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Cardiovascular

MI - secondary prevention

Last revised in May 2025

Myocardial infarction (MI), colloquially known as a heart attack, is necrosis of myocardial tissue due to ischaemia.

MI - secondary prevention: Summary

  • Myocardial infarction (MI) is necrosis of myocardial tissue due to ischaemia, usually caused by blockage of a coronary artery by a thrombus.
  • MIs are classified, based on ECG (electrocardiogram) changes, as:
    • ST-segment elevation myocardial infarction (STEMI).
    • Non-ST-segment elevation myocardial infarction (NSTEMI).
  • STEMI and NSTEMI are considered part of a spectrum known as acute coronary syndrome (ACS), which refers to a range of acute myocardial ischaemia that also includes unstable angina.
    • In STEMI, complete and persistent blockage of the artery occurs, resulting in myocardial necrosis.
    • In NSTEMI and unstable angina, a partial or intermittent blockage of the artery occurs, usually resulting in myocardial necrosis in NSTEMI but not in unstable angina. 
  • MI is one of the most severe presentations of coronary heart disease (CHD). The British Heart Foundation (BHF) estimates that in the UK:
    • Around 2.3 million people are living with CHD.
    • Around 100,000 hospital admissions each year are due to MIs. 
    • Around 1.4 million people have survived an MI.
  • Possible complications of MI include heart failure, angina, arrhythmias, depression, and sudden death (for example, due to another MI or an arrhythmia).
  • Following initial treatments for acute MI, secondary prevention measures are initiated in secondary care to reduce the risk of complications and further cardiovascular events. These include:
    • Cardiac rehabilitation — this should be started as soon as possible after admission and before hospital discharge.
    • Drug treatments for secondary prevention — usually an angiotensin-converting enzyme (ACE) inhibitor (or angiotensin-II receptor antagonist if the person is intolerant to an ACE inhibitor), dual antiplatelet therapy, a beta-blocker, and a statin.
    • Lifestyle modification — addressing diet, physical activity, alcohol consumption, smoking cessation, and weight management, as appropriate. 
  • The hospital discharge summary should include: 
    • Confirmation of the diagnosis of acute MI.
    • Results of any investigations.
    • Details and timing of further drug titration.
    • Monitoring requirements, including blood pressure and renal function.
    • Future management and follow-up plans. 
    • Advice on secondary prevention.
  • Primary care management of a person who has had an MI includes:
    • Encouraging participation in the cardiac rehabilitation programme.
    • Prescribing and monitoring the drug treatments for secondary prevention.
    • Reinforcing lifestyle advice and offering support where needed, for example, with weight loss or smoking cessation.
    • Managing other risk factors for MI, such as hypertension and diabetes.
    • Managing complications of MI, such as angina and depression.
    • Encouraging attendance to follow-up assessments. 
    • Addressing any concerns the person may have, such as returning to work and resuming normal activities.
    • Offering information and sources of help as needed, such as on economic issues, welfare rights, and housing and social support issues.

Have I got the right topic?

From age 16 years onwards.

This CKS topic covers secondary prevention measures to reduce the risk of complications and further cardiovascular events in people who have had a myocardial infarction (MI) in primary care.

This CKS topic does not cover the diagnosis of MI, the management of people immediately after an MI, or the management of complications of MI, such as heart failure, post-infarction angina, and arrhythmias.

There are separate CKS topics on Angina, Antiplatelet treatment, Atrial fibrillation, CVD risk assessment and management, Diabetes - type 2, Heart failure - chronic, Hypertension, Lipid modification - CVD prevention, Obesity, Palpitations, and Smoking cessation.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

May 2025 — minor update. QOF indicators updated in line with the NHS England Quality and Outcomes Framework guidance for 2025/26.

Previous changes

March 2024 — reviewed. A literature search was conducted in March 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made. The contraindications, cautions, adverse effects, and drug interactions of angiotensin-converting enzyme inhibitors and beta-blockers have been removed, and links have been added to relevant sections in the CKS topic on Hypertension.

May 2020 — minor update. Prescribing information has been added in response to the National Institute for Health and Care Excellence (NICE) COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19 to reflect the advice during the COVID-19 pandemic.

February to March 2019 — reviewed. A literature search was conducted in February 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

October 2015 — minor update. The Prescribing information section has been updated to include:

  • Advice from the Medicines and Healthcare products Regulatory Agency (MHRA) and the drug manufacturers that concurrent use of drugs from two classes of the renin-angiotensin system (RAS) blocking agents, for example, an angiotensin-converting enzyme (ACE) inhibitor plus an angiotensin-II receptor antagonist or aliskiren, is not recommended.
  • Information from the manufacturer's Summary of Product Characteristics (SPC) for Tritace® regarding the drug interaction between ramipril tablets (Tritace®) and vildagliptin.
  • Information from the manufacturer's SPC for Tritace® regarding other common adverse effects of ACE inhibitors.
  • Updated advice from manufacturers' SPCs regarding the cautions and contraindications of beta-blockers in people with a form of obstructive airway disease.

