MI — Secondary Prevention
Red Flags — post-MI symptoms requiring urgent assessment
| Red flag | Why dangerous | Action |
|---|---|---|
| Acute chest pain or pressure on DAPT | In-stent thrombosis (IST): catastrophic occlusion of the stented coronary artery; occurs in 1–3% of patients post-PCI, usually when DAPT has been stopped or interrupted. Mortality 30%. Presents as STEMI. Also: incomplete revascularisation (treated vessel open but other vessels have disease); new MI. Any acute chest pain in a patient on DAPT = 999; treat as STEMI until proven otherwise. | 999 immediately; aspirin 300mg loading if not already on antiplatelet; do not delay |
| Palpitations with presyncope or syncope | Post-MI arrhythmia: ventricular tachycardia (VT) and ventricular fibrillation (VF) risk is highest in the first 48 hours but persists, especially if LV function is impaired. Sustained VT/VF post-MI may require ICD implantation. Brady-arrhythmia from bisoprolol or complete heart block (if inferior MI): AV node damage. Syncope post-MI is a cardiology emergency. ECG immediately in surgery; if VT/VF: 999. | 12-lead ECG immediately; same-day cardiology referral if ECG abnormal; if haemodynamically unstable: 999 |
| Breathlessness at rest or on minimal exertion + peripheral oedema | Post-MI heart failure: LV remodelling after MI (especially STEMI; large territory infarct) causes systolic dysfunction; heart failure develops in 15–25% of post-MI patients within months. Signs: breathlessness; orthopnoea; PND; bilateral ankle oedema; raised JVP; third heart sound. Echocardiogram needed (if EF <35%: eplerenone + ICD assessment; if EF <40%: ACEi + BB + consider sacubitril-valsartan). | Urgent echocardiogram; loop diuretic if HF confirmed; cardiology referral; eplerenone if EF <35% + HF |
| Severe muscle pain or weakness on statin (CK >10× ULN) | Statin-induced rhabdomyolysis: severe myopathy with CK >10× upper limit of normal; myoglobin release causes acute kidney injury. Rare but serious. Symptoms: severe proximal muscle pain; dark urine (myoglobinuria). Stop statin immediately; IV fluids; hospital if severe. Mild myalgia (CK normal or <4× ULN): continue; reassess; consider switching to alternative statin (rosuvastatin; pravastatin lower myopathy risk). | Stop statin immediately; check CK; if CK >10× ULN or renal impairment: hospital admission; IV fluids |
| Major bleeding on DAPT (GI; intracranial) | DAPT increases bleeding risk 2–3× compared to aspirin alone. Major GI bleeding: haematemesis or melaena; requires hospital admission and urgent cardiology advice before DAPT is stopped (stopping increases thrombosis risk; a haemostatically-treated patient may need DAPT restarted quickly). Intracranial haemorrhage: stop all antiplatelets immediately; 999; neurosurgical emergency. For GI bleed: PPI (omeprazole 40mg OD) should have been prescribed at discharge — if not, add now. | Major GI bleed or intracranial haemorrhage: 999; urgent hospital; cardiology + gastroenterology / neurosurgery co-management |
Post-MI Vulnerability — Psychological and Social Considerations
💔 Post-MI Depression and Anxiety
- PHQ-9 and GAD-7 at 6 weeks and 3 months post-MI — not optional; should be part of the review template
- Depression post-MI is underdiagnosed: fatigue and reduced activity are attributed to cardiac disease rather than mood
- Treatment: SSRIs are safe in post-MI depression (sertraline has the best cardiac safety data); do NOT use tricyclics (QTc effects)
- Cardiac rehabilitation has a significant psychological benefit component — non-attendance worsens mood outcomes
🚘 Occupational Impact — DVLA and Livelihoods
- Mr. Henderson cannot drive his HGV until DVLA approves return — this directly threatens his income and identity
- The GP must be honest and clear about DVLA obligations without being punitive
- DVLA notification is a legal obligation: GP should document that the patient has been advised
- Occupational health referral: explore what alternative work may be available while not cleared to drive; employer may have sedentary roles
🪝️ Cardiac Rehabilitation Non-Attendance
- Mr. Henderson has not attended cardiac rehabilitation — this is very common (40–50% non-completion nationally)
- Barriers: work commitments; embarrassment; practical barriers (transport; time); minimising the event (“I feel fine now”)
- Evidence: cardiac rehabilitation reduces mortality 20–25%; equivalent benefit to adding a drug
- GP should actively chase non-attendance: phone call; explore barriers; offer remote/online alternative if practical barriers
💑 Relationship and Sexual Health Impact
- Mr. Henderson’s wife is anxious about him resuming activities — partner anxiety is extremely common; both members of the couple need information and reassurance
- Consider inviting the partner to a review appointment to discuss prognosis and exercise tolerance
- Sexual dysfunction post-MI: from depression; anxiety; beta-blocker; altered body image; fear
- Proactively raising sex normalises it; if GP doesn’t raise it, it will not be discussed
🚘 Work Identity and DVLA
Lorry driving is not just a job for Mr. Henderson — it is his identity and his livelihood. The DVLA obligation is not just an administrative inconvenience; it is a potentially permanent threat to the work he has done for decades. The GP who delivers this message must do so with compassion and practical support: occupational health referral; employer discussion; alternative roles; realistic timeline for DVLA return.
