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The percentage of patients with a history of myocardial infarction (from 1 April 2011) currently treated with an ACE inhibitor (or ARB if ACE intolerant), aspirin or an alternative anti-platelet therapy, beta blocker and statin (unless a contraindication or side effects are recorded)

Myocardial infarction codes, diagnosis added on or after 1st April 2011.

G30..% G30.. Acute myocardial infarction to G30z. Acute myocardial infarction NOS (Excluding G30A. Mural thrombosis)

G35..% G35.. Subsequent myocardial infarction to G35X. Subsequent myocardial infarction of unspecified site

G38..% G38.. Postoperative myocardial infarction to G38z. Postoperative myocardial infarction, unspecified

Gyu34 [X]Acute transmural myocardial infarction of unspecified site

Gyu36 [X]Subsequent myocardial infarction of unspecified site


Ace inhibitor contraindications; persistent

14LM. H/O: angiotensin converting enzyme inhibitor allergy
U60C4 [X]Angiotensin-converting-enzyme inhibitors causing adverse effects in therapeutic use
ZV14D [V]Personal history of angiotensin-converting-enzyme inhibitor allergy
TJC77 Adverse reaction to captopril
TJC78 Adverse reaction to enalapril
TJC79 Adverse reaction to ramipril
K0430 Acute renal failure due to ACE inhibitor (v26)

Ace inhibitor contraindications; expiring (in the last 12 months)

8I28. Angiotensin converting enzyme inhibitors contraindicated
8I3D. Angiotensin converting enzyme inhibitor declined
8I64. Angiotensin converting enzyme inhibitor not indicated
8I74. Angiotensin converting enzyme inhibitor not tolerated


AII antagonist contraindications: persisting

14LN. H/O: angiotensin II receptor antagonist allergy
U60CB [X]Angiotensin II receptor antagonists causing adverse effects in therapeutic use
ZV14E [V]Personal history of angiotensin II receptor antagonist allergy

AII antagonist contraindications: expiring (in the last 12 months)

8I2H. Angiotensin II receptor antagonists contraindicated
8I3P. Angiotensin II receptor antagonist declined
8I6C. Angiotensin II receptor antagonist not indicated
8I75. Angiotensin II receptor antagonist not tolerated

Statin Contraindications: persisting

U60CA [X]Statin causing adverse effect in therapeutic use
TJC24 Adverse reaction to simvastatin
TJC25 Adverse reaction to pravastatin


Salicylate contra-indications: persistent

14LK. H/O: aspirin allergy
ZV148 [V]Personal history of aspirin allergy
U6051 [X]Salicylates causing adverse effects in therapeutic use
TJ53. Adverse reaction to salicylates

Salicylate contra-indications: expiring (12 months)

8I24. Aspirin prophylaxis contra-indicated
8I38. Aspirin prophylaxis refused
8I66. Aspirin not indicated
8I70. Aspirin not tolerated

Warfarin contraindications: persistent

14LP. H/O: warfarin allergy
TJ42. Adverse reaction to anticoagulants
TJ421 Adverse reaction to warfarin sodium
TJ422 Adverse reaction to nicoumalone
TJ423 Adverse reaction to phenindione
TJ42z Adverse reaction to anticoagulants NOS
U6042 [X]Anticoagulants causing adverse effects in therapeutic use
ZV14A [V]Personal history of warfarin allergy

Warfarin contraindications: expiring (12 months)

8I25. Warfarin contraindicated
8I3E. Warfarin declined
8I65. Warfarin not indicated
8I71. Warfarin not tolerated
8I2R. Anticoagulation contraindicated
8I3d. Anticoagulation declined
8I6N. Anticoagulation not indicated
8I7A. Anticoagulation not tolerated
8I2o. Dabigatran contraindicated
8IES. Dabigatran declined
8I611 Dabigatran not indicated
8I7R. Dabigatran not tolerated

8I2u. Novel oral anticoagulant contraindicated (v29)
8IH1. Novel oral anticoagulant declined (v29)
8I6s. Novel oral anticoagulant not indicated (v29)
8I7V. Novel oral anticoagulant not tolerated (v29)


Clopidogrel contraindications: persistent

14LQ. H/O: clopidogrel allergy
U6048 [X]Clopidogrel causing adverse effects in therapeutic use
ZV14B [V]Personal history of clopidogrel allergy

Clopidogrel contraindications: expiring (12 months)

8I2K. Clopidogrel contraindicated
8I3R. Clopidogrel declined
8I6B. Clopidogrel not indicated
8I72. Clopidogrel not tolerated

OTC salicylate codes ( in last 12 months)

67I8. Advice about taking aspirin
8B63. Salicylate prophylaxis
8B3T. Over the counter aspirin therapy

Beta-blocker contraindications: persistent

14LL. H/O: betablocker allergy
TJC6. Adverse reaction to betablockers
TJC61 Adverse reaction to acebutolol
TJC62 Adverse reaction to atenolol
TJC63 Adverse reaction to labetalol
TJC64 Adverse reaction to metoprolol
TJC65 Adverse reaction to nadolol
TJC66 Adverse reaction to oxprenolol
TJC67 Adverse reaction to sotalol
TJC68 Adverse reaction to timolol
TJC6z Adverse reaction to betablockers NOS
U60B7 [X]Beta-adrenoreceptor antagonists causing adverse effects in therapeutic use, not elsewhere classified
ZV14C [V]Personal history of betablocker allergy
U60B9 [X]Adverse reaction to bisoprolol
U60BA [X]Adverse reaction to carvedilol
U60BB [X]Adverse reaction to nebivolol
ZVu6i [X]Personal history of allergy to bisoprolol
ZVu6o [X]Personal history of allergy to carvedilol
ZVu6q [X]Personal history of allergy to nebivolol
TJC00 Adverse Reaction to Practolol
TJC02 Adverse Reaction to Propranolol

