Post-MI Care

Introducing Follow Your Heart: optimal care after a heart attack – a

guide for you and your patients

Acknowledgements and Conflicts of Interest• Follow Your Heart Steering Committee

– Members of HEART UK, PCCS and Pfizer

• The Follow Your Heart partnership between HEART UK, the PCCS and Pfizer has been financially supported by Pfizer

• Each of the organisations contributed equally through the Steering Committee and enjoyed parity in decision-making

• Members of the Steering Committee have received honoraria for their contribution to the Follow Your Heart project, from Pfizer

• All recommendations included in this presentation are taken from guidance published on behalf of the Follow Your Heart Steering Committee in the July/August issue of the British Journal of Cardiology1

Use of this presentation• This presentation is designed to inform about Follow Your

Heart - a project established to promote optimal care of post-MI patients

• Presentation can be used:

– For desktop review by individual GPs and nurses

– To educate HCPs and facilitate discussion in a group setting

– Comments are provided in the Notes sections of appropriate slides to give further information/direction about how to use the information in a group session

– You can explore areas of the project in more depth by following the hyperlinks where you see this sign:

What is Follow Your Heart?• A unique three-way partnership between HEART UK, the

PCCS and Pfizer

– Multi-disciplinary Steering Group convened to drive project

• Steering Group identified a need for simple, consistent, evidence-based post-MI guidance tailored to primary care HCPs and their patients

• Consolidated existing clinical evidence and published guidance into a consensus of recommendations for optimal care

Steering Committee members

Primary care Secondary care Patient

Dr Alan Begg Dr Dermot Neely Mr Brian Ellis

Dr David Milne Dr Malcolm Walker

Dr Jonathan Morrell

Dr Michael Norton

Michaela Nuttall

Stakeholder representatives: Jules Payne (HEART UK), Fran Sivers

(PCCS), Ruth Bosworth (Pfizer), Seleen Ong (Pfizer), Andrew Thomas (Pfizer)

How and why the guidance was developed

• Research revealed significant variation in adherence to and implementation of post-MI guidelines in the UK2

• For further details about the research, follow this link:

• If patients do not receive optimal post-MI care, the individual and socio-economic burden is significant3

• Follow Your Heart Steering Group consolidated existing clinical evidence to create guidance1 that:– Provides succinct

recommendations for optimal post-MI management

– Includes separate HCP and patient components

• Guidance designed to:– Encourage two-way dialogue between patients

and HCPs– Reduce practice variation – Raise standards of care– Maximise healthcare resource utilisation– Improve outcomes in post-MI patients

• Guidance covers five key topics: 1. Cardiac rehabilitation and ongoing care 2. Lifestyle modification3. Goal of intervention4. Therapeutic interventions 5. Integrated communication

Five steps to optimal post-MI care

1. Cardiac rehabilitation and ongoing care • Cardiac rehabilitation:

– Vital to help post-MI patients improve risk factors for cardiovascular disease (CVD)

– Provides link in post-MI care between primary and secondary care

• Each post-MI patient should have an individualised plan developed prior to hospital discharge

• Each cardiac rehabilitation plan should: – Enable patients to understand and take responsibility for their recovery

and continued health

– Introduce concept of risk and importance of cardiovascular (CV) risk factors

– Address specific areas concerning patients and their partners

2. Lifestyle modification

• Lifestyle changes are essential to improve CV health

• Partners and family members should be encouraged to adopt positive healthy lifestyle changes together

Eat a healthy balanced diet4

• Consider a Mediterranean-style diet. Increase fresh food intake and reduce processed foods5

• Eat less fat. Reduce intake of foods high in saturated fat, e.g. fatty and processed meat, full-fat dairy products, biscuits, cakes, pastries and some convenience snack foods. Opt for unsaturated fats, e.g. sunflower and olive oil (polyunsaturated and monounsaturated fat)6

• Eat more fruit and vegetables – at least five portions of different types a day7

• Choose wholegrain and high-fibre foods, e.g. wholegrain rice/pasta, wholemeal bread, oats, seeds, nuts, pulses, etc8.