"I know this is not what you want to hear about the driving. The rule exists because we need to be sure your heart is stable enough for the demands of driving a lorry. I want to help you get back there as quickly as safely possible — and I can explain what the process looks like."♥️ Fear of Recurrence
Fear of having another heart attack is universal post-MI. It drives excessive caution (avoiding exercise; avoiding sex; avoiding excitement) which is itself harmful. The GP’s counter-message is evidence-based reassurance: “The treatment you received — the stent, the tablets — significantly reduces your risk. We know that. Exercise does not increase your risk — it reduces it. Sex at this stage does not meaningfully increase your risk.” Specific, concrete reassurance outperforms vague encouragement.
"I want to address the fear directly. The risk of having another heart attack while having sex is extremely small — similar to climbing two flights of stairs. The medications are doing their job, and being active is part of your recovery, not a risk."💑 Relationship Impact
Mrs. Henderson is anxious about her husband’s activities. This is protective in one sense but harmful in another: it creates a dynamic where normal activity is perceived as dangerous, which increases the patient’s anxiety and prevents rehabilitation. The couple need joint information — ideally at a cardiac rehabilitation family session — about what activities are safe, what the warning signs are, and how to recognise if something needs urgent attention. Excluding the partner from post-MI information leaves them as an anxiety amplifier rather than a recovery supporter.
"Would it be helpful to bring your wife in to one of these appointments? I’d like to be able to reassure you both together — because it sounds like she is also finding this very worrying, and I think hearing the information from me might help her as well."🩺 Smoking Relapse Without Shame
Mr. Henderson knows he has relapsed on smoking. He may be expecting to be told off. A shame-based approach reduces engagement with future cessation attempts. The GP who responds with normalisation and re-engagement is more effective: “Most people who quit after a heart attack — even those who really wanted to — find themselves starting again. The post-MI period is one of the most stressful of a person’s life. The question isn’t why you started — it’s how we help you stop again in a way that actually works.”
"Restarting smoking after a heart attack is more common than people think — this is not something to feel bad about. It just means we need to try something that might work better this time. Can I tell you about some of the options?"- Starting immediately with drug checklist without emotional opener
- Not raising sexual health (patient said he “didn’t want to bring it up” — the GP must raise it)
- Not addressing DVLA Group 2 obligations — legal duty and Tasks criterion
- Shaming response to smoking relapse — reduces re-engagement with cessation
999 / A&E now
Immediate escalation- Acute chest pain / pressure on DAPTPossible in-stent thrombosis — do NOT wait; 999; aspirin 300mg if available
- Palpitations with collapse or loss of consciousnessVT/VF post-MI — cardiac arrest risk; 999 immediately
- Rhabdomyolysis — severe muscle pain + dark urine on statinStop statin; IV fluids; 999
- Major GI or intracranial bleed on DAPTHospital immediately; do NOT stop DAPT without cardiology advice
Same-Day Cardiology
Same-day assessment- New angina or atypical chest pain post-MIECG; troponin; same-day cardiology
- Palpitations with ECG abnormality (VT; complete heart block)Same-day cardiology; may need monitoring
- Breathlessness + ankle oedema (possible HF)BNP; echocardiogram; consider loop diuretic urgently
GP-managed
Secondary prevention- 6-week post-MI review — stable, asymptomaticMedication review; risk factor targets; cardiac rehab; lifestyle
- LDL-C above target; BP above targetOptimise; review in 3 months; escalate if persisting
- Smoking relapseRe-engage cessation programme; varenicline; NRT
- DVLA Group 2 notificationAdvise patient; document; DVLA referral if needed
- Not checking for symptoms of recurrence (new angina; palpitations; breathlessness) before proceeding to the lifestyle review — a symptom review is the safety-critical first check at every post-MI review
- Not measuring BP at a post-MI medication review — BP is both a risk factor target and the basis for medication titration; it is a non-negotiable examination finding at every secondary prevention review
- Not reviewing LDL-C and giving the target explicitly — patients cannot engage with an abstract blood test result; they need to know the target, their current number, and what the plan is to close the gap
"I want to explain something important. The stent has opened the artery that was blocked — and that has been really successful. But the process that caused the artery to become blocked in the first place — the build-up of cholesterol and damage to the artery wall — is still there in your other arteries. What the tablets are doing is slowing that process down and preventing it from causing another blockage. That is why the medications are not just for now — they are for life. And it is why the lifestyle changes — particularly the smoking — are so important. Smoking speeds up exactly the process the tablets are trying to slow down."
