Coronary heart disease (CHD) is the single commonest cause of premature death in the United Kingdom (UK). The research evidence relating to the management of CHD is well established and if implemented can reduce the risk of death from CHD and improve the quality of life for patients. This measure is one of ten Secondary Prevention of Coronary Heart Disease (CHD) measures. The "Secondary Prevention of Coronary Heart Disease (CHD)" indicator set focuses on the management of patients with established CHD consistent with clinical priorities in the four nations.

Aspirin (75-150 mg per day) should be given routinely and continued for life in all patients with CHD unless there is a contraindication. Clopidogrel (75 mg/day) is an effective alternative in patients with contraindications to aspirin, or who are intolerant of aspirin. Aspirin should be avoided in patients who are anti-coagulated.

Refer to the Scottish Intercollegiate Guidelines Network (SIGN) guidelines, "Management of stable angina" (SIGN Publication No. 96, February 2007), and "Risk estimation and the prevention of cardiovascular disease" (SIGN Publication No. 97, February 2007) for further information.

Since the original General Medical Services (GMS) Guidance in 2003, the National Institute for Health and Clinical Excellence (NICE) has released guidance on the appropriate use of clopidogrel:

• Clopidogrel alone (within its licensed indications) is recommended for people who are intolerant of low-dose aspirin and either have experienced an occlusive vascular event or have symptomatic peripheral artery disease. NICE define aspirin intolerance as either of the following: proven hypersensitivity to aspirin-containing medicines or history of severe dyspepsia induced by low-dose aspirin.
• Clopidogrel, in combination with low-dose aspirin, is recommended for use in the management of non-ST-segment-elevation acute coronary syndrome (ACS) in people who are at moderate to high risk of myocardial infarction (MI) or death. NICE recommend that treatment with clopidogrel in combination with low-dose aspirin should be continued for up to 12 months after the most recent acute episode of non-ST-segment-elevation ACS. Thereafter, standard care, including treatment with low-dose aspirin alone, is recommended. Moderate to high risk of MI or death in people presenting with non-ST-segment-elevation ACS can be determined by clinical signs and symptoms, accompanied by one or both of the following:
  
  
  1. The results of clinical investigations, such as new electrocardiogram (ECG) changes (other than persistent ST-segment-elevation), indicating ongoing myocardial ischaemia, particularly dynamic or unstable patterns.
  2. The presence of raised blood levels of markers of cardiac cell damage such as troponin.

Refer to the NICE guideline, "Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome" for further information.

Quality and Outcomes Framework Indicators

Secondary Prevention of Coronary Heart Disease (CHD)

The individual measure, "CHD 9. The Percentage of Patients with Coronary Heart Disease with a Record in the Previous 15 Months That Aspirin, an Alternative Anti-platelet Therapy, or an Anti-coagulant is Being Taken (Unless a Contraindication or Side-effects Are Recorded)," is published in the "Quality and outcomes framework guidance." This document is available from the British Medical Association Web site.

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