• Eat oily fish, at least two portions a week to provide omega-3 (e.g. salmon, trout, mackerel) 9. Consider 1 g Omacor per day as an alternative• Reduce salt intake, aim for <6 g a day10. Beware of hidden salt content• Consider foods enriched with plant sterols or stanols, e.g. yoghurt, milk,margarine spreads11

Increase physical activity12

• Be physically active, e.g. take the stairs, walk to shops, wash the car• Aim for at least 20–30 minutes of moderate activity each day to the pointof mild breathlessness, e.g. walking, jogging, cycling, dancing or swimming

Do not smoke13• Post-MI patients should not smoke• Smokers should be offered medication for smoking cessation andreferred to local stop-smoking services

Manage weight13

• Balance energy intake with energy expenditure • Advice should be provided to individuals when body mass index (BMI) >25 kg/m2 or those with an increased waist circumference • If overweight aim to lose around 0.5 kg/1 lb per week

Limit alcohol intake12

• Drink alcohol in moderation:, women ≤1–2 units/day, men ≤2–3 units/day

3. Goal of intervention

Blood pressure • <130/80 mmHg13

• <125/75 mmHg for patients with chronic kidney disease (CKD)14

Cholesterol

• TC <4.0 mmol/L13,15

• HDL-C >1.0 mmol/L for males and >1.3 mmol/L for females16

• Non-HDL-C <2.8 mmol/L17-19

• LDL-C <2.0 mmol/L13

• Blood test must be fasting for LDL-C (otherwise non-fasting LDL-Ccalculation invalid) 13

• Goal of intervention is to achieve optimal control of all modifiable CV risk factors

• Clinical evidence consolidated for concise, definitive guidance on optimal targets

Blood sugar • HbA1c <6.5%13

Weight

BMI13

• <25 kg/m2

Waist circumference16

• Europidso Male <94 cmo Female <80 cm• South Asians and Chineseo Male <90 cmo Female <80 cm

Key: BMI = body mass index; HbA1c = glycosylated haemoglobin; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TC = total cholesterol

4. Therapeutic interventions: Lipid-lowering therapy • For patients with previous MI:

– Simvastatin 40 mg daily (if statin naïve)15

– Follow up at three months and switch to more potent statin if cholesterol target not met e.g. atorvastatin 40-80 mg or rosuvastatin 10 – 40 mg daily20

– If target not met with maximum tolerated dose of statin consider adding ezetimibe 10mg daily21

• For patients with acute MI or ACS: – Higher intensity statin15 e.g. atorvastatin 80

mg

• Pre-testing and monitoring:– Monitor liver function15 and lipid profile13

Therapeutic interventions: ACE inhibitors and ARBs• For all post-MI patients:12

– Commence ACE inhibitor e.g. ramipril, perindopril– Commence ARB e.g. losartan in ACE-intolerant patients – Titrate upwards and aim for maximum tolerated dose of

individual drug

• Pre-testing and monitoring:– Urea, creatinine and electrolytes should be measured

regularly12

Therapeutic interventions: anti-platelet agents• For all post-MI patients:

– Commence aspirin 75 mg daily for life12

• Use clopidogrel as add on therapy in patients with: – Non-ST elevation MI (NSTEMI) ACS and who are moderate-to-

high risk of MI or death – continue for 12 months12 – STI-elevation MI (STEMI) – continue for at least four weeks

unless otherwise indicated12

– PCI with stent insertion – continue for as long as indicated at time of PCI22

• Consider clopidogrel monotherapy for patients with aspirin hypersensitivity12

Therapeutic interventions: beta-blockers • For all post-MI patients:

– Commence beta blocker before discharge from hospital, e.g. bisoprolol12

– Use beta blocker licensed for heart failure where evidence of left ventricular systolic dysfunction12

– Titrate up to target or maximum tolerated dose12 – Clinical experience suggests continuing treatment indefinitely23

Therapeutic interventions: warfarin

• For particular post-MI patients:12

– For patients with existing indication for anticoagulation continue warfarin

• Consider addition of aspirin if risk of bleeding is low– For patients unable to tolerate aspirin or clopidogrel consider

moderate-intensity warfarin for up to four years – Individualised risk/benefit analysis warranted where

combination therapy is being considered

Therapeutic interventions: aldosterone antagonists • For particular post-MI patients with clinical evidence

of heart failure:12 – For patients with significant clinical symptoms and/or signs of

heart failure and significant evidence of left ventricular systolic dysfunction, consider treatment with an aldosterone antagonist licensed for post-MI treatment. Initiate 3–14 days post-MI and preferably after introduction of ACE inhibitor