June to September 2014 — reviewed. A literature search was conducted in June 2014 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. The main significant changes made to this topic reflect recommendations in the 2013 NICE guideline Secondary prevention in primary and secondary care for patients following a myocardial infarction and include:

  • Routine use of dual antiplatelet therapy for up to 12 months following a myocardial infarction (MI).
  • A greater emphasis on offering an exercise-based cardiac rehabilitation programme to people as soon as possible post-MI and ways to encourage greater participation in the programme.

December 2013 — minor update. Two broken links were fixed.

July 2013—minor update. The links to the Driver and Vehicle Licensing Agency (DVLA) website have been updated.

July 2013 — minor update. The management of abnormal results in people taking an ACE inhibitor has been updated according to the updated NICE guideline Chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care.

June 2013 — minor update. The 2013 Quality Outcomes Framework (QOF) options for local implementation have been added to this topic.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

January 2013—minor update. The text has been updated to reflect the MHRA's simvastatin safety advice.

November 2012 — minor update. Links to the electronic medicines website (www.medicines.org.uk) have been updated.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

April 2012 — minor update. The 2012/2013 QOF indicators have been added to this topic. 

March 2012 — minor update. Updated to include a recommendation from the House of Commons Science and Technology Committee that people should have at least two alcohol-free days per week. 

February 2012 — minor update. Information from the MHRA about the risk of hyperglycaemia and diabetes with statin use has been added. 

June 2011 — minor update. The 2011/2012 QOF indicators and the 2010/2011 QIPP options for local implementation have been added to this topic. 

March 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

October 2010 — minor update. Advice about flying for people with atrial fibrillation, based on the British Heart Foundation Factfile Fitness to fly for passengers with cardiovascular disease, which is derived from the British Cardiovascular Society Working Group's expert guidance, has also been included. 

July 2009 — minor update to clarify the MHRA's advice regarding the use of ACE inhibitors and angiotensin-II receptor antagonists in breastfeeding women.

June 2009 — minor update to the basis for the recommendation regarding not starting beta-blockers if it is more than one year after a diagnosis of MI. Included drug safety advice from the MHRA regarding the use of ACE inhibitors and angiotensin-II receptor antagonists in breastfeeding women. 

May 2009 — updated to include the QOF indicators for coronary heart disease from the General Medical Services (GMS) contract. 

October 2008 — minor typographical correction. 

May 2008 — minor update to text regarding a new product (perindopril arginine).

March 2008 — minor update. The MHRA has issued advice regarding several additional class adverse effects of statins.

January 2008 — updated. The MHRA has recently advised that ACE inhibitors and angiotensin II receptor antagonists should not be used at any stage of pregnancy and has also issued updated advice on interactions with statins. 

September to December 2007 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. The topic has been updated to reflect the NICE guideline on secondary prevention for people who have had an MI. The main change to the recommendations is that people who have had a proven MI more than 12 months ago should not be routinely started on a beta-blocker if they have preserved left ventricular function and are asymptomatic unless they are at increased risk of further cardiovascular events, or there are other compelling indications for beta-blocker treatment.

October to December 2005 — reviewed. Validated in March 2006 and issued in May 2006.

March 2002 — written. Validated in October 2002 and issued in December 2002.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2024.

HTAs (Health Technology Assessments)

No new HTAs published since 1 March 2024.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2024.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 March 2024.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2024.

New policies

No new national policies or guidelines since 1 March 2024.

New safety alert

No new safety alerts since 1 March 2024.

Changes in product availability

No changes in product availability since 1 March 2024.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Implement secondary prevention measures to reduce the risk of complications and further cardiovascular events after a myocardial infarction (MI).
  • Encourage participation in the cardiac rehabilitation programme.
  • Support people in their physical and psychosocial rehabilitation after an MI.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

Table 1. Indicators related to secondary prevention of coronary heart disease in the Quality and Outcomes Framework (QOF) of the General Medical Services (GMS) contract.

Indicator

Points

Payment stages

CHD005 The percentage of patients with coronary heart disease with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken756–96%
CHD015 The percentage of patients aged 79 years or under, with coronary heart disease, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or less, (or equivalent home blood pressure reading)3340-90%
CHD016 The percentage of patients aged 80 years or over, with coronary heart disease, in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less, (or equivalent home blood pressure reading) 1446–90%
SMOK002 The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 12 months2550–90%
Data from: [NHS England, 2025]

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

  • Adults admitted to hospital with an MI have the results of investigations and a plan for future treatment and monitoring shared with their GP.
  • Adults referred to a cardiac rehabilitation programme after an MI have an assessment appointment within 10 days of discharge from hospital.
  • Adults referred to a cardiac rehabilitation programme after an MI are offered sessions during and outside working hours and the choice of undertaking the programme at home, in the community or in a hospital setting.
  • Adults with newly diagnosed CVD are offered atorvastatin 80 mg.
  • Adults on a high‑intensity statin who have side effects are offered a lower dose or an alternative statin.
  • Adults on a high-intensity statin have a repeat measurement of full lipid profile and liver transaminases at 2 to 3 months of treatment.

