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A New UK Survey Suggests Primary Care Clinicians Need Clearer Post-Mi Guidelines To Provide Their Patients With Optimal Care

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A new survey published in the British Journal of Cardiology suggests that inconsistencies in clinical guidance for the ongoing management of post-myocardial infarction (MI) patients may contribute to significant variation in clinical practice reported by GPs and practice nurses.1a These findings indicate that, in some areas of the UK, care for post-MI patients after leaving hospital may not be optimal,1b according to authors from the Follow Your Heart group. *
The research survey suggests that GPs and practice nurses, tasked with the ongoing management of post-MI patients, follow a range of different national guidance depending on where in the country they are based.1c As such, patient care may vary across the UK, as recommendations made by NICE, SIGN and the Joint British Societies (JBS) for the use of therapeutic interventions and targets for management of risk factors are not always consistent.1d In the current NHS environment, adherence to the Quality and Outcomes Framework (QOF) is a further key consideration influencing clinical decisions for many GPs and practice nurses. As QOF is benchmarked at minimum audit standards, it may not stipulate optimal care for high risk patients.1e
Dr David Milne, a GP in Colchester and member of the Primary Care Cardiovascular Society (PCCS) commented: "Post-MI patients are at a much higher risk of having a further CV event and should consequently be prioritised for individual clinical assessment and provided with optimal care and treatment. Yet guidelines available to GPs and practice nurses may not be aligned, creating inconsistencies and thus lack of clarity, potentially making it difficult in some instances to achieve optimal care for these patients, who by definition are at higher risk of a further event."
Whilst mostly useful and well-intended, in some cases local guidelines may be out of date or not fully implemented and this, coupled with the finding that there is substantial variation in the local interpretation of national post-MI clinical guidance, may explain why clinical management of such patients, as reported by GPs and nurses around the UK varies.1f
Communication between primary and secondary care may also be challenging in some areas, where continuity in patient care may be hampered by limited verbal communication.1g The research suggests that GPs and practice nurses in most regions typically receive a generic discharge statement when a post-MI patient is returned to their care.1h Incomplete information and delays in the primary care clinician receiving the discharge statement may result in crucial individual patient information being lost, making it difficult for GPs to appreciate why certain therapeutic interventions have been recommended, and others not.
Evidence of regional disparities
The research looked at risk factor targets as one of the measures of regional comparison and found some differences. GPs and practice nurses surveyed as part of the research most commonly followed cholesterol targets recommended by NICE and the Department of Health (as part of the QOF),1i although respondents in the North West indicated that they most commonly manage post-MI patients' cholesterol to the lowest targets,1j as recommended by the JBS.2a In patients at higher cardiovascular risk - such as those who have already suffered a heart attack - there is a wealth of evidence to show that for every 1mmol/l reduction in LDL cholesterol, the risk of a further major coronary event is reduced by almost a quarter.3 Although GPs and practice nurses surveyed as part of the study indicated they are more committed to following the most stringent targets to manage blood pressure, this research suggests that almost half1k do not treat to the toughest targets of 130/80mmHg.2b
It would appear that whilst the survey respondents reported that they choose to follow national guidance, with 65% of clinicians in England and 78% in Wales claiming to follow NICE, actual clinical practice may differ. Although most patients with acute coronary syndrome (ACS) will have their statin initiated by a secondary care clinician before discharge from hospital, nearly half of the survey respondents said if it were their choice they would initiate ACS patients with simvastatin 40mg,1k despite the recommendation in the NICE Lipid Modification guideline to treat patients with ACS with a 'higher intensity' ** statin.4a
The research published today is qualitative in design, and therefore the results cannot be considered conclusive. However, the study does raise some interesting topics for discussion and debate, and highlights the need to have unifying guidance to ensure less practice variation in the management of post-MI patients. At a time when there are divergent post-MI guidelines, the Follow Your Heart group has come together to highlight the need for simple, consistent, evidence-based guidance, which promotes a better understanding of optimal post-MI care amongst primary care clinicians and patients. It is hoped that this will help to reduce disparities in care and treatment across the UK, driving improved patient outcomes and reducing mortality.