"I feel fine now — do I still need all these tablets?"
"Absolutely. The tablets are doing their job precisely because you feel fine. If you stop them, you won’t feel different for a while — but your risk of another heart attack goes up immediately. The aspirin and the ticagrelor in particular: stopping those could cause a blockage in the stent, which is very serious. These are not tablets you can take a break from."
"The stent is fixed now — surely that means the problem is sorted?"
"The stent has fixed one part of the problem — the blocked artery. But it doesn’t change the underlying condition, which is atherosclerosis: the furring up of the blood vessels. That process is in all your arteries, including the stent site. The tablets and lifestyle changes are what manage the wider disease — and they are just as important as the stent."
BP: 142/86 mmHg; target <130/80 mmHg — above target ⇒ titrate ramipril
Smoking: 15/day — target: complete cessation
BMI: 29 — target: <25 or 5–10% weight loss
Exercise: cardiac rehabilitation; 30 min 5×/week
HbA1c: check if not done — post-MI T2DM risk elevated
6 months post-PCI: drug-eluting stent
Ticagrelor 90mg BD + aspirin 75mg OD — continue to 12 months post-PCI. At 12 months: stop ticagrelor; aspirin 75mg lifelong. Never stop DAPT without cardiology agreement before 12 months — in-stent thrombosis risk.
ALT 52 U/L (1.15× ULN)
<3× ULN: continue atorvastatin 80mg. Exclude alcohol and NAFLD (BMI 29). Recheck LFTs in 3 months. If ALT persistently >3× ULN: reduce dose or switch statin.
- Using clinical jargon without plain-language explanation: “your LDL-C is 2.1 and the target is 1.8” without explaining what this means and what we are going to do about it; this scores a Global Skills deduction for inadequate communication of clinical information
- Accepting cardiac rehabilitation non-attendance without active follow-up — failing to explore barriers and re-refer is a significant missed opportunity; the cardiac rehabilitation referral (and active follow-up on non-attendance) is a Tasks mark in this SCA case
Validate the progress — the stent worked
Always begin with what has gone well. The PCI was successful; the stent is open; he has been taking his medications. This is genuine good news and should be said first — before any discussion of what is still above target.
"First — the stent is doing its job. You feel better, which is exactly what we would hope. That is genuinely good news. The treatment you had was very effective at fixing the immediate problem."Explain why the work is ongoing
The illness model shift: from “I had a heart attack and now I’m better” to “I have an ongoing condition that is now well-managed” is the central educational task of secondary prevention. Without this shift, Mr. Henderson will stop medications, restart fully smoking, and avoid cardiac rehab.
"The thing is — the stent fixed the pipe. But the process that caused it to get blocked in the first place is still there. The tablets are managing that process. The lifestyle changes — particularly the smoking — are making that process worse every day."Offer concrete good news where it is warranted
Mr. Henderson has specific concerns: sex; driving; having another heart attack. Each of these has a real, evidence-based answer that can be given with confidence. Giving these specific reassurances is motivating and builds trust.
"Here is what I can tell you today: sex is safe at this stage — the risk is very small. Exercise is not only safe — it is part of your treatment. And driving: I want to explain exactly what the timeline looks like."Smoking cessation post-MI reduces relative risk of further MI or death by 36% — equivalent to adding aspirin, a statin, and an ACE inhibitor combined. Every cigarette smoked damages the endothelium and accelerates exactly the atherosclerotic process the medications are trying to slow. The most effective intervention for secondary cardiovascular prevention available to a GP.
Non-judgemental re-engagement with cessation: normalise relapse; explore what triggered it (post-MI stress); discuss options: varenicline (most effective; 22% 12-month abstinence; start 1–2 weeks before quit date); combination NRT (patch + short-acting gum or lozenge); e-cigarettes (harm reduction if other methods failed). Set a quit date. NHS Stop Smoking Service referral (self-referral available). Follow up at 4 weeks.