[NICE, 2015; NICE, 2023a]

Background information

What is it?

  • Myocardial infarction (MI) is necrosis of myocardial tissue due to ischaemia. 
    • It is usually caused by blockage of a coronary artery by a thrombus formed from a ruptured or eroded atherosclerotic plaque.
    • Typical features include severe chest pain, changes in an ECG (electrocardiogram), and raised concentrations of serum troponin (a protein released from injured cardiac myocytes into the blood). 
  • MIs are classified, based on ECG changes, as:
    • ST-segment elevation myocardial infarction (STEMI) — ECG shows persistent ST-segment elevation in at least two anatomically contiguous leads.
    • Non-ST-segment elevation myocardial infarction (NSTEMI) — ECG does not show persistent ST elevation but may show ischaemic changes, such as transient ST elevation, ST depression, or T-wave changes, or it may be normal. 
  • STEMI and NSTEMI are considered part of a spectrum known as acute coronary syndrome (ACS), which refers to a range of acute myocardial ischaemia that also includes unstable angina. 
    • In STEMI, complete and persistent blockage of the artery occurs, resulting in myocardial necrosis.
    • In NSTEMI and unstable angina, a partial or intermittent blockage of the artery occurs, usually resulting in myocardial necrosis in NSTEMI but not in unstable angina. High-sensitivity blood tests for serum troponin are used to differentiate between NSTEMI and unstable angina. 
    • For more information, see the section on Acute coronary syndrome in the Prodig topic on Chest pain.

[NICE, 2015; NICE, 2020; BMJ Best Practice, 2023a; BMJ Best Practice, 2023b; BNF, 2024]

How common is it?

  • Myocardial infarction (MI) is one of the most severe presentations of coronary heart disease (CHD) [NICE, 2015]. 
  • The British Heart Foundation (BHF) estimates that in the UK [BHF, 2024]:
    • CHD is one of the leading causes of death (responsible for around 68,000 deaths each year) and the most common cause of premature death. 
    • Around 2.3 million people are living with CHD (about 1.5 million men and 830,000 women).
    • Around 100,000 hospital admissions each year are due to MIs (equivalent to 290 admissions daily or one admission every five minutes). 
    • Around 1.4 million people have survived an MI (about one million men and 380,000 women).

What are the risk factors?

  • Modifiable risk factors for myocardial infarction (MI) include:
    • Hypertension.
    • Smoking. 
    • Low blood level of high-density lipoprotein (HDL) cholesterol. 
    • High blood level of non-HDL cholesterol. 
    • Sedentary lifestyle/lack of physical activity. 
    • Overweight and obesity. 
    • Unhealthy diet. 
    • Diabetes mellitus (and impaired glucose tolerance and metabolic syndrome). 
    • Alcohol intake above the recommended levels.
  • Non-modifiable risk factors for MI include:
    • Age — in a systematic review and meta-analysis, the global prevalence of MI was found to be 3.8% in people aged under 60 (n = 29.826.717) and 9.5% in people aged over 60 (n = 5,071,185) [Salari, 2023].
    • Gender — men have a higher incidence of MI than women, with men accounting for approximately 70% of MIs and having an MI 7–10 years earlier than women [Millett, 2018; Schulte, 2023].
    • Family history of cardiovascular disease (CVD) — in people with a family history of clinically-proven CVD (MI, angina, transient ischaemic attack, or ischaemic stroke) in a first-degree relative (parent or sibling) before the age of 60 years, the risk of a coronary event is approximately doubled [SIGN, 2017]. This may reflect a shared environment, genetic factors, or both. 
    • Ethnic background — rates of CVD vary considerably between ethnic groups, which may reflect increased susceptibility and differential exposure to risk factors [SIGN, 2017]. For example, people of South Asian origin have a higher risk of CVD than other populations [Visseren, 2021].
  • Other risk factors for MI include:
    • Air pollution.  
    • Chronic kidney disease.
    • Obstructive sleep apnoea.
    • Chronic obstructive pulmonary disease.
    • Geographic location (probably associated with lifestyle, disease prevention plans, and availability of diagnostic resources) [Salari, 2023].
    • Familial hypercholesterolaemia.
    • Atrial fibrillation.
    • Rheumatoid arthritis, systemic lupus erythematosus, and other systemic inflammatory disorders.
    • Periodontitis.
    • Influenza [Kwong, 2018].
    • Mental health problems, including anxiety, depression, personality disorders, and psychotic disorders.
    • Cocaine use.

[Visseren, 2021; BMJ Best Practice, 2023a; BMJ Best Practice, 2023b; Byrne, 2023; BHF, 2024]

What are the complications of a myocardial infarction?

