [2007]

For people whose condition is stable after an MI, calcium channel blockers may be used to treat hypertension and/or angina. For people with heart failure with reduced ejection fraction, use amlodipine, and avoid verapamil, diltiazem and short-acting dihydropyridine agents in line with the NICE guideline on chronic heart failure in adults. [2007, amended 2020]

Do not offer nicorandil to reduce cardiovascular risk after an MI. [2007]

For people who have had an acute MI and who have symptoms and/or signs of heart failure and reduced left ventricular ejection fraction, initiate treatment with an aldosterone antagonist licensed for post‑MI treatment within 3 to 14 days of the MI, preferably after ACE inhibitor therapy. [2007]

People who have recently had an acute MI and have clinical heart failure and reduced left ventricular ejection fraction, but who are already being treated with an aldosterone antagonist for a concomitant condition (for example, chronic heart failure), should continue with the aldosterone antagonist or an alternative, licensed for early post‑MI treatment. [2007]

For people who have had a proven MI in the past and heart failure due to reduced left ventricular ejection fraction, treatment with an aldosterone antagonist should be in line with the NICE guideline on chronic heart failure in adults. [2007]

Monitor renal function and serum potassium before and during treatment with an aldosterone antagonist. If hyperkalaemia is a problem, halve the dose of the aldosterone antagonist or stop the drug. [2007]

Statin therapy is recommended for adults with clinical evidence of cardiovascular disease in line with the NICE guideline on cardiovascular disease. [2007]

People who have reduced left ventricular ejection fraction should be considered for an implantable cardioverter defibrillator in line with NICE technology appraisal guidance on implantable cardioverter defibrillators and cardiac resynchronisation therapy for arrhythmias and heart failure. [2007]

Treat hypertension in line with the NICE guideline on hypertension in adults. [2007, amended 2013]

Deliver cardiac rehabilitation in a non-judgemental, respectful and culturally sensitive manner. Consider employing bilingual peer educators or cardiac rehabilitation assistants who reflect the diversity of the local population. [2013]

Establish people's health beliefs and their specific illness perceptions before offering appropriate lifestyle advice and to encourage attendance to a cardiac rehabilitation programme. [2013]

Offer cardiac rehabilitation programmes designed to motivate people to attend and complete the programme. Explain the benefits of attending. [2013]

Discuss with the person any factors that might stop them attending a cardiac rehabilitation programme, such as transport difficulties. [2013]

Offer cardiac rehabilitation programmes in a choice of venues (including at the person's home, in hospital and in the community) and at a choice of times of day, for example, sessions outside of working hours. Explain the options available. [2013]

Provide a range of different types of exercise, as part of the cardiac rehabilitation programme, to meet the needs of people of all ages, or those with significant comorbidity. Do not exclude people from the whole programme if they choose not to attend specific components. [2013]

Offer single-sex cardiac rehabilitation programme classes if there is sufficient demand. [2013]

Enrol people who have had an MI in a system of structured care, ensuring that there are clear lines of responsibility for arranging the early initiation of cardiac rehabilitation. [2013]

Begin cardiac rehabilitation as soon as possible after admission before discharge from hospital, and invite the person to a cardiac rehabilitation session. This should start within 10 days of their discharge from hospital. [2013]

Contact people who do not start or do not continue to attend the cardiac rehabilitation programme with a further reminder, such as:

• a motivational letter

• a prearranged visit from a member of the cardiac rehabilitation team

• a telephone call

• a combination of the above. [2013]

Seek feedback from cardiac rehabilitation programme users and aim to use this feedback to increase the number of people starting and attending the programme. [2013]

Be aware of the wider health and social care needs of a person who has had an MI. Offer information and sources of help on:

• economic issues

• welfare rights

• housing and social support issues. [2013]

Make cardiac rehabilitation equally accessible and relevant to all people after an MI, particularly people from groups that are less likely to access this service. These include people from black, Asian and minority ethnic groups, older people, people from lower socioeconomic groups, women, people from rural communities, people with a learning disability and people with mental and physical health conditions. [2007, amended 2013]

Encourage all staff, including senior medical staff, involved in providing care for people after an MI, to actively promote cardiac rehabilitation. [2013]