Mediterranean diet is the best-evidenced dietary pattern for secondary cardiovascular prevention. Evidence: Lyon Diet Heart Study (1996) showed 56% reduction in recurrent MI; PREDIMED trial (2013) confirmed cardiovascular benefit. Components: olive oil as primary fat; oily fish 2×/week; high vegetable and fruit intake; legumes and wholegrain; limited red and processed meat; moderate red wine (optional). Not low-fat — the quality of fat matters, not the quantity.
Omega-3 supplements: NOT routinely recommended post-MI (NICE 2020; ASCEND and ORIGIN trials). Oily fish 2 portions/week (mackerel; salmon; sardines; trout). Salt restriction if hypertensive (<6g/day). Alcohol: maximum 14 units/week; no binge drinking (raises BP; arrhythmia risk after large intakes). Mr. Henderson: weight loss 5–10% from 94kg target — reduces BP; LDL-C.
Regular moderate aerobic exercise reduces recurrent MI risk by 20–25% (Cochrane meta-analysis); reduces BP; improves LDL-C; reduces thrombotic risk; improves LV function and cardiac output; reduces depression and anxiety; improves quality of life. Exercise is not a risk factor for recurrence in stable post-MI patients — it is a treatment. Cardiac rehabilitation provides supervised, graduated exercise with monitoring and education.
Cardiac rehab: Phase II — re-refer Mr. Henderson; remote / online option if practical barriers. At home: walking programme building to 30 minutes/day at moderate pace (able to hold a conversation) 5×/week. Avoid heavy lifting for 6 weeks post-PCI; no heavy manual labour for 4–6 weeks. Reassure: exercise does not increase recurrence risk. Heart rate target: 40–70% of maximum predicted HR (220 − age) during exercise.
Sexual activity in a stable partner is equivalent to climbing two flights of stairs in terms of cardiac demand: MET 2–3. Risk of triggering an MI during sexual activity is extremely low in treated, stable post-MI patients (2.5 per million person-hours). Fear of sex causing recurrence is much more prevalent than the actual risk — and leads to unnecessary sexual dysfunction and relationship strain. GP should proactively raise this.
Sildenafil; tadalafil; vardenafil: safe to use post-MI once cardiovascular status is stable (typically 4–6 weeks). ABSOLUTE CONTRAINDICATION: concurrent use with any nitrate (GTN spray; isosorbide mononitrate; isosorbide dinitrate) — severe, potentially fatal hypotension. Mr. Henderson: not currently on nitrates — PDE5 inhibitors are safe. If bisoprolol is causing erectile dysfunction (common; 10% of patients): switch to nebivolol (vasodilatory beta-blocker; less ED risk).
Mr. Henderson drives an HGV (Group 2 DVLA licence). Post-NSTEMI/PCI: Group 2 minimum 6 weeks; must notify DVLA (patient’s legal obligation — not the GP’s); must meet DVLA Group 2 medical standards before return. DVLA assessment may require: exercise tolerance test; resting 12-lead ECG; no symptoms; no residual ischaemia. GP documents that the patient has been counselled. Do not advise he can return to driving after 6 weeks without DVLA confirmation.
Occupational health referral (ask if the employer has an OHA service). Explore alternative sedentary roles during the assessment period. Explain DVLA process timeline: notification now; DVLA assessment; medical standards satisfied; then return. DVLA phone: 0300 790 6806. Fitness to work letter for employer if needed (covering the cardiac event and expected return timeline).
Post-MI depression occurs in 20–30% of patients and independently increases mortality risk (HR 1.8). Cardiac rehabilitation includes psychological support. PHQ-9 is part of the standard post-MI review template. Administer at 6 weeks (today) and again at 3 months. If PHQ-9 ≥10: treat (sertraline has best cardiac safety data — SADHART trial; avoid tricyclics: QTc effects). Depression may present as physical symptoms (fatigue; low energy; poor motivation) that can be attributed to cardiac disease rather than mood — always screen actively.
SSRIs in post-MI depression: sertraline 50mg OD (titrate to 100–200mg); citalopram: avoid if QTc concern (>40ms prolongation at doses >20mg). Tricyclics (amitriptyline): absolutely avoid post-MI — QTc prolongation; anticholinergic effects; arrhythmia risk. If SSRI not tolerated: mirtazapine; bupropion (also smoking cessation tool — dual benefit if both depression and smoking present). Psychological therapies: CBT is NICE first-line for depression; referral to NHS Talking Therapies or psychological therapies service.