Beta-blocker contraindications: expiring (Added in the last 12 months)

8I26. Beta blocker contraindicated
8I36. Beta blocker therapy refused
8I62. Beta blocker not indicated
8I73. Beta blocker not tolerated
8I2g. Bisoprolol contraindicated (v16)
8I2h. Carvedilol contraindicated (v16)
8I2i. Nebivolol contraindicated (v16)
8I6i. Bisoprolol not indicated (v16)
8I6j. Carvedilol not indicated (v16)
8I6k. Nebivolol not indicated (v16)
8I7K. Bisoprolol not tolerated (v16)
8I7L. Carvedilol not tolerated (v16)
8I7M. Nebivolol not tolerated (v16)
8IAS. Bisoprolol therapy refused (v16)
8IAT. Carvedilol therapy refused (v16)
8IAV. Nebivolol therapy refused (v16)

Ace inhibitor prescription codes (prescribed in the last 6 months)



AII antagonist prescription codes (prescribed in the last 6 months)

bk3.. - bk5z.
bk7.. - bk9z.
bkI..% (v23)
bkH..% (v23)
bkJ..% AZILSARTAN (v24)


AND Statin prescription codes (prescribed in the last 6 months)


AND Salicylate prescription codes (prescribed in last 6months)


Or Clopidogrel prescription codes (prescribed in last 6 months)

8B6P. Clopidogrel prophylaxis

Or Warfarin prescription codes (prescribed in last 6 months)

8B2K. Anticoagulant prescribed by third party

AND Beta-blocker prescription codes (Issued in the last 6 months)



Myocardial Infarction Exception Reporting codes

9hM.. Exception reporting: myocardial infarction quality indicators
9hM0. Excepted from myocardial infarction quality indicators: informed dissent
9hM1. Excepted from myocardial infarction quality indicators: patient unsuitable

CHD exception reporting codes (In last 15 months)

9h0.. Exception reporting: CHD quality indicators
9h01. Excepted from CHD quality indicators: Patient unsuitable
9h02. Excepted from CHD quality indicators: Informed dissent


CHD 006.1 Rationale

There is evidence from meta-analyses and randomised controlled trials (level one evidence) for a range of relevant health outcomes, including mortality, to support all patients who have had an acute myocardial infarction (MI) being offered treatment with a combination of the following drugs:

There is also health economic evidence to suggest that these drug interventions are cost effective. The evidence presented here is summarised from NICE clinical guideline 172. http://guidance.nice.org.uk/CG172

ACE inhibitor (ACE-I)
In the studies reviewed, short-term treatment with an ACE-I in unselected patients immediately after an MI was associated with a small reduction in mortality.

Long term treatment with an ACE-I in patients with signs of heart failure and/or left ventricular systolic dysfunction who have recently experienced an MI was associated with a substantial reduction in all-cause mortality, recurrent MI and re-admission for heart failure. Where patients are intolerant of an ACE inhibitor (for example because of a cough or allergy) it is recommends offering an ARB (angiotensin receptor blocker) instead.

Aspirin and alternative antiplatelet therapy
In the studies reviewed, treatment with aspirin after an MI reduced the risk of death and cardiovascular events. In a subgroup of patients with recent MI, aspirin and clopidogrel (an alternative antiplatelet therapy) have similar cardiovascular benefits.

Patients may be treated with anticoagulants for the management of co-morbid conditions such as AF and HF. NICE recommends clinicians take into account bleeding risk, thromboembolic risk and cardiovascular risk when considering treatment in people who have had an MI and who have an indication for anticoagulation. Unless there is a high risk of bleeding, anticoagulation should be continued and aspirin added to treatment. For the purpose of this indicator, anticoagulant therapy will be included in the 'aspirin or an alternative anti-platelet therapy' component of this indicator.

In the studies reviewed, in unselected patients after acute MI, long term treatment with betablockers was associated with reduced mortality compared with placebo.

In a meta-analysis of primary and secondary prevention studies, treatment with a statin was associated with a reduction in all-cause mortality and cardiovascular mortality.

Further information
NICE clinical guideline CG172 (2013). MI secondary prevention in primary and secondary care for patients following a myocardial infarction. http://guidance.nice.org.uk/CG172

NICE clinical guideline 67 (2007). Lipid modification. www.nice.org.uk/guidance/CG67

National collaborating centre for primary care. Lipid modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. 2008. http://www.nice.org.uk/nicemedia/live/11982/40742/40742.pdf

CHD 006.2 Reporting and verification

This indicator requires a patient to be on four drugs, one from each of the following categories:

A patient will be counted towards the target if they are:

a. receiving an ACE AND receiving either aspirin or alternative anti-platelet or anticoagulant therapy AND receiving a beta-blocker AND receiving a statin

b. the patient is contraindicated for an ACE BUT receiving an ARB AND receiving either aspirin or an alternative anti-platelet or anticoagulant therapy AND receiving a betablocker AND receiving a statin.

A patient will not be included in the denominator if they are:

a. exception reported using one of the nine QOF exception reporting criteria (apart from if they have a contraindication as per 'b' above but receiving the other drugs)

b. receiving a drug from the last three groups but contraindicated for both an ACE and ARB.

A patient will be included in the denominator and not the numerator if they are:

a. not appropriately exception coded

b. not receiving the medicines described above.


Prepared By Jean Keenan