Comprehensive cardiac rehabilitation programmes should include health education and stress management components. [2007]

A home-based programme validated for people who have had an MI (such as NHS Lothian's heart manual) that incorporates education, exercise and stress management components with follow ups by a trained facilitator may be used to provide comprehensive cardiac rehabilitation. [2007]

Take into account the physical and psychological status of the patient, the nature of their work and their work environment when giving advice on returning to work. [2007]

Be up to date with the latest Driver and Vehicle Licensing Agency (DVLA) guidelines. Regular updates are published by the DVLA. [2007]

After an MI without complications, people who wish to travel by air should seek advice from the Civil Aviation Authority. People who have had a complicated MI need expert individual advice. [2007, amended 2013]

People who have had an MI who hold a pilot's licence should seek advice from the Civil Aviation Authority. [2007]

Take into account the person's physical and psychological status, as well as the type of activity planned when offering advice about the timing of returning to normal activities. [2007]

An estimate of the physical demand of a particular activity, and a comparison between activities, can be made using tables of metabolic equivalents (METS) of different activities (for further information, please refer to the information from the Centers for Disease Control and Prevention). Advise people how to use a perceived exertion scale to help monitor physiological demand. People who have had a complicated MI may need expert advice. [2007]

Advice on competitive sport may need expert assessment of function and risk, and is dependent on what sport is being discussed and the level of competitiveness. [2007]

Offer stress management in the context of comprehensive cardiac rehabilitation. [2007]

Do not routinely offer complex psychological interventions such as cognitive behavioural therapy. [2007]

Involve partners or carers in the cardiac rehabilitation programme if the person wishes. [2007]

For recommendations on managing clinical anxiety or depression, refer to the NICE guidelines on anxiety, depression in adults and depression in adults with a chronic physical health problem. [2007]

Reassure people that after recovery from an MI, sexual activity presents no greater risk of triggering a subsequent MI than if they had never had an MI. [2007]

Advise people who have made an uncomplicated recovery after their MI that they can resume sexual activity when they feel comfortable to do so, usually after about 4 weeks. [2007]

Raise the subject of sexual activity within the context of cardiac rehabilitation and aftercare for people who have had an MI. [2007]

Advise people to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on plant oils). [2007]

Do not routinely recommend eating oily fish for the sole purpose of preventing another MI. If people choose to consume oily fish after an MI, be aware that there is no evidence of harm, and fish may form part of a Mediterranean-style diet. [2013]

Do not offer or advise people to use the following to prevent another MI:

• omega-3 fatty acid capsules

• omega-3 fatty acid supplemented foods. [2013]

If people choose to take omega‑3 fatty acid capsules or eat omega‑3 fatty acid supplemented foods, be aware that there is no evidence of harm. [2013]

Advise people not to take supplements containing beta-carotene. Do not recommend antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk. [2007]

Offer people an individual consultation to discuss diet, including their current eating habits, and advice on improving their diet. [2007]

Give people consistent dietary advice tailored to their needs. [2007]

Give people healthy eating advice that can be extended to the whole family. [2007]

For advice on alcohol consumption, see the UK government drinking guidelines. [2020]

Advise people to undertake regular physical activity sufficient to increase exercise capacity. [2007]

Advise people to be physically active for 20 to 30 minutes a day to the point of slight breathlessness. Advise people who are not active to this level to increase their activity in a gradual, step-by-step way, aiming to increase their exercise capacity. They should start at a level that is comfortable, and increase the duration and intensity of activity as they gain fitness. [2007]

Advice on physical activity should involve a discussion about current and past activity levels and preferences. The benefit of exercise may be enhanced by tailored advice from a suitably qualified professional. [2007]

Advise all people who smoke to stop and offer assistance from a smoking cessation service in line with the NICE guideline on stop smoking interventions and services. [2007]

If a person is unable or unwilling to accept a referral to a stop smoking service, they should be offered pharmacotherapy in line with the NICE guideline on stop smoking interventions and services. [2007, amended 2020]

After an MI, offer all people who are overweight or obese advice and support to achieve and maintain a healthy weight in line with the NICE guideline on obesity. [2007]