The research also suggests that information provided to post-MI patients is rarely aligned to clinical guidance,1l making it difficult for patients to take an active role in their own risk prevention. It is widely accepted that patient involvement and behaviour change in relation to their condition is one of the most important factors affecting patient outcomes.5 This is particularly necessary to increase patient understanding about the importance of compliance.
Speaking on behalf of the Follow Your Heart group, Michaela Nuttall, cardiovascular nurse specialist at Bromley Primary Care Trust commented: "GPs and practice nurses need clear, evidence-based guidance to enable the provision of optimal and consistent care to post-MI patients in their day-to-day practice. The central role of the patient should be prioritised by aligning patient information to clinical guidance so they have a better understanding of the standard of care they should be receiving and feel included in decisions to best manage their own condition."
* The Follow Your Heart group is a collaboration between HEART UK - The Cholesterol Charity, the PCCS and Pfizer.
** 'Higher intensity statins' are defined as statins used in doses that produce greater cholesterol lowering than simvastatin 40mg4b
The research paper 'Post-MI clinical guidelines: Variation in availability, development, content and implementation across the UK' is published in the May/June issue of the British Journal of Cardiology. The qualitative research project, which aimed to understand the extent to which national guidance on CHD is being locally adapted (in the form of local post-MI guidelines) and implemented as well as to gauge regional variations in post-MI care, consisted of two parts: a survey of PCTs and cardiac networks in England to ascertain the existence and availability of current post-MI guidelines and explore any regional variations present; and a survey of GPs and practice nurses to establish the level of awareness of both national and local post-MI clinical guidance amongst primary healthcare professionals across the UK and identify any reported variations in the management of post-MI patients. This latter phase of research included HCPs in England, Scotland, Wales and Northern Ireland and allowed for comparisons to be made between the approach taken in England and that in the devolved nations, in addition to providing greater insight in to the management of post-MI care across the whole of the UK.
About Follow Your Heart
HEART UK - The Cholesterol Charity, the Primary Care Cardiovascular Society (PCCS) and Pfizer have come together in a novel three-way partnership - bringing together the right mix of individual perspectives, skills and key experts - in a bid to minimise the significant variation in care and treatment of heart attack patients across the UK and promote improved and consistent patient care. Although facilitated by financial support from Pfizer, each of the organisations contributed equally through the steering committee and enjoyed parity in decision-making.
About the Primary Care Cardiovascular Society (PCCS)
The Primary Care Cardiovascular Society (PCCS) was established in 1998 to promote high quality cardiovascular disease management in the primary care setting.
The organisation's aims are to improve the care and outcome of patients with cardiovascular disease through the exchange of knowledge, and the promotion amongst clinical practitioners of research, education and development relating to cardiovascular disease in general, and community cardiovascular medicine in particular.
The Society, which is affiliated to the British Cardiovascular Society and a member organisation of the National Heart Forum, has been granted charitable status.
For further information please go to
About HEART UK - The Cholesterol Charity
HEART UK's mission is to help prevent premature deaths caused by high cholesterol and cardiovascular disease. To achieve this mission, HEART UK - The Cholesterol Charity:
- Helps and supports individuals, families and healthcare professionals to understand and control cholesterol conditions and related cardiovascular risks
- Promotes cholesterol education and research to improve identification, prevention, treatment and care
- Works in partnership with government, the NHS, industry and other charities to promote awareness and action on cholesterol related issues
- Promotes best clinical practice in addressing inherited cholesterol conditions including familial hypercholesterolaemia (FH)
1. Ong S, Milne D, Morrell J. Post-MI clinical guidelines: variation in availability, development, content and implementation across the UK. Br J Cardiol 2009; 16:142-6
2. Joint British Societies 2. Heart 2005; 91(suppl V)
3. Cholesterol Treatment Trialists' (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90 056 participants in 14 randomised trials of statins. The Lancet 2005; 366; 1267 - 1278
4. NICE CG67 Lipid Modification Clinical Guidelines. (Accessed May 2009)
5. Say, R and Thomson, R. The importance of patient preferences in treatment decisions - challenges for doctors. BMJ 2003, 327; 542
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