  • Complications of myocardial infarction (MI) include:
    • Ischaemic complications, such as:
      • Angina. 
      • Re-infarction.
      • Infarct extension.
    • Mechanical complications, such as:
      • Left ventricular (LV) dysfunction and heart failure.
      • Cardiogenic shock.
      • LV aneurysm.
      • Cardiac rupture (ventricular septum, papillary muscle, or ventricular free wall).
      • Acute mitral regurgitation.
    • Thromboembolic complications, such as: 
      • LV thrombus.
      • In-stent thrombosis — often precipitated by cessation of dual antiplatelet therapy but can also be caused by technical factors and other comorbidities, such as diabetes.
      • Venous thromboembolism. 
    • Pericardial complications, such as:
      • Early infarct-associated pericarditis — occurs from a few hours to 4 days after an MI and is mostly transient [Byrne, 2023].
      • Late pericarditis or post-cardiac injury (Dressler) syndrome — typically occurs 1–2 weeks after an MI [Byrne, 2023].
      • Pericardial effusion.
    • Arrhythmias, such as: 
      • Tachyarrhythmias, including sinus tachycardia, atrial fibrillation, and atrial flutter.
      • Bradyarrhythmias, including sinus bradycardia.
      • Atrioventricular blocks.
      • Ventricular arrhythmias (ventricular fibrillation or ventricular tachycardia).
    • Other complications, such as:
      • Bleeding (for example, intracranial or gastrointestinal) following thrombolysis.
      • Anxiety and depression. 
      • Sudden death — can occur shortly after an MI (for example, due to myocardial rupture or arrhythmia) or at any time (for example, due to re-infarction).

[BMJ Best Practice, 2023a; BMJ Best Practice, 2023b; Byrne, 2023] 

What is the prognosis following a myocardial infarction?

  • The prognosis following myocardial infarction (MI) has improved. This is mainly attributable to modern treatments (particularly percutaneous coronary interventions) and secondary prevention measures (cardiac rehabilitation, drug treatments, and lifestyle modification).  
    • The British Heart Foundation reports that in the 1960s, more than 70% of heart attacks in the UK were fatal; today, at least 7 out of 10 people survive an MI [BHF, 2024].
  • The overall prognosis depends on the extent of heart muscle damage. 
    • A greater degree of myocardial necrosis is associated with a worse prognosis and a higher risk of heart failure.
    • Other factors that can adversely affect prognosis include:
      • Delayed reperfusion.
      • Site of the infarction (anterior MI has a less favourable prognosis than inferior MI).
      • Choice of treatment (people who undergo revascularization have better outcomes than those who do not).
      • Comorbidities, such as hypertension, diabetes, chronic kidney disease, congestive heart failure, and frailty.
      • Complications, such as heart failure, arrhythmias, bleeding, and depression.
      • Older age.
      • Female sex [Wang, 2019; Schulte, 2023].
      • Poor compliance with secondary prevention measures.
  • A systematic review assessed the prevalence of 30-day readmission following acute MI [Wang, 2019]:
    • The 30-day readmission rates ranged from 11–14%.
    • Acute coronary syndrome, angina, acute ischemic heart disease, and heart failure were the main cardiovascular reasons for 30-day readmission. Non-specific chest pain was the main non-cardiovascular reason for 30-day readmission.
    • The risk factors for readmission included kidney disease, female sex, diabetes mellitus, and chronic obstructive pulmonary disease.

[BMJ Best Practice, 2023a; BMJ Best Practice, 2023b; Byrne, 2023; Mechanic, 2023; Ojha, 2023]

Management

Scenario: Secondary prevention following a myocardial infarction

From age 16 years onwards.

How should I manage a person who has had a myocardial infarction?

  • Ensure that the person has been offered a cardiac rehabilitation programme with exercise, health education, lifestyle advice, and stress management components. 
    • Encourage participation in the programme. 
    • Explain the benefits of the programme.
    • Where appropriate, discuss any factors that might stop the person from attending cardiac rehabilitation, such as transport difficulties.
    • If formal cardiac rehabilitation is impractical or declined:
      • Encourage the person to consider using a home-based rehabilitation programme, such as the NHS Lothian's heart manual.
      • Offer information on local and national patient support groups.
  • Continue prescribing and monitoring the secondary prevention drug treatments initiated in secondary care.
  • Reinforce relevant lifestyle advice on diet, physical activity, alcohol consumption, smoking, and weight management.  
    • Offer written materials to support appropriate lifestyle advice.
    • Offer support where needed, for example, with weight loss, smoking cessation, or problem drinking.
    • Do not recommend:
      • Eating oily fish to prevent another MI. If people choose to consume them, be aware that there is no evidence of harm, and fish may form part of a healthy diet.
      • Omega-3 fatty acid capsules or omega-3 fatty acid-supplemented foods to prevent another MI. If people choose to take them, be aware that there is no evidence of harm.
      • Antioxidant supplements (vitamin E or C) or folic acid to reduce cardiovascular risk.
    • Advise people not to take supplements containing beta-carotene.
  • Optimize management of other reversible or modifiable risk factors or conditions.
    • If the person has high blood pressure, see the CKS topic on Hypertension for management information.
    • If the person has diabetes, see the CKS topics on Diabetes - type 2 for management information.
    • If a person without known diabetes has had hyperglycaemia after an MI:
      • Offer at least annual monitoring of HbA1c or fasting blood glucose levels. 
      • Advise them to seek medical advice if they experience symptoms such as frequent urination, excessive thirst, weight loss, and fatigue.
    • If the person is obese, assess for symptoms of sleep apnoea and treat as appropriate. For more information, see the CKS topic on Obstructive sleep apnoea syndrome.
  • Assess for and manage complications of MI, such as depression, anxiety, and heart failure.  
  • Encourage the person to have an annual influenza immunization to reduce the risk of serious illness from influenza infection.
  • Ensure that the following routine post-MI assessments have been arranged by secondary care:
    • An assessment of left ventricular function. 
    • An assessment of bleeding risk (usually at a first follow-up hospital appointment post-MI).
    • A cardiology assessment to consider the appropriateness of coronary revascularization.
  • Be aware of the person's wider health and social care needs.
    • Address any concerns the person may have, such as those related to returning to work and resuming normal activities.
    • Offer information and sources of help as needed, for example, on economic issues, welfare rights, and housing and social support issues.

