Prevention

Arrange for your patient to attend a structured secondary prevention programme. ^a

Diet

Encourage patients to eat a Mediterranean-style diet ^a  

Consider giving patients

• n-3 polyunsaturated fatty acid supplements ^a  
• vitamin E supplements (alpha-tocopherol) ^a  

Avoid giving beta-carotene ^a  

Cholesterol

• diet modification: ^a  encourage patients to eat less fat ^a  (particularly cholesterol) ^a  and more oats ^a,  fish ^a and soy protein ^b  
• a statin ^a
• gemfibrozil for patients with a low HDL levels ^a
• garlic ^a

There is no clear benefit from referring your patient to a dietician - self-help material is equally effective. ^a  

Treat hypertension ^a  

Smoking

Encourage patients to stop smoking ^a, and ask nurses ^a and other staff  ^a to provide further advice.

Offer buproprion ^a

Alternatives include

• nortryptiline ^a
• nicotine replacement therapy - a combination works best (e.g. patches ^a and gum ^a ) 
• clonidine - but adverse effects are common ^a 

Arrange for self-help material and follow-up advice after discharge, with personalised feedback. ^a

Alternatives include

• individual counselling ^a 
• telephone-based counselling ^b 

There is no clear benefit from 

• a exercise programme.   ^a 
• anxiolytics    ^a 
• silver acetate  ^d

Exercise

Encourage patients to stay active. ^a

Offer an exercise rehabilitation programme. ^a

There is no clear benefit from giving postmenopausal women oestrogen and progestin ^a  

Consider giving amiodarone ^a particularly to patients with ventricular arrhythmias ^a

• class I antiarrhythmic agents ^a particularly class Ic drugs ^a and lidocaine ^a
• sotalol ^a  

Further investigations

• myocardial perfusion imaging ^b
• echocardiography ^b
• a symptom-limited ^c exercise tolerance test looking for ^b
  • limited exercise duration
  • impaired systolic blood pressure changes
  • impaired systolic blood pressure changes
  
  Refer all patients for arteriography (followed by PTCA or CABG as required) if they develop ^a  
  • symptomatic angina pectoris during pre-discharge exercise test 
  • ST changes during exercise, compatible with ischaemia