- Aspirin 75mg OD + ticagrelor 90mg BD: continue for 12 months post-ACS (PLATO trial; superior to clopidogrel)
- At 12 months: transition aspirin 75mg lifelong monotherapy; stop ticagrelor (or clopidogrel if used instead)
- PPI (omeprazole 20mg OD) with DAPT: reduces GI bleeding risk by 50–60%
- Never stop DAPT early: discuss with cardiology; in-stent thrombosis risk
- Atorvastatin 80mg OD: high-intensity; maximum dose; LDL-C target <1.8 mmol/L
- If LDL-C above target despite atorvastatin 80mg + confirmed adherence: add ezetimibe 10mg OD
- Ezetimibe reduces LDL-C by an additional 15–20% via cholesterol absorption inhibition
- If LDL-C still above target on atorvastatin 80mg + ezetimibe: PCSK9 inhibitor via lipid clinic or cardiology
- Ramipril: titrate to maximum tolerated dose (target 10mg OD); BP target <130/80 mmHg
- If ACEi cough (10–15%): switch to candesartan 32mg OD (ARB)
- Bisoprolol: titrate to HR 50–60 bpm (target for LV protection); review continuation beyond 12 months if EF preserved
- If bisoprolol causes ED: switch to nebivolol (vasodilatory; less ED risk)
- Eplerenone 25mg OD (titrate to 50mg OD): indicated post-MI if echocardiogram shows EF <35% AND signs of heart failure (EPHESUS trial)
- NOT indicated if EF preserved (no HF post-MI — which is Mr. Henderson’s current picture)
- Monitor: K+ and creatinine at 1 week, 1 month, then 3-monthly (hyperkalaemia risk with ACEi + eplerenone)
- If K+ >5.5: reduce dose; if >6.0: stop
- Atorvastatin 80mg OD ⇒ maximum tolerated statin dose first
- Add ezetimibe 10mg OD if LDL-C above target
- If still above target on atorvastatin 80mg + ezetimibe: PCSK9 inhibitor
- Evolocumab 140mg SC fortnightly (FOURIER trial; 59% additional LDL-C reduction)
- Inclisiran 284mg SC 6-monthly (ORION trial; convenient twice-yearly dosing; NICE TA614)
- Both available via lipid clinic or cardiology — not GP-initiated
Select patient characteristics — post-MI medication guidance
"This is your cholesterol tablet — it is one of the most important things you can take after a heart attack. It actively works to slow down the process that caused the blockage. You should take it every day, for life — even when your cholesterol looks good, because the tablet is what is making it good. If you get any muscle aches — particularly if they are severe or if you notice dark urine — please stop it and contact me."
Atorvastatin 80mg: high-intensity statin; all post-MI regardless of baseline cholesterol. LDL-C target <1.8 mmol/L (or >50% reduction). LFTs at 3 months. Myopathy: CK only if symptomatic. ALT <3× ULN: continue. ALT >5× ULN: stop. Mild myalgia (normal CK): continue; consider switching statin. Rhabdomyolysis (CK >10×): stop; hospital. Add ezetimibe 10mg OD if LDL-C above target. Drug interactions: clarithromycin; ciclosporin; fibrates — all increase statin levels and myopathy risk.
"This tablet — ticagrelor — works with the aspirin to stop the blood from clotting in the stent. It is critical that you take both of these every day for the next 12 months. I want to be very direct: if you stop this tablet without speaking to me or the cardiologist first, you are at risk of the stent blocking again — and that is very serious. If you need an operation or procedure: do not let anyone stop this tablet without ringing us first."
Ticagrelor 90mg BD: preferred P2Y12 inhibitor in ACS (PLATO trial; superior to clopidogrel). 12 months DAPT with aspirin 75mg. NEVER stop without cardiology advice — in-stent thrombosis risk is fatal in 30%. Dyspnoea (10–15%): continue — prostaglandin-mediated; not bronchospasm. If intolerable: switch to clopidogrel 75mg (not stop). 12-month transition: stop ticagrelor; aspirin 75mg lifelong. If surgery needed while on DAPT: cardiology discussion mandatory before stopping.
"This tablet — ramipril — helps protect your heart after the heart attack in two ways. It lowers your blood pressure, which reduces the strain on the heart. It also directly helps the heart recover by reducing the stiffening and changes that can happen after a heart attack. You may develop a cough — a dry tickly cough — from this tablet. If that happens, please tell me; I can switch you to a different type that works the same way but without the cough."