– If spironolactone already prescribed at low dose for pre-existing heart failure, continue, or replace with eplerenone in patients intolerant to spironolactone

• Pre-testing and monitoring – Urea, creatinine and electrolytes should be measured

5. Integrated communication

• Good communication between secondary and primary care, community services and the patient is essential12

• Post-MI hospital discharge summary is vital component of successful communication24

• Hospital discharge summary:– Confirms diagnosis– Provides results of investigations performed and future investigations

required– Documents any in-hospital complications and resulting interventions– Provides details of medication prescribed with guidance on up-titration– Provides recommendations on testing the patient’s relatives– Includes the patient’s agreed care plan

• All patients should receive an individualised management plan, which:

– Is culturally sensitive

– Contains evidence-based information

– Includes input from the patient and carers/family

– Provides recommendations on daily living25

– Documents what to expect of primary care services

• A ‘best practice’ discharge summary information sheet has been developed by the Follow Your Heart group on the basis of the recommendations in the guidance

• The summary sheet provides a list of information which is necessary to communicate to primary care when a patient is being discharged from hospital following an MI

• Based on the guidance, the Follow Your Heart group developed complementary practical, user-friendly tools for primary care clinicians and patients

• Tools summarise the guidance for incorporation into day-to-day practice for clinicians and day-to-day life for patients and their families

Complemetary tools for HCPs and patients

Case studies in post-MI care

Case study 1: Mr X

• 46 years old• Smoker• HGV driver• Hospitalised yesterday with MI –

no previous history of MI• BMI of 34 kg/m2 • Lives with wife and teenage son

• What would you recommend for Mr X in terms of:– Cardiac rehabilitation? – Lifestyle modification?

• What would you want to see included in his hospital discharge summary?

• Cardiac rehabilitation:1, 26

– Individualised plan for each patient and initiated PRIOR to hospital discharge

– Introduce the concept of risk and the usefulness of individualised targets

– Highlight the importance of cardiovascular risk factors– Provide results of investigations performed and future

investigations required– The programme should address specific areas of concern to the patient

and their partners/families:– Education

– Allaying misconceptions

– Pathophysiology and symptoms

– Exercise, smoking, diet, BP, cholesterol

– Occupation (Phased return to work. HGV driving rules stricter post-MI than for normal driving and further assessment required)

– Sexual dysfunction and sexual intercourse

– Psychological

– Medical and surgical interventions

– CPR

– Risk factor management– Lifestyle

– Physical activity

– Diet and weight management

– Smoking cessation

– Psychological status and quality of life– Valid psychological assessment (anxiety, depression)

– Stress management

– Discussion of social needs (benefits etc)

– Cardioprotective drug therapy– Long-term management strategy

– Ongoing care mainly within primary care with specialist intervention

– As required; defined pathways

– Exercise groups; community dietetic and weight management services

• Lifestyle modification:– Eat a healthy, balanced diet

– Increase fresh food and reduce processed foods; consider a Mediterranean style diet5

– Eat less fat – decrease intake of foods high in saturated fat and opt for foods which have unsaturated (polyunsaturated and monounsaturated )fats6

– Eat more fruit and veg – 5 a day7

– Increase whole grain and high in fibre foods8

– Oily fish – at least 2 portions a week; consider Omacor 1g daily as an alternative9

– Reduce salt intake (<6g/day).10 Remember hidden salt content of foods

– Consider foods enriched with plant sterols or stanols eg.yoghurt, milk,margarine11

– Limit alcohol intake12 – Men : <2-3 units per day

– Increase physical activity12

– Build up gradually over 4-6 weeks

– Aim for at least 20-30 mins of moderate activity each day to the point of mild breathlessness (walking, jogging, cycling, dancing or swimming)

– Do not smoke13

– Should be offered a combination of medication for smoking cessation and behavioural support (i.e. referred to local stop smoking services)diet and weight management