Cardiac rehabilitation after a myocardial infarction

  • Cardiac rehabilitation is a coordinated and structured programme that aims to address the underlying causes of cardiovascular disease (CVD) and improve physical and mental health after a myocardial infarction (MI).
    • It encourages a healthy lifestyle, which slows the progression of heart disease. It also reduces the risk of premature death, especially as a result of an MI or stroke. 
    • Cardiac rehabilitation is one of the best-researched examples of long-term condition management. It has a strong clinical evidence base, saves costs (through a reduction in unplanned readmissions for cardiac problems), and improves outcomes for people with CVD.
    • The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) defines cardiac rehabilitation as 'The coordinated sum of activities required to influence favourably the underlying cause of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behaviour, slow or reverse progression of disease.'
  • The National Institute for Health and Care Excellence (NICE) recommends that all people who have had an MI (regardless of their age) should be advised about and offered a cardiac rehabilitation programme with an exercise component.
    • Cardiac rehabilitation after an MI reduces all-cause and cardiovascular mortality rates, provided it includes an exercise component.
    • Comprehensive cardiac rehabilitation programmes should also include health education, lifestyle advice, and stress management components.
    • Cardiac rehabilitation should be started in hospital as soon as possible after admission, before discharge. The person should be invited to attend an assessment appointment within 10 days of hospital discharge. Further sessions are organized after that.
    • Starting cardiac rehabilitation as soon as possible after an MI significantly improves ongoing attendance at cardiac rehabilitation programmes and clinical outcomes. An assessment appointment within 10 days of discharge ensures that people have contact with a member of the cardiac rehabilitation team as soon as possible.
  • Cardiac rehabilitation programmes should provide various options, and people should be encouraged to attend those appropriate to their clinical needs.
    • People should not be excluded from the programme if they choose not to attend certain components. 
    • To encourage adherence, cardiac rehabilitation programmes should be offered 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 (including outside working hours).

Lifestyle advice for cardiovascular disease risk reduction

  • Advise the person to eat a cardioprotective diet. They should:
    • Choose wholegrain varieties of cereals, breads, and other starchy foods. The recommended total daily fibre intake is 30–45 g.
    • Eat at least 5 portions of fruits and vegetables per day. 
    • Eat at least 4–5 portions of unsalted nuts and seeds weekly. One portion is about a handful or about 30 g.
    • Eat at least 2 portions of fish per week, including a portion of oily fish. (Pregnant women should limit their oily fish intake to no more than 2 portions per week and avoid marlin, shark, and swordfish, which may contain relatively high levels of methylmercury.)
    • Reduce salt intake to less than 6g (around one level teaspoon) per day.
    • Reduce intake of sugar and foods containing refined sugars, including fructose. 
    • Reduce total fat intake to 30% or less of total energy intake, and reduce saturated fat intake to 7% or less of total energy intake. Where possible, they should replace saturated fats (mainly found in animal sources) with monounsaturated and polyunsaturated fats (mainly found in oils from plants and fish). 
  • Advise the person to aim to be physically active every day for good physical and mental health. They should:
    • Do muscle-strengthening activities at least twice a week, but any strengthening activity is better than none. Examples include heavy gardening, carrying heavy shopping, or resistance exercises. 
    • Do at least 150 minutes of moderate-intensity activity (such as brisk walking or cycling), 75 minutes of vigorous-intensity activity (such as running), shorter durations of very vigorous-intensity activity (such as sprinting or stair climbing), or a combination of moderate, vigorous, and very vigorous-intensity activity.
    • Reduce time spent being sedentary, and when physically possible, break up long periods of inactivity with at least light physical activity.
    • If moderate-intensity physical activity is unmanageable because of comorbidity, medical conditions, or personal circumstances, they should exercise to their maximum safe capacity. 
  • Advise people who drink to:
    • Keep within the recommended limits (no more than 14 units per week for men and women [spread over 3 days or more]).
    • Have several alcohol-free days per week.
    • Avoid binge drinking and intoxication.
      • If the person is pregnant or trying to become pregnant, the safest approach is not to drink alcohol at all to keep risks to the baby to a minimum.
  • Advise smokers to stop smoking and non-smokers to avoid passive smoking. 
  • Advise weight loss if the person is overweight or obese.
    • Explain that a healthy diet and physical activity will help with weight loss.