Ramipril post-MI: all patients; titrate to 10mg OD; BP target <130/80 mmHg. AIRE trial; HOPE trial evidence. Monitor U&E 1–2 weeks after each dose change. Cough: switch to candesartan 32mg (not stop ACEi class). Hyperkalaemia: stop or reduce if K+ >5.5. Bilateral RAS: absolute CI. Never combine ACEi + ARB (dual RAAS blockade): increased hyperkalaemia and renal failure risk. Mr. Henderson: currently 5mg; titrate to 10mg; recheck U&E in 2 weeks.
"This tablet — bisoprolol — slows the heart down slightly, which helps it recover from the heart attack. It also helps prevent dangerous heart rhythm problems. You might find you feel more tired than usual at first — this usually settles. One thing I want to mention: this tablet can affect sexual function in some men. If that becomes an issue, please tell me — there is a different version I can switch you to that has less effect on that."
Bisoprolol post-MI: all patients; titrate to resting HR 50–60 bpm; review continuation at 12 months (continue indefinitely if reduced EF or HF). ED side effect: switch to nebivolol (not stop beta-blocker class). Never stop abruptly (rebound hypertension; angina; arrhythmia). COPD: use with caution (not absolute CI; cardioselective). Asthma (severe): avoid. Bradycardia (<50 bpm): reduce dose; check ECG.
"The aspirin you are on — 75mg — is not the same as the aspirin you might take for a headache. This is a low dose that works specifically to stop blood clots forming in the arteries. You will need to take it every day for life — not just when you feel you need it. Always take it with food. And please avoid ibuprofen and similar anti-inflammatory painkillers without speaking to me first — they can interfere with how the aspirin works."
Aspirin 75mg lifelong post-DAPT. PPI (omeprazole 20mg) mandatory — reduces GI bleeding by 50–60%. NSAIDs: avoid (GI bleeding risk + potential interference with aspirin’s COX-1 mechanism). Aspirin during DAPT: always combined with ticagrelor or clopidogrel for 12 months. At 12 months: stop ticagrelor; continue aspirin. Never stop aspirin post-MI without cardiologist input — even for dental procedures (usually safe to continue; inform dentist).
"This tablet helps protect your heart by blocking a hormone that can cause the heart to stiffen and become weaker after a heart attack. It is particularly important for you because the scan of your heart showed that the pumping function is slightly reduced. We will need to check your kidney function and the potassium level in your blood regularly — particularly in the first few months — as this tablet can sometimes cause those levels to change."
Eplerenone: post-MI only if EF <35% AND HF signs (EPHESUS criteria). NOT for preserved EF. Start 25mg OD; titrate to 50mg. Critical monitoring: K+ at 1 week, 1 month, 3-monthly. K+ >5.5: reduce dose. K+ >6.0: stop immediately. CI: eGFR <30; K+ >5.0 at baseline; concomitant potassium-sparing diuretics. ACEi + eplerenone = high hyperkalaemia risk; monitor closely. ICD referral if EF <35% persists at 40 days post-MI. Spironolactone: cheaper alternative; more gynaecomastia risk than eplerenone.
Work and Identity (DVLA)
HGV driving is not just Mr. Henderson’s job — it is his identity, his income, and his independence. The DVLA obligation is a direct threat to all three. Compassionate delivery: “I know this is the news you didn’t want. The rule exists to protect you and others on the road — not to punish you.” Practical support: occupational health referral; employer discussion; alternative roles during DVLA assessment.
"I want to help you get back to driving as quickly as we safely can — and I can tell you what the process looks like and what we need to do to make it happen."Sexual Health and Fear
Mr. Henderson wanted to raise sex but didn’t. The GP must raise it. The risk of MI from sexual activity in a stable treated post-MI patient is extremely small. Reassurance: “If you can climb two flights of stairs comfortably, you are physically ready to have sex.” Bisoprolol may be contributing to ED — switch to nebivolol if this is the case. PDE5 inhibitors safe if no nitrates.
"The risk of sex triggering another heart attack is extremely small for someone at your stage of recovery. I would expect you to be able to manage this without any problem at 6 weeks."Fear of Recurrence
Fear of another MI is universal post-MI; it drives excessive caution, avoidance of exercise and sex, and hypervigilance about symptoms. Counter-evidence: “The treatment you have had — the stent, the medications — significantly reduces your risk. You are doing far better than if you hadn’t had the stent.” Specific exercises and activities confirmed safe. PHQ-9 to detect anxiety converting to clinical depression.