– Manage weight13

– Education regarding balancing energy intake with energy expenditure

– Advice as BMI >25

– To lose around 0.5kg/1lb per week

• Hospital discharge summary should include:1

– Confirm diagnosis– Modifiable risk factors– Significant past medical history– Family history– Investigations and results– Procedures and any complications– Medication prescribed and guidance on up titration– Recommendations on testing patient’s family– Cardiac rehabilitation information (offered/accepted;

coordinator)– Planned follow up

Case study 2: Mrs Y

• 76 years old• Seen in practice for hypertension

review• Noted previous MI, 12 years ago• LDL-C of 5.6 mmol/L• BP of 150/90 mmHg• Evidence of left ventricular systolic

dysfunction• Allergic to aspirin • Lives alone

• What would you recommend for Mrs Y in terms of:– Goals of intervention?– Therapeutic interventions?

• Who, beyond the primary care team, would you alert to her care needs?

• Goals of intervention:– BP <130/80 mmHg13

– TC<4.0 mmol/L13,15

– LDL-C <2.0mmol/L13

– HbA1C <6.5%13

– BMI <25kg/m2 13

• Therapeutic interventions:– Lipid lowering

– Patient has had previous MI so simvastatin 40mg (as patient is statin naïve)

15

– Follow up at three and 12 months to ensure cholesterol target met

– Check annually once target achieved

– LFTs prior to initiation and three and 12 months after initiation and then at 12 months (but not again unless clinically indicated)

– Beta Blocker12 – Hypertension and has evidence of left ventricular systolic dysfunction

– ACE inhibitor12

– Titrate upwards at short intervals

– Pre-testing and monitoring of renal function

– Clopidogrel12

– Allergic to aspirin

– Aldost antagonists12 – If echo reveals evidence of left ventricular systolic dysfunction

• Guidance designed to:Encourage two-way dialogue between patients and

HCPs

Reduce practice variation

Raise standards of care

Maximise healthcare resource utilisation

Improve outcomes in post-MI patients

Overcoming barriers to implementation

Do you foresee any barriers to implementing the guidance?

Potential barriers

Potential barriers

Practical? Practical?

Personal?Personal? Other?Other?

Educational? Educational?

How can we overcome these barriers?

Solutions?Solutions?

How can HCPs engage patients to become more involved in their care?

Others? Others?

Family involvement?

Family involvement?Target-setting?Target-setting?

Group activities?

Group activities?

Communication?Communication?

Thank you!

Post-MI Care

Variation in availability, awareness, content and implementation of post-

MI guidelines

Research

• These slides provide a summary of the key findings of the Follow Your Heart research2

• Supporting information is provided in the ‘Notes’ section of each slide

• Should you wish to return to the ‘Guidance’ section of the presentation, click on the hyperlinked arrow on each slide

Rationale • Qualitative research project

– To examine availability and content of local guidelines for management of post-MI patients in primary care

– To identify if there are subsequent regional variations in post-MI care

– Focus on:• Cardiac rehabilitation

• Lifestyle modification

• Clinical management targets

• Therapeutic interventions

• Communication between primary and secondary care

Methodology

• Search to identify guidelines available online– PCTs

– Cardiac networks (CNs)

• Telephone interviews with cardiac networks to identify additional guidelines not available online and better understand uptake and implementation of guidelines

• Online survey of 1,003 UK primary care clinicians27

– 802 GPs and 201 practice nurses

– Establish awareness of locally developed guidelines, use vs. national guidelines and identify areas of variation in clinical practice

Results – Availability and Awareness of Local GuidelinesResearch • 15 local post-MI guidelines

identified– 8 PCT developed– 7 CN developed

• Where local guidelines not available, CNs typically recommend following NICE

Survey• 60% of clinicians aware of local

guidelines in their area

Results – Content of guidelines / relevance to clinical practiceRecommendations in PCT/CN guidelines

Primary care survey results

Cardiac rehabilitation

Included in 87% of guidelines - Psychological/social well-being, relaxation, exercise, return to work, social services and benefits, driving and travel, sexual activity

88% of respondents indicated CR services available in their area

Lifestyle modifications

Included in 87% of guidelines - Diet, weight management, exercise, smoking cessation, alcohol reduction

Smoking cessation prioritised as most important intervention by 79% of respondents