Common concerns after a myocardial infarction

Concerns reported by people who have recently had a myocardial infarction (MI) may relate to:

  • Resumption of normal daily activities and return to work
    • After an MI, most people can return to their normal daily activities. The timing of resumption depends on the person's physical and psychological status and the type of activity.
    • Most people who have had an MI can safely return to work. When and how depends on the person's physical and psychological status, the nature of the work, and the work environment.
  • Safety to drive:
    • For a car or motorcycle licence, the person does not need to inform the Driver and Vehicle Licensing Agency (DVLA). However, driving should stop for a time (the length depends on factors such as type of MI and treatments). The person should check with their insurer that they are still covered for driving.
    • For a bus, coach, or lorry licence, the person must stop driving for a set period and inform the DVLA using form VOCH1. Advise people that they can be fined if they continue to drive and do not inform the DVLA, and prosecuted if they are involved in an accident.
    • Detailed information regarding medical fitness to drive after an MI is available:
  • Resumption of sexual activity
    • Sexual activity can be resumed when comfortable to do so, usually about four weeks after an MI.
    • Sexual activity presents no greater risk of triggering a subsequent MI in a person than if they had never had an MI.
  • Erectile dysfunction (ED)
    • Treatment of ED with a phosphodiesterase type 5 (PDE5) inhibitor (sildenafil, tadalafil, or vardenafil) is usually effective and safe in men with stable coronary heart disease.
    • Lifestyle and drug interventions, including weight loss, exercise, smoking cessation, and statin treatment, may also improve sexual function for some people.
    • For more information, see the CKS topic on Erectile dysfunction.
  • Safety of air travel
    • 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 may need expert individual advice.
  • Resumption of competitive sport
    • Athletes who have had an MI should cease athletic training and competition until recovery is deemed complete. The duration before resuming sport depends on the severity of the cardiovascular event.
    • After the recuperation period, advice on competitive sports may require expert assessment of function and risk, which depends on the sport and the level of competitiveness.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guidelines Acute Coronary Syndromes [NICE, 2020] and Cardiovascular Disease: Risk Assessment and Reduction, Including Lipid Modification [NICE, 2023b] and the European Society of Cardiology (ECS) guidelines 2021 ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice [Visseren, 2021] and 2023 ESC Guidelines for the Management of Acute Coronary Syndromes [Byrne, 2023].

Secondary prevention measures 
  • Following initial treatment for acute myocardial infarction (MI), secondary prevention measures (cardiac rehabilitation, drug treatment, and relevant lifestyle modification) are initiated in secondary care to reduce the risk of MI complications and further cardiovascular events.
  • The hospital discharge summary should include [NICE, 2020]:
    • Confirmation of the diagnosis of acute MI.
    • Results of any investigations.
    • Details and timing of further drug titration.
    • Monitoring requirements, including blood pressure and renal function.
    • Future management and follow-up plans. 
    • Advice on secondary prevention.
Cardiac rehabilitation 
  • The information on cardiac rehabilitation is based on the NICE guideline on acute coronary syndromes (ACS) [NICE, 2020], the NICE quality standard Secondary Prevention After a Myocardial Infarction [NICE, 2015], the ECS guideline on the management of ACS [Byrne, 2023], and the BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2023 (4th Edition) published by the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) [BACPR, 2023].
Lifestyle advice 
Influenza vaccination
  • The ECS states that annual influenza vaccination in people with stable atherosclerotic cardiovascular disease (CVD) appears to be associated with reduced incidence of MI, an improved prognosis in people with heart failure, and decreased cardiovascular (CV) risk in adults 65 years and older. In addition, influenza vaccination given early after an MI or in high-risk coronary artery disease has been shown to result in a lower risk of all-cause death and CV death at 12 months. Therefore, influenza vaccination is recommended for all people with ACS and should be given preferentially during index hospitalization during influenza season for those not protected by a seasonal influenza vaccination [Byrne, 2023].
  • The UK Health Security Agency (UKHSA) recommends that the influenza vaccination should be offered to people requiring regular medication and/or follow up for ischaemic heart disease [UKHSA, 2023]. For more information, see the CKS topic on Immunizations - seasonal influenza.
Common concerns after an MI 
  • The information on common concerns after an MI is largely based on the NICE ACS guideline [NICE, 2020].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section, specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) or the British National Formulary (BNF).

ACE inhibitors

General information

Secondary prevention drug treatments are initiated in hospital after an acute myocardial infarction (MI). The hospital discharge summary should detail the medications, dosages, and necessary titrations or monitoring requirements.