"I want to be clear about the risk: the stent has dramatically reduced your risk of another event. The tablets are doing more of the same work. Exercise is not a risk — it is actively protective."Smoking Relapse Without Shame
Mr. Henderson is smoking again. He may be expecting criticism. A shame-based approach reduces engagement. Normalise: “Restarting after a heart attack is more common than people think — the post-MI period is one of the most stressful of someone’s life.” Re-engage: explore what triggered the relapse (stress; anxiety; habit); offer a better-supported cessation attempt this time (varenicline rather than willpower alone).
"I am not here to judge you for starting again — I just want to help you stop in a way that actually works this time. Can we try something different?"Today — 6-week review actions
All 5 medications reviewed; ezetimibe 10mg OD added (LDL-C 2.1); ramipril titrated to 10mg OD; varenicline 0.5mg OD started (quit date in 2 weeks); cardiac rehab re-referred (remote option offered); DVLA Group 2 advised and documented; PHQ-9 administered; sexual health addressed; wife invited to next review; smoking cessation service referred; PPI confirmed prescribed.
2 Weeks — U&E after ramipril titration + quit date check
Renal function and electrolytes (2 weeks after ramipril 10mg OD started). Smoking: quit date review; CO test; varenicline tolerability. BP recheck. Any new symptoms? Side effects? DVLA: has he notified? Occupational health: has he made contact?
4 Weeks — Smoking cessation review
4-week CO test (NRT or varenicline); smoking cessation service check-in. PHQ-9 recheck if scores were 5–9 at 6 weeks. Side effects of new medications (ezetimibe; ramipril 10mg). Has wife attended? Cardiac rehab: has he started?
3 Months — LDL-C target recheck; full review
LDL-C recheck (3 months on atorvastatin 80mg + ezetimibe 10mg). LFTs. Renal function. BP. PHQ-9. Cardiac rehab completion (or explore barriers). HbA1c if not done. Cardiology review: has he attended? DVLA: has he been cleared to drive? Smoking: CO test; sustained quit?
12 Months — DAPT transition; annual review
Stop ticagrelor (with cardiologist agreement at 12-month cardiology review); continue aspirin 75mg lifelong. Annual secondary prevention review: LDL-C; BP; BMI; smoking; HbA1c; PHQ-9; ECOG; renal function; LFTs. Review beta-blocker continuation (cardiologist guidance). DVLA annual report if required for Group 2 licence. 12-month cardiac rehab completion.
SMART secondary prevention monitoring mnemonic
Statin: LFTs at 3 months; LDL-C at 3 months (target <1.8 mmol/L); CK only if myopathy symptoms. Medicines (ACEi + BB): U&E after each ramipril titration; BP at every review; HR (target 50–60 bpm on bisoprolol). Antiplatelet: DAPT adherence; bleeding symptoms; 12-month DAPT transition; aspirin lifelong. Rehab: cardiac rehab attendance; exercise tolerance at each review; PHQ-9 at 6 weeks and 3 months. Targets: LDL-C; BP <130/80; BMI; smoking status; HbA1c (if diabetic); PA level (150 min moderate/week).
⚠ Three critical safety-net conversations
Documentation requirements
- Not raising sexual health — patient said he “didn’t want to bring it up”; this is the signal for the GP to raise it, not a reason to leave it
- Not addressing DVLA Group 2 — this is both a Tasks mark and a legal obligation; omitting it is a significant consultation failure
- Shaming the smoking relapse — reduces engagement with cessation; Relating to Others deduction
- Not explaining what will happen at 12 months with DAPT — patient must know ticagrelor is time-limited and aspirin continues
- All 5 medications reviewed; ezetimibe added (LDL-C above target)
- Ramipril titrated to 10mg; U&E booked for 2 weeks
- Smoking cessation re-engaged; varenicline prescribed; SSS referred
- DVLA Group 2 obligation explained and documented
- Sexual health raised; PDE5/nitrate rule explained
- Cardiac rehab barriers explored; re-referred
- PHQ-9 administered
- Safety-net: chest pain = 999; never stop ticagrelor
- Emotional opener; acknowledged the post-MI journey
- ICE all three explored; hidden concerns named
- Smoking relapse normalised without judgement
- Sexual health raised proactively; embarrassment acknowledged
- DVLA delivered with compassion; practical support offered
- Ticagrelor importance emphasised without alarming
- Wife invited; closing question with genuine pause
Who you are
James Henderson, 58, HGV lorry driver for a national haulage company. Married to Sandra (55). Two grown-up children. NSTEMI 6 weeks ago; treated with PCI (drug-eluting stent to LAD). Post-hospital period has been difficult: bored at home; anxious; started smoking 15/day again about 2 weeks after discharge. You haven’t attended cardiac rehab — first appointment clashed with a family commitment. Sandra is very anxious and does not want you doing anything strenuous. Your boss has said he can hold your job for another 6 weeks. You want your life back.