Recommendations in PCT/CN guidelines

Primary care survey results

Clinical management targets

Blood pressureIncluded in 53% of guidelines; targets vary – most recommend 140/90 mmHg; one recommends 150/90 mmHg (consistent with QOF)

Blood lipidsIncluded in 53% of guidelines; targets vary but include: • TC <5 mmol/L and LDL-C <3 mmol/L or 30% reduction in these parameters, whichever is greatest• TC <4 mmol/L and LDL-C <2 mmol/L

Blood pressureRespondents more likely to follow JBS-2 (130/90 mmHg – 53%) than QOF; respondents in East Midlands and North East more likely to follow QOF (150/90 mmHg)

Blood lipidsConsiderable variation in clinical practice - QOF (33%) and NICE (33%) most commonly followedJBS-2 most commonly followed in the North West

Recommendations in PCT/CN guidelines

Primary care survey results

Therapeutic interventions

Blood pressureACE inhibitors recommended in 80% of guidelines – e.g. ramipril, perindopril, lisinopril – dose recommendations vary

Beta-blockers recommended in 80% of guidelines – e.g. Atenolol, bisporolol, carvedilol, metoprolol – dose recommendations vary

Calcium channel blockers and angiotensin receptor antagonists – each recommended in 7% of guidelines

Blood pressureHigh level of prescribing throughout the UK of ACE inhibitors (92%) and Beta-blockers (83%)

Recommendations in PCT/CN guidelines

Primary care survey results

Therapeutic interventions

Blood lipidsStatins recommended in 87% of guidelinesSome guidelines recommend only generic statins; other recommend higher-intensity satins if cholesterol levels not adequately controlled

Simvastatin 40mg usually recommended first line

AntiplateletsAspirin and clopidogrel recommended in 80% of guidelines

Blood lipidsSimvastatin 40mg first-line treatment of choice in statin-naive patients (56%)

Simvastatin 40mg also therapy option of choice in ACS patients (45%)

AntiplateletsHigh level of prescribing throughout the UK (88%)

Recommendations in PCT/CN guidelines

Primary care survey results

Communication between primary and secondary care

Included in 60% of guidelines

Main channel of communication assumed to be discharge summary

Referral back to secondary care advised in cases of recurrent CV events or failure of risk factor control

Most commonly used discharge letters are generic (57%) – only respondents in East of England, South Central and the South East Coast more likely to receive a tailored letter

Routine verbal exchange between primary care secondary care reported by only 5% of respondents

Results - Guideline Implementation

Research• CNs feel they can only offer clinicians guidance• Implementation of CN developed guidelines limited and

variable - methods include:– Distribution to every practice OR individual clinician in the area– Distribution only on request– Embedding in GP operating systems– Training events

Survey• 27% of clinicians feel ‘obliged’ to follow local post-MI guidelines

– Where applicable, enforcement predominantly through practice (48%) or PCT-led (39%) audits and alignment to QOF (39%)

Conclusions

• Considerable regional variation in guidelines followed– Little consistency in availability, content and

implementation of local post-MI guidelines

• May contribute to significant variation in clinical practice, as reported by HCPs

• In some areas, patient care may not be

optimal

References1. Sivers, F et al. Follow your heart: optimal care after a heart attack – a guide for you

and your patients. Br J Cardiol 2009;16:187-91

2. Ong S, Milne D and Morrell J (on behalf of the Follow Your Heart Steering Committee). Post-MI clinical guidelines: Variation in availability, development, content and implementation across the UK. Br J Cardiol 2009; 16:142-146

3. British Heart Foundation. Healthcare and economic costs of CVD and CHD. Available from: http://www.heartstats.org/datapage.asp?id=101 [accessed May 2009]

4. Food Standards Agency. Healthy diet. Available from: http://www.eatwell.gov.uk/healthydiet/ [accessed May 2009]

5. HEART UK. Healthy eating fact sheet D10: Mediterranean diet. Available from: http://www.heartuk.org.uk/images/uploads/healthylivingpdfs/HUK_factsheet_D10_MediterraneanDiet.pdf [accessed May 2009]

6. Food Standards Agency. Saturated fat. Available from: http://www.eatwell.gov.uk/healthydiet/fss/fats/satfat/ [accessed May 2009]