  • An angiotensin-converting enzyme (ACE) inhibitor is offered. If the person is intolerant to an ACE inhibitor, an angiotensin-II receptor blocker is offered as an alternative.
    • Doses are usually titrated upwards at short intervals (for example, every 12 to 24 hours) before the person leaves the hospital. If the titration cannot be completed during this time, it should be completed within 4–6 weeks of hospital discharge. 
    • Renal function, serum electrolytes, and blood pressure are checked before starting the treatment. They should be repeated:
      • Within 1 or 2 weeks of starting treatment.
      • As the dose is titrated upwards.
      • At least annually after the maximum tolerated or target dose is reached.
      • More frequently in people who are at increased risk of deterioration in renal function, with frequency dependent on clinical judgement. 
  • Treatment with an ACE inhibitor (or angiotensin-II receptor blocker) is usually continued indefinitely after an MI.
    • It may be appropriate to offer an ACE inhibitor to anyone who has had an MI more than 12 months ago and who is not currently taking one.
      • The treatment should be titrated to the maximum tolerated or target dose (over a 4–6-week period) and continued indefinitely.
      • If the person cannot take an ACE inhibitor, an angiotensin-II receptor blocker should be offered.
  • For detailed prescribing information on ACE inhibitors and angiotensin-II receptor blockers, see the sections on Angiotensin-converting enzyme inhibitors and Angiotensin-II receptor blockers in the CKS topic on Hypertension.

[NICE, 2020]

Antiplatelet treatments

General information

Secondary prevention drug treatments are initiated in hospital after an acute myocardial infarction (MI). The hospital discharge summary should detail the medications, dosages, and necessary titrations or monitoring requirements.

  • Dual antiplatelet therapy (DAPT) with aspirin plus a second antiplatelet is offered (unless contraindicated) and continued for up to 12 months after an MI.
    • If the person is aspirin intolerant, clopidogrel monotherapy is offered as an alternative treatment.
    • If the person has an indication for anticoagulation, the duration and type (dual or monotherapy) of antiplatelet treatment will be considered, taking into account the person's bleeding, thromboembolic, and cardiovascular (CV) risks and their wishes. For more information, see the National Institute for Health and Excellence (NICE) guideline on Acute coronary syndrome. 
  • After DAPT, treatment with aspirin is usually continued indefinitely (unless the person is aspirin intolerant or has an indication for anticoagulation).  
    • It may be appropriate to offer aspirin to anyone who has had an MI more than 12 months ago and who is not currently taking aspirin. The treatment should be continued indefinitely if tolerated.
    • Clopidogrel, instead of aspirin, is recommended for people who also have other clinical vascular diseases and who have had:
      • An MI and stopped DAPT or
      • An MI more than 12 months ago.
  • For detailed prescribing information on antiplatelets, see the CKS topic on Antiplatelet treatment.

[NICE, 2020]

Beta-blockers

General information

Secondary prevention drug treatments are initiated in hospital after an acute myocardial infarction (MI). The hospital discharge summary should detail the medications, dosages, and necessary titrations or monitoring requirements.

  • A beta-blocker is offered (unless contraindicated).
    • If beta-blockers are contraindicated or need to be discontinued, diltiazem or verapamil may be considered for secondary prevention in people who do not have pulmonary congestion or reduced left ventricular ejection fraction (LVEF).
    • The beta-blocker should be titrated to the maximum tolerated or target dose. 
  • In people with a reduced LVEF, beta-blockers should be continued indefinitely.
    • It may be appropriate to offer a beta-blocker to anyone who has had an MI more than 12 months ago and who has reduced LVEF, whether or not they have symptoms.
    • For information on managing people with heart failure plus reduced LVEF, see the CKS topic on Heart failure - chronic.
  • In people without reduced LVEF, it may be appropriate to discontinue the beta-blocker after 12 months, considering the potential benefits and risks of continuation and the person's wishes.  
    • Beta-blockers should not be offered to people without reduced LVEF or heart failure who have had an MI more than 12 months ago unless there is an additional clinical indication for a beta-blocker.
  • For detailed information on prescribing beta-blockers, see the section on Beta-blockers in the CKS topic on Hypertension.

[NICE, 2020]

Statins

General information

Secondary prevention drug treatments are initiated in hospital after an acute myocardial infarction (MI). The hospital discharge summary should detail the medications, dosages, and necessary titrations or monitoring requirements.

  • A statin is offered (unless contraindicated) and continued indefinitely.
    • It may be appropriate to offer a statin to anyone who has had an MI more than 12 months ago and who is not currently taking one. The treatment should be continued indefinitely if tolerated.
  • For detailed prescribing information on statins, see the section on Prescribing information in the CKS topic on Lipid modification - CVD prevention.