Hidden concerns — disclose if directly asked
Sex (disclose if GP raises it): “I’ve been wanting to ask about that. Sandra and I haven’t … since the heart attack. She’s scared, and honestly I am too. What’s the risk?” Responds very well to reassurance: “Two flights of stairs equivalent — that’s honestly all? OK, that’s a relief.”
Financial concern (disclose if DVLA conversation happens compassionately): “If I can’t drive the lorry, I lose my job. The company can only hold it so long. What am I supposed to do about money?” — this reveals the real stakes of the DVLA conversation; GP should acknowledge this with empathy and occupational health referral.
Smoking guilt: “I know I shouldn’t have started again. I just … the first two weeks at home were terrible. I was bored and anxious and it was just there.” — respond well if GP is non-judgemental: “Actually it would really help to have something proper to try this time.”
Responses to key conversations
- On medications: “do I need all these?”: "The stent fixed it, didn't it?" — respond to plain-language explanation of atherosclerosis as an ongoing condition: "OK — I hadn't thought of it that way. Like the stent fixed the pipe but not the furring."
- On DVLA (compassionate delivery): initially crestfallen then: "What's the actual process? Is there anything I can do to speed it up?" — practical information is reassuring
- On ticagrelor stopping warning: visibly surprised: "I didn't know you couldn't just stop it. My mate had a stent and he stopped his tablets after a year and nothing happened." — respond to clear explanation: "OK, I'll be careful."
- On cardiac rehab: initially dismissive ("I feel fine, I don't need it") — respond to evidence: "20 to 25% risk reduction — that much? OK. Maybe I should give it a go."
Clinical details
- Age 58; NSTEMI 6 weeks ago; PCI to LAD (drug-eluting stent)
- Current medications: aspirin 75mg OD; ticagrelor 90mg BD; atorvastatin 80mg OD; ramipril 5mg OD; bisoprolol 2.5mg OD
- Today: BP 142/86; HR 72 bpm; weight 94 kg; BMI 29
- Bloods: LDL-C 2.1 mmol/L; total cholesterol 4.6; eGFR 78; Na+ 139; K+ 4.2; ALT 52 (ULN 45 — mildly elevated)
- Smoking: 15/day since 2 weeks post-discharge
- PHQ-9: ask in-consultation — likely score 7–9 (subthreshold depression; occupational stress; anxiety about recurrence)
Resolution: Mr. Henderson accepts the DVLA news if delivered with compassion and practical support (occupational health referral; realistic timeline; GP supporting letter offered). He agrees to try varenicline if the GP is non-judgemental about the relapse. He is visibly relieved when sex is raised proactively and reassured. He agrees to cardiac rehab re-referral when evidence is given specifically (“20–25% risk reduction”). He leaves having agreed to ezetimibe, ramipril 10mg, varenicline, cardiac rehab, DVLA notification, and a 2-week review. He says: “I didn’t expect this appointment to go like that. I thought you’d just be checking boxes.”
| SMART | Parameter | Timing | Action |
|---|---|---|---|
| S — Statin | LDL-C; LFTs; CK if symptomatic | LDL-C + LFTs at 3 months; annually | LDL-C >1.8: add ezetimibe. ALT >5× ULN: stop. CK >10×: stop; hospital |
| M — Medicines (ACEi + BB) | U&E; BP; HR; side effects | U&E 1–2 weeks post titration; BP at every review | BP above target: titrate ramipril; add amlodipine. K+ >5.5: reduce ACEi. HR >70 on bisoprolol: titrate |
| A — Antiplatelet | DAPT adherence; bleeding; dyspnoea | Every review; 12-month transition | Ticagrelor dyspnoea: continue (prostaglandin-mediated). At 12M: stop ticagrelor; aspirin lifelong |
| R — Rehab | Cardiac rehab attendance; PHQ-9; exercise tolerance | PHQ-9 at 6W + 3M; cardiac rehab review at 3M | Non-attender: explore barriers; re-refer; remote option. PHQ-9 ≥10: sertraline |
| T — Targets | LDL-C; BP; smoking; BMI; HbA1c | 3M until target; then annually | Smoking: re-engage with cessation support; varenicline. BMI >30: weight management referral |