Coronary heart disease (CHD), which usually presents as a heart attack (or myocardial infarction, MI) is the most common cause of death and disability both in the UK and globally. The way in which CHD is treated and prevented therefore has huge implications for patients, health professionals and policymakers. Once a person has a heart attack, prevention of further heart attacks, stroke or death, or secondary prevention, is crucial. There is strong evidence for benefit of several drugs and treatments after heart attacks to this end, including aspirin, statins, ACE inhibitors and beta-blockers. Such treatments have undoubtedly saved lives, but studies in the US and the UK, have shown that between 30-60% of MI patients receive appropriate treatment. There are strong arguments for giving more people the right drugs with benefits in terms of mortality and cost-effectiveness. Current NICE guidelines therefore recommend these treatments for all patients following a heart attack.

This week, the British Heart Foundation reported that only 38% of such patients were receiving adequate rehabilitation care. “Cardiac rehab includes advice from dieticians, physiotherapists and psychologists about how to live with the consequences and improve the survival chances following heart attacks, coronary artery bypass operations and angioplasties.” The components of cardiac rehab have benefits individually and together. For example, a review of 46 trials including 9000 patients showed that exercise-based rehabilitation reduces all deaths by 20%, and cardiac deaths by 26%. Some patients are too ill to benefit from cardiac rehabilitation, and others choose not to partake or continue with the rehabilitation programme.

Provision of drug treatment and primary angioplasty programmes has improved more than cardiac rehabilitation, which has remained the poor relation. This is partly because we tend to favour treatment rather than prevention, and pills rather than behaviour changes. To a greater extent than other treatments, cardiac rehabilitation needs the commitment of the patient. However, this does not mean that we cannot be innovative in designing ways of increasing access to this vital aspect of care for patients after MI.

Myocardial infarction (MI) results from a blockage in one or more of the coronary arteries and represents the largest single cause of death worldwide [1]. Even before the introduction of coronary-artery bypass grafting (CABG) in 1968, the focus of treatment and research was opening the blocked artery. Percutaneous coronary intervention (PCI) was first used in 1977, and includes angioplasty, bare-metal stents and more recently, drug-eluting stents (DES). Heart surgeons and cardiologists have argued for the last 30 years over the best way to open up coronary arteries.