[NICE, 2020]

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guidelines Acute Coronary Syndromes [NICE, 2020] and Cardiovascular Disease: Risk Assessment and Reduction, Including Lipid Modification [NICE, 2023b] and the European Society of Cardiology (ECS) guidelines 2021 ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice [Visseren, 2021] and 2023 ESC Guidelines for the Management of Acute Coronary Syndromes [Byrne, 2023]. The rationale for recommendations is summarized in the relevant basis for recommendation sections. The evidence for specialist management strategies is not discussed as they are beyond the scope of this CKS topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on secondary prevention after myocardial infarction in primary care. 

Search dates

February 2019 - March 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 7th February 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S11  S7 AND S10
S10  S8 OR S9
S9    AB secondary prevention OR TI secondary prevention 
S8    (MH "Secondary Prevention") 
S7    S1 OR S2 OR S3 OR S4 OR S5 OR S6 
S6    AB acute coronary syndrome* OR TI acute coronary syndrome* 
S5    (MH "Acute Coronary Syndrome") 
S4    AB ( (cardiac or cardiovascular) N1 (rehabilitation) ) OR TI ( (cardiac or cardiovascular) N1 (rehabilitation) ) 
S3    (MH "Cardiac Rehabilitation") 
S2    AB myocardial infarct* OR TI myocardial infarct* 
S1    (MH "Myocardial Infarction+") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • BACPR (2023) BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2023 (4th Edition). British Association for Cardiovascular Prevention and Rehabilitation. http://www.bacpr.com [Free Full-text]
  • BHF (2024) UK Factsheet. British Heart Foundation. http://www.bhf.org.uk [Free Full-text]
  • BMJ Best Practice (2023a) ST-elevation myocardial infarction. BMJ Publishing Group Ltd. https://bestpractice.bmj.com/info
  • BMJ Best Practice (2023b) Non-ST-elevation myocardial infarction. BMJ Publishing Group Ltd. https://bestpractice.bmj.com/info
  • BNF (2024) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • Byrne, R.A., Rossello, X., Coughlan, J.J., et al. (2023) 2023 ESC Guidelines for the management of acute coronary syndromes. European Heart Journal 44(38), 3720-3826. [Free Full-text]
  • DH (2016) UK Chief Medical Officers' low risk drinking guidelines. Department of Health. http://www.gov.uk [Free Full-text]
  • Kwong, J.C., Schwartz, K.L., Campitelli, M.A., et al. (2018) Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection. The New England Journal of Medicine, 378(4), 345–353 378(4), 345-353. [Abstract] [Free Full-text]
  • Mechanic, O.J., Gavin, M. and Grossman, S.A (2023) Acute Myocardial Infarction. Updated 2023 Sep 3 edn. Treasure Island (FL): StatPearls Publishing.
  • Millett, E.R.C., Peters, S.A.E. and Woodward, M (2018) Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants. BMJ 363(k4247), k4247. [Free Full-text]
  • NHS England (2025) Quality and Outcomes Framework guidance for 2025/26. NHS England. https://www.england.nhs.uk [Free Full-text]
  • NICE (2015) Quality standard: Secondary prevention after a myocardial infarction. QS99. National Institute of Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2020) Acute coronary syndromes. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2023a) Cardiovascular risk assessment and lipid modification. Quality standard (QS100). National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • NICE (2023b) Cardiovascular disease: risk assessment and reduction, including lipid modification [NG238]. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • Ojha, N. and Dhamoon, A.S (2023) Myocardial Infarction. Updated 2023 Aug 8 edn. Treasure Island (FL): StatPearls Publishing.
  • Salari, N., Morddarvanjoghi, F., Abdolmaleki, A., et al. (2023) The global prevalence of myocardial infarction: a systematic review and meta-analysis. BMC Cardiovascular Disorders 23(1), 206. [Abstract] [Free Full-text]
  • Schulte, K.J. and Mayrovitz, H.N (2023) Myocardial Infarction Signs and Symptoms: Females vs. Males. Cureus 15(4), e37522. [Free Full-text]
  • SIGN (2017) Risk estimation and the prevention of cardiovascular disease: a national clinical guideline. Scottish Intercollegiate Guidelines Network. http://www.sign.ac.uk [Free Full-text]
  • Szczepańska, E., Gacal, M., Sokal, A., et al. (2023) Diet in Patients with Myocardial Infarction and Coexisting Type 2 Diabetes Mellitus. International Journal of Environmental Research and Public Health 20(8), 5442. [Free Full-text]
  • UK CMO (2019) UK Chief Medical Officers' physical activity guidelines. UK Chief Medical Officers. http://www.gov.uk [Free Full-text]
  • UKHSA (2023) Immunisation against infectious disease (the 'Green Book') Chapter 19: Influenza. UK Health Security Agency. https://www.gov.uk [Free Full-text]
  • Visseren, F. L. J., Mach, F., Smulders, Y. M., et al. (2021) 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. European Heart Journal 42(34), 3227-3337. [Abstract] [Free Full-text]
  • Wang, H., Zhao, T., Wei, X., et al. (2019) The prevalence of 30-day readmission after acute myocardial infarction: A systematic review and meta-analysis. Clinical Cardiology 42(10), 889-898. [Free Full-text]
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