7. HEART UK. Healthy eating factsheet D04. Available from: http://www.heartuk.org.uk/images/uploads/healthylivingpdfs/HUK_factsheet_D04_fruitVeg.pdf [accessed May 2009]

References

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9. Food Standards Agency. Oily fish. Available from: http://www.eatwell.gov.uk/healthydiet/nutritionessentials/fishandshellfish/#cat232819 [accessed May 2009]

10. Food Standards Agency. Salt. Available from: http://www.eatwell.gov.uk/healthydiet/fss/salt/ [accessed May 2009]

11. HEART UK. Healthy eating factsheet F06. Available from: http://www.heartuk.org.uk/images/uploads/healthylivingpdfs/HUK_factsheet_F06_PlantSterols.pdf [accessed May 2009]

12. National Institute for Health and Clinical Excellence. NICE CG 48. Secondary prevention in primary and secondary care for patients following a myocardial infarction. London: NICE, May 2007. Available from: http://www.nice.org.uk/nicemedia/pdf/CG48NICEGuidance.pdf [accessed May 2009]

13. Joint British Societies. JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005;91(SupplV):v1–v52

References

14. Williams B, Poulter NR, Brown MJ et al. British Hypertension Society. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004;18:139–85

15. National Institute for Health and Clinical Excellence. NICE CG67. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. London: NICE, May 2008. Available from: http://www.nice.org.uk/nicemedia/pdf/CG067NICEGuideline.pdf [accessed May 2009]

16. International Diabetes Federation. IDF Consensus worldwide definition of the metabolic syndrome, 2006. Available from: http://www.idf.org/webdata/docs/MetS_def_update2006.pdf [accessed May 2009].

17. Brunzell JD, Davidson M, Curt D et al. Lipoprotein management in patients with cardiometabolic risk: consensus report from the American Diabetes Association and the American College of Cardiology Foundation. J Am Coll Cardiol 2008;51:1512–24

18. Charlton-Menys V, Betteridge DJ, Colhoun H et al. Targets of statin therapy: LDL cholesterol, non-HDL cholesterol, and apolipoprotein B in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS). Clin Chem 2009;53:473–80

References

19. Robinson JG, Songfeng Wang MS, Smith BJ et al. Meta-analysis of the relationship between non-high-density lipoprotein cholesterol reduction and coronary heart disease risk. J Am Coll Cardiol 2009;53:316–22

20. Law M, Wald N, Rudnicka A. Quantifying effect of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: systematic review and meta-analysis. BMJ 2003;326:1423–9

21. National Institute for Health and Clinical Excellence. NICE Technology Appraisal Guidance 132. Ezetimibe for the treatment of primary (heterozygous-familial and non-familial) hypercholesterolaemia. London: NICE, November 2007. Available from: http://www.nice.org.uk/nicemedia/pdf/TA132QRGFINAL.pdf [accessed May 2009].

22. Silber S, Albertsson P, Aviles FF et al. Guidelines for percutaneous coronary interventions. The Task Force for percutaneous coronary interventions of the European Society of Cardiology. Eur Heart J 2005;26:804–47

23. Scottish Intercollegiate Guidelines Network. SIGN CG 93. Acute coronary syndromes: a national clinical guideline. Edinburgh: SIGN, February 2007. Available from: http://www.sign.ac.uk/pdf/sign93.pdf [accessed May 2009]

References

24. NHS Quality Improvement Scotland. Draft clinical standards for prevention and treatment of coronary heart disease. Standard Statement 2. Edinburgh: NHS Quality Improvement Scotland, February 2009. Available from: http://www.nhshealthquality.org/nhsqis/files/HeartDisease_CHDDraftStandards_FEB09.pdf [accessed May 2009]

25. National Institute for Health and Clinical Excellence. NICE CG83. Rehabilitation after critical illness. London: NICE, March 2009. Available from: http://www.nice.org.uk/nicemedia/pdf/CG083NICEGuideline.pdf [accessed May 2009]

26. British Association for Cardiac Rehabilitation. Standards and Core Components for Cardiac Rehabilitation, 2007

27. Post Myocardial Infarction Care in Practice. Online survey conducted by medeConnect Healthcare insight (part of the Doctors.net.uk group), March 2009

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