Public Release: 

Heart attack care -- Whilst STEMI are getting optimal care, care of nSTEMI is uncertain

University College London

The Myocardial Ischaemia National Audit Project (MINAP), the largest of the national clinical audits (over 1.25 million records), seeks to assure that patients admitted to hospitals in England, Wales & Belfast with a heart attack receive the best possible care. The 12th annual MINAP Public Report contains information on the care of 81,000 patients provided by 13 ambulance services and 219 hospitals between April 2012 and March 2013.

Heart attack remains a major problem in the UK. Urgent treatment reduces the likelihood of death, further heart attack and disability, and can lead to full recovery. Precisely what treatment is required is determined by assessing the electrical activity of the heart using an ECG ('heart tracing'). In this way heart attacks are classified as STEMI or nSTEMI, each with slightly different early treatment.

For STEMI, rapid reopening of the blocked coronary artery (reperfusion) is the optimum management. This is best achieved by the direct mechanical technique of primary PCI (Percutaneous Coronary Intervention). This 'gold standard' treatment is delivered most quickly via direct admission to a designated Heart Attack Centre - a hospital with suitable facilities and expert staff. The shorter the interval between the patient calling for help and the performance of pPCI (the 'call-to-balloon' time) the greater the chance of recovery. Ambulance services play a pivotal role in identifying suitable patients and providing emergency care while rapidly transporting them to the nearest Heart Attack Centre.

The MINAP Report shows that the vast majority (95%, or about 77,000) of patients receiving reperfusion therapies underwent primary PCI and that most of these (82%) were treated within the target 150 minutes of calling for help. As primary PCI services have become available to more people, including those in more remote areas, the delay from calling for help to arrival at hospital has increased - journey times being longer - yet the proportion of patients treated within 150 minutes has remained the same. This demonstrates the effective working relationships that exist between ambulance services and receiving hospitals.

Achieving the call-to-balloon time standard is more difficult when patients are first assessed in a noninterventional hospital before transfer to a Heart Attack Centre. Only 56% of such patients were treated by primary PCI within 150 minutes.

Following heart attack - STEMI or nSTEMI - patients should wherever possible receive a variety of drugs shown to reduce the likelihood of further heart attack. This year MINAP reports a 'composite score' for the overall prescription of secondary prevention medication. About 90% of patients were discharged with all medications for which they were eligible, with some variation between hospitals.

Compared with STEMI, patients with nSTEMI are likely to have only a partial blockage of a coronary artery, and so immediate PCI is not required. These patients tend to be older (over half are older than 70 years) and have more associated medical problems. Unlike patients with STEMI, those with nSTEMI tend to be admitted to the nearest district general hospital, and in many cases later transferred to Heart Attack Centres for further detailed assessment, using an X-ray procedure called a coronary angiogram.

For those patients with nSTEMI who are referred for diagnostic angiography (74% of all nSTEMI patients in 2012/13) the national target is to have performed the angiogram within 96 hours of admission to hospital. The MINAP Public Report shows improvement over the last ten years in the proportion of patients treated within this time. However in 32% of cases the target was not achieved. Further, this analysis excludes those patients admitted first to a hospital that did not have the facilities to perform an angiogram, and therefore were later transferred to a second hospital for angiography.

Patients that are treated by cardiology specialist teams have better outcomes than those who are not. Only 53% were admitted to a cardiac ward in 2012/13 (a slight improvement from 50% in 2011/12). Most of the remainder spent their first 24 hours in an acute assessment unit (or similar). Yet, the majority (93%) of patients were seen by a cardiologist or a member of the cardiology specialist team within 24 hours of admission.

It is known that not all nSTEMI patients are entered into the MINAP database. A number of hospitals report that they lack resources to enter data on any or all nSTEMI patients. More generally, patients not admitted to a cardiac unit are less likely to be reported to MINAP. Thus, the percentages reported in this report do not, in every case, reliably capture the total number of nSTEMI patients admitted to a hospital, but only reflect those records entered into the MINAP database.

Dr Clive Weston, Clinical Director of MINAP, said: "The identification of nSTEMI (and therefore the collection of data about these patients) is not always easy but it is not an impossible task, and should, we believe, be the aspiration of all admitting hospitals that are interested in assuring and improving the quality of care provided to this group. Although there has been an improvement in nSTEMI data collection, there are still a number of hospitals that are submitting limited, and in some cases no, data."

Alan Keys, patient representative for MINAP, said: "The Francis Report and Keogh Review have highlighted shortcomings and failure to care properly for patients in some areas of the NHS. Budgetary restraint raises concerns that such troubles may not be behind us in a minority of hospitals. Therefore, vigilance remains essential."

Professor Huon Gray, Interim National Clinical Director for Cardiovascular Disease, said: "MINAP has been a major driving force in improving services for people who have suffered heart attacks across the reflects a professional approach to practice that goes beyond the immediate care of an individual patient, to include a readiness to describe and understand variations in care between hospitals...and promotes best and